Thursday, September 27, 2012

A Non-Inflammatory Article About Vaccinations

Last week, the New York Times published an article about Washington state’s efforts to increase vaccination rates, which include a new law that would require parents to get a physician’s signature should they choose to opt out. Interestingly, the article quoted a naturopathic physician who supported vaccination and talked about some of the reasons parents avoid them, rather than opposing vaccinations, as NDs are often accused of doing. It always makes me happy to see NDs portrayed positively in the media, but on this topic in particular I was glad that an ND got a voice.

Let me put it in simple terms right here at the beginning: in a conversation dominated by loud voices at either end of the spectrum, the naturopathic profession should promote a moderate point of view, one the resonates with what the majority of parents and healthcare providers understand, and that respects the needs of both the population as a whole and individual children. Both the movement against vaccines, as well as physicians who ‘fire’ patients for refusing vaccination have major failings. Rejecting vaccines ignores the tremendous victories over infectious diseases that we’ve seen in the past century, and allows for the re-emergence of diseases that are currently well-controlled. On the other hand, firing patients who decline vaccination alienates people from the healthcare system and is self-defeating in the effort to increase vaccination rates.

As healthcare providers and as good scientists, NDs understand the important role that vaccinations have played in the history of disease. Smallpox, a disease which in the 20th century alone killed over 300 million people worldwide, has been eradicated in the wild since 1979. Polio, a disease that affected even the future President of the United States, has been nearly eradicated, save for isolated regions in Nigeria, Afghanistan, and Pakistan. Many potentially fatal diseases, such as pertussis and diphtheria have been curbed, primarily due to vaccination. Clinical success of this magnitude is undeniably important.

Vaccines are sometimes called victims of their own success – their importance is easily forgotten because, when successful, nothing happens. To draw modern analogies, imagine that we were able to completely eliminate smoking, or Type II Diabetes, or Breast Cancer – the effect on public health would be massive. To prevent these illnesses through a public health campaign would save millions of lives and prevent suffering on an enormous scale. This is the same type of effect that vaccinations have had. To be able to continue to eradicate these infectious diseases, and prevent future epidemics, is a great opportunity for our profession.

At the same time, because of our attention to individual needs and individual cases, NDs understand that some patients have needs or desires that must be respected. A growing number of physicians are ‘firing’ patients who decline vaccinations, and while this is not without reason, I think there are serious problems behind this practice. Firing patients (or more specifically parents) who refuse vaccinations alienates these families from the healthcare system, and may result in these families seeking out providers who agree with them regarding vaccination, but who may not be fully qualified to deal with the ramifications of non-vaccination. Additionally, firing patients loses the battle for vaccination – while parents may not be willing to have their child fully vaccinated at 2 years old, they may be persuaded to do so a few years later, with the birth of a second child, for example. Vaccination is not an on-or-off switch, and catch-up schedules do exist for children who are not vaccinated on the first pass. It’s important to keep these families in the conversation, and at least under medical supervision.

I should note here that the American Academy of Pediatrics’ official position is that physicians should respect parents wishes, but continue the conversation on vaccination. The American Association of Naturopathic Physicians has a similar position. Of course, these moderate points of view don’t make headlines, as it’s the loudest, most extreme voices that make it into newspapers.

My last note today is simple: we need to understand more. One of the primary concerns raised by vaccine objectors is the proposed link to autism. I’m not going to make a comment on that proposed connection, but what I will say is that we need to understand autism better than we currently do – we can describe it quite well, and have diagnostic criteria for it, but still have little understanding of why it occurs in the first place, and are still scraping the surface of how to treat it. There are treatments and theories out there, but nothing has really come to the fore as a unifying explanation of autism. Autism can be a very scary disease for parents, and it’s not surprising that parents are frustrated with physicians’ lack of answers; a better understanding of the cause and treatment of this disease would almost certainly take some pressure off vaccination.

Additionally, we need to understand more about vaccines and adverse events. We know that they happen, we know the basics of preventing them, but we haven’t fully eliminated them. Some are minor, like pain and redness around the injection site. Some are more serious, including neurological damage, high fevers, and other issues. Vaccines have improved over time, even in the past few years, so that they are far more targeted, with less likelihood of side effects – even so, though, their near universal use necessitates that we understand why adverse events happen in isolated cases. Unfortunately, this will take some time to determine, as these events are rare enough that it takes significant amounts of time for enough cases to accumulate to make conclusions.

The system isn’t yet perfect, but efforts are being made. In the interim, consumers should work with qualified healthcare providers who are willing to have a conversation about vaccines and supply information. Likewise, providers shouldn’t alienate skeptics, but rather keep them in the conversation. A moderate course of action, based on advancing public health and respecting individuals is currently the best solution to this slightly thorny issue, and it’s no surprise that both the AAP and AANP have advocated for this approach.

Monday, September 24, 2012

Another Article on Money and Medication

A few months ago, I wrote a brief blog entry that directed you readers to this article, written by a former editor of the New England Journal of Medicine. The article, one of the most strongly worded condemnations of the pharmaceutical industry I've ever seen, goes on at length and in detail about how money has corrupted the science behind the practice of medicine. If you've not read it, I recommend it highly. However, this article was written some years ago at this point, and precious little has been done to improve the situation.

I recently came across another article on the topic, again written by a medical doctor who decried the influence that pharmaceutical companies have on research, and thus the practice of medicine. A main example he cites is the use of antidepressants in children - not only have these drugs not been proven to be effective in children, but there is strong, clear evidence that they cause harm by increasing the risk of depression-related suicide in children.

This Monday, I highly recommend you read this piece, which was published in The Guardian last Friday. While Dr. Angell's article from several years ago was excellent, it cited few examples, and this newer article cites many specific cases and a good amount of research - research that shows the biases of research conducted by pharmaceutical companies. If you don't finish the article feeling indignant, you may not have been paying attention.

Of course, the issue is not that drugs don't work, nor that as a naturopathic physician I'm 'opposed' to drugs, but rather that when the lives and health of patients is on the line, we should have access to accurate, unbiased information, be it about pharmaceutical drugs, herbs, supplements or other treatments. Articles like this one and other recent events may be moving us towards an era of unbiased information, but it's still some time off. In the mean time, working with a healthcare provider you trust and know, who stays abreast of current information and is open to learning more is your best bet. Even if research is fallible, individual docs can still sort the wheat from the chaff and guide patients to health.

Thursday, September 20, 2012

Garlic and Hypertension

A busy schedule in recent weeks has kept me from diving deeply into research the way have been able to in the past, but this week I‘ve got a bit of extra time and some research to share, so am excited to dig in and talk about evidence.

Earlier this week, I posted a great graphic that presented evidence about supplements in a clean and easy to read format. Though I think the graphic was great, I thought that I might put it to the test, just to see if the assessments bore out. The subject I chose was garlic as a treatment for hypertension. Though I’d previously reviewed garlic for its use in lowering cholesterol, I didn’t run into any significant references for garlic’s use in hypertension – to be sure, it’s often mentioned as an herb for high blood pressure, but as I hadn’t seen any data, I was surprised to see it listed so highly.

The article the author of the graphic referenced was this one, a recently updated meta-analysis originally published in 1994. The researchers, working at the University of Adelaide in Australia found that, according to data from the eleven studies included in the meta-analysis, garlic preparations produced approximately an 8 point drop in both systolic and diastolic blood pressures in patients with hypertension. While that number is on the one hand statistically significant, it’s also clinically significant as well – in combination with lifestyle changes which can generate some pretty important reductions in blood pressure themselves, an extra eight points can help bring the blood pressure under control.

While this study was the one cited in the graphic, it’s not the only one that showed positive results. Another meta-analysis, which looked at many of the same studies as the first study mentioned, found that the effect of garlic on blood pressure was quite strong in patients who had elevated blood pressure in the first place, but not on those who did not. Those of you who read my blog post on hawthorn a hypertension may recall that hawthorn appeared to have a similar effect, i.e. normalizing elevated blood pressure, but not causing hypotension in those with normal blood pressure. A variety of individual studies have shown positive effects, but these two meta-analyses, which compiled data from these smaller studies, throw some pretty strong weight behind garlic’s use in hypertension.

However, not all studies have raved about the benefits of garlic. One systematic review, done by the well-respected Cochrane Database, found that, while research indicated very positive trends, and that garlic held promise for future research, current research was lacking, and that it was impossible to make firm statements regarding the efficacy of garlic. Likewise, another study, published in the Netherlands, also found that there was too little evidence to make firm statements about the effect of garlic on blood pressure, and that garlic could not yet be recommended as a treatment for hypertension. Neither of these studies were negative, pe se, but both said, ‘We have to wait and see.’

Before I go on to discuss the conclusions that I’m drawing from this evidence, I’d like to mention an issue in research that these studies bring up.

Conflicting evidence exists on just about every topic in medicine, and that it takes the human brain of a physician to interpret and apply evidence correctly. In some cases, the conflict between pieces of evidence is due to problems in one of the study’s design – mistakes in design can result in incorrect results. In others, it’s because the studies asked slightly different questions, and found differing answers about a common topic. These conflicting results are an issue not only with research into ‘alternative’ treatments, but even commonly prescribed medications. Without being flippant, I think it’s safe to say that, given all the research that exists in the world, there’s some piece of evidence against nearly everything we do, but we do these things anyway, because the job of a physician isn’t to be a slave to data, but to pay attention to the patient, and use data (positive and negative) to aid the patient in their return to health. When the evidence is overwhelming, this job becomes a little easier, but frequently it's a careful balanced approach taking into account conflicting pieces of data.

So here’s my take on the data. Sometimes, when data is conflicting, it’s because the positive studies were just outliers, and the bulk of the research is negative. Other times it’s the opposite. However, sometimes, when research conflicts, it’s because there’s something going on that we didn’t previously know. Based on these articles, it would appear to me that garlic modulates/normalizes blood pressure, but doesn’t act exactly like a hypotensive drug – this might explain why many of these studies found little or no effect, but that the most specific study (that which looked at the effect of garlic on blood pressure in hypertensives) was so strongly positive. It’s not yet known how garlic lowers blood pressure, but it may be that it does not do so directly, but rather secondarily, as a ‘side effect’ of a primary action.

Monday, September 17, 2012

A Graphic About Evidence

I think I have a new favorite graphic. Shown below is a great graphic that combines information on the popularity of supplements with the amount of evidence that exists regarding their efficacy. The blue and darker green ones at the top have more evidence, whereas those lighter green or yellow ones at the bottom have less evidence behind them. The orange-ish ones have less evidence, but look very promising, so are singled out because they may rise in the ranks in the future.

What's great about this graphic is that it addresses the perennial question of evidence, and presents the information in a clear format. If you're having a hard time reading the fine print in this image, click here to see the original version.

What makes this graphic truly excellent, however, is not that the data is presented well, or that it looks nice, but rather that it's a live graphic that is continually being updated with more information. Click here to see a really cool live version, which you'll notice that it's slightly different than the one below. What's especially cool is that the bubbles link through to the studies being cited - talk about a great interactive data presentation! You'll also be able to select for data related to various topics, like cardiovascular disease, cancer, etc.

I can't say that this is a perfect graphic, as there are some inclusions that strike me as ridiculous - the glaring one here being the assertion that omega-6 fatty acids (omega-3 fatty acids' more inflammatory counterparts) are heart healthy. Nonetheless, on the whole, this is a great piece of work.

As always, this is unfiltered data, and working with a healthcare professional is important, because even though this graphic might show that a given supplement is efficacious, it can't tell you how much to take, monitor for side effects, or track your progress over time, not to mention the fact that it can't advise you on improving your exercise regimen or diet. Have fun playing with this device, but don't forget that it takes the human brain of a trained practitioner to assess and implement this information.

Thursday, September 13, 2012

Hair Loss and Vitamin D

I were able to solve the problem of male pattern baldness, I'd be wildly successful and famous. At this point, I think everyone in America has seen an ad for hair replacement surgery. They are nearly ubiquitous in American society at this point, cropping up on TV, in magazines, and on billboards by the side of the highway. This is a multibillion dollar industry worldwide, and it's one that's not likely to go away soon. My patients ask me about hair loss very regularly, and so I keep my eye out for any info that might be helpful - I recently read an article in the Wall Street Journal about hair loss that presented some info that was new to me, so I'm going to comment on it here.

The article presented info on the use of vitamin D in hair loss, a recent area of research that has started coming up in the past few years. Hair replacement surgery and the use of Rogaine or Propecia has been  the standard of care for some time now, but these treatments are not fully effective, and come with side effects or hefty price tags. Vitamin D may prove to be an important ally in reversing baldness, but the research is still very preliminary.

What has been shown is this - the vitamin D receptor has a role to play in determining whether a hair follicle is active or dormant, and that interfering with the activity of the receptor, either positively or negatively, can either stimulate or decrease hair growth. Additionally, vitamin D can promote follicle growth in the lab in conjunction with traditional treatment, suggesting that it may have an important role to play as an adjunct to treatment.

However, though this is all very intriguing, there isn't a lot of clinical information to go on yet. We don't know if people with healthy vitamin D levels have less baldness and we don't know if taking vitamin D supplements helps prevent or reverse baldness. Having read the article, I did a literature search, and found that, actually, very little research has been done into vitamin D and hair loss, and that most focuses on less common forms of baldness.

The most common form of chronic baldness is androgenic baldness, also called male pattern baldness, which is believed to be caused by an excess of DHT, a metabolite of testosterone. Propecia and some natural treatments are aimed at reducing the conversion of testosterone to DHT, thus preventing male pattern baldness. However, other causes of baldness include dietary deficiencies, hypothyroidism, chemotherapy, and severe stress - these causes are reversible, and can be resolved using treatments meant to target these specific causes. The point is that hair loss can be attributed to a wide variety of vastly disparate causes, and so a unified treatment is going to be difficult to devise. While vitamin D has shown some interesting results in the lab, its only clinical evidence relates to less common types of baldness, and I've not found any information about that all important holy grail of baldness, male pattern baldness. Future research may show that vitamin D may be effective in this condition, but at the moment we're best to rely on better understood, more common treatments.

Of course, vitamin D can be effective in a variety of conditions, and optimal vitamin D levels help to prevent a variety of conditions, and so health-conscious Americans should continue to work to achieve and maintain optimal vitamin D levels, but for now, consuming large amounts of vitamin D supplements with the hope of regrowing hair is ill-advised.

Monday, September 10, 2012

A Graphic on What Americans Eat

I'm not a big reader of Men's Health Journal, but I was recently looking for a graphic to share with you all, and came across this little beauty. According to their research, the average American ate 2000 pounds, literally a ton, in 2011.

I don't know how this compares to previous years, or to historical trends. Of course we'd all guess that Americans haven't eaten such Herculean amounts in the past, but I don't have any figures to back that up. What is interesting, though, is that our eating patterns have changed considerably - more meat, soda, cheese and grains, and interestingly, less coffee. Obviously, this chart leaves out the important question of how many fruits and vegetables Americans ate in the 1980s and 1950s, but it sheds light on how our diet has changed in the past 50 years. Some of you might recall this graphic from a few months ago, which further underlines that Americans are shifting their eating habits, and eating more. Is it any surprise, then, that Americans are eating more meat, cheese and soda?

Thursday, September 6, 2012

Primary Care vs. Complementary Care

Naturopathic medicine is a work in progress. I’m not saying that it’s in need of significant improvement, or that it’s lagging in some way, but rather that it’s a profession undergoing evolution. I’ve written in the past about how the terminology of naturopathic medicine has reflected the shifting focus of the profession. The latest, and most recent shift, has been a move from strictly complementary or alternative care to primary care – NDs, who used to be doctors of last resort when all else had failed, are now emerging as the entry point into the medical system, the doctor who keeps you well and prevents illness.

That the nation is facing a shortage of primary care providers is not news. More and more medical students are electing to go into specialties rather than primary care, leading to a significant lack of primary care providers. This shortfall, which was in place before the passage of the Affordable Care Act (ACA), will probably become worse as 30 million previously uninsured Americans will enter the insurance market.

Many groups are scrambling to fill this shortfall. Physician’s Assistants (PAs) have been working to fill the void, and the expanding role of Nurse Practitioners (NPs) has been partly motivated by the need to get primary care providers in the field. There have even been efforts to design 3-year MD programs (a year shorter than traditional medical school) with a strict focus on primary care. In addition, of course, there have been efforts to woo medical students back to the practice of primary care, which can be a hard sell to newly minted students with $250,000 in student loans to pay off.

Naturopathic physicians have also been entering the fray, and practice as primary care providers in a number of states. In Washington state, NDs are licensed as PCPs, and can be designated as such on a variety of insurance plans. Vermont and Oregon have both passed recent legislation that provides for NDs to head medical homes, organizations that serve as one-stop-shops for primary care. Other states include language in licensing laws that specifically designates NDs as primary care providers.

This all makes me excited because of the potential that NDs offer the healthcare system.

While different people will have differing opinions on the ACA, we can all agree that we need to save money in order to maintain our healthcare system and serve the American people. A lot of wrangling has gone on about cutting reimbursement to doctors, trying to save money on pharmaceuticals, and a variety of other cost-cutting measures, but I don’t think nearly enough time is spend discussing the importance of preventing people from getting sick in the first place. While not all disease is preventable, a significant portion is; just a few months ago, I blogged about a study which suggested that 40% of cancer cases were due to lifestyle factors and therefore preventable.

In the  20th century, we’ve managed to stem the tide of infectious diseases, which used to be the main emphasis of healthcare, but have seen grow up in their place a large number of chronic, lifestyle-related diseases. This is exactly the type of disease that naturopathic physicians are trained to prevent and manage. While MDs get a precious few hours of training in nutrition and lifestyle medicine (exercise, stress management, etc.), NDs get this from day one, and it’s drilled home in every class an ND takes. At the same time, unlike a nutritionist, an ND knows how to diagnose and treat disease, integrating the diagnosis with changes to the patient’s diet and lifestyle.

A very interesting study came out this summer on the topic of primary care and naturopathic medicine. The Puget Sound Health Alliance is an organization that tracks healthcare results in western Washington state in order to provide information to consumers. Every year, the PSHA publishes a Community Checkup, which tracks the performance of healthcare institutions (both clinics and hospitals) in meeting healthcare goals in areas such as prevention, management of certain conditions, and patient experience. The survey covers everything from small clinics to high volume institutions, and includes high profile institutions such as Virginia Mason, the University of Washington, and Swedish Medical Group. While the Bastyr Center for Natural Health (the teaching clinic of Bastyr University) is a smaller clinic and, like many smaller clinics, didn’t service enough patients to be ranked for outcomes measures, it hit the top of the rankings for patient satisfaction, coming in first place for timeliness of care and quality of doctor-patient communication, and in the top three for customer service and overall provider rating. This is an important verification of quality from a well-known third party that naturopathic primary care offers great promise in modern healthcare.

This study highlights two essential features of primary care that NDs excel at. The first is that, in primary care, the role of the physician is partly to ‘do’ science, but primarily to communicate science, connecting lab values and physical exam findings with the personal experience of the patient. That providers at the Bastyr Center ranked so highly in the study indicates that the school is providing excellent training in this regard. The second is that, in primary care, it is crucially important that the patient feel cared for. It’s right there in the name primary care, and yet this is often lost in the modern medical experience. The Bastyr Center’s excellent performance in this study again indicates that NDs are excellent healthcare providers.

Other research will be necessary to bring naturopathic medicine fully to the forefront of primary care, but it’s clear to me that as the nation moves from a disease-care model to a wellness-promoting model, naturopathic physicians will have a vital role to play in keeping our nation healthy and happy, while saving us money.

Monday, September 3, 2012

A Graphic About Driving and Obesity

Why are so many Americans overweight? If I had the answer, I'd be rich and famous, and would be writing this blog - actually, scratch that, dictating this blog - from the comfort of an armchair overlooking the Mediterranean. People have suggested a lot of answers to this question, from too much saturated fat, to too many carbs, to hidden food allergies, to undiagnosed thyroid conditions. These are all potential causes in unique cases, but when we are looking at the US population as a whole, none of these really hold up as the primary cause.

This fantastic graphic looks at driving as a cause of obesity. The graphic (which can be enlarged) charts state-by-state use of public transportation, bicycles, and cars, as well as walking rates, and then correlates them to obesity rates. The chart doesn't show direct one-to-one causation, but a general trend can be seen - the more we drive, the less we walk, bike and ride public transit, and the more we weigh.

Now obviously, this isn't an formal study, and the graphic doesn't give important information like caloric intake by state, but does give us a worthwhile message - one reason that Americans are overweight isn't because they eat McDonald's, it isn't because they drink soda instead of water, it isn't even because they haven't joined a gym to take spinning classes - it's because they don't incorporate low-intensity regular exercise into their activities of daily living. Walking to work, biking to work, even walking to and from the bus we take to work apparently help maintain normal weight, and in no small part.

Shedding weight can be a more difficult process, and one which may necessitate the assistance of a health professional, but this graphic underlines the importance of the basics - just because you haven't signed up for a rigorous weight loss program with a personal trainer doesn't mean you're doing nothing.