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. 

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.

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!

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.


Via: Medical Billing And Coding

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.

 
Via: Medical Billing And Coding

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.

Even Kids Will Love This Cauliflower Recipe

Last Monday's blog entry featured a recipe for salmon, a fantastically healthy food, but one that can be hard to get kids to eat. This week's recipe is for cauliflower - the very same cauliflower recipe pictured in last week's blog, in fact!

Mark Twain once said 'Cauliflower is nothing but cabbage with a college education' - people often assume he's mocking the vegetable, but in reality, he's extolling its improvements over the simple cabbage. Even so, it's no secret that kids have a tough time with cauliflower. When overcooked, it can take on a sulphurous smell and soggy texture that makes children the world over run. However, when cooked properly, it can be slightly sweet, with a pleasant firmness. Additionally, cauliflower, like all foods of the Brassica species, imparts large amounts of fiber and cancer-fighting antioxidants. Building kids' love for cauliflower early establishes great habits for the rest of their lives.

This recipe is adapted from a favorite of mine, Claudia Roden's The New Book of Middle Eastern Food.

1 head of cauliflower
1/2 cup water
1/4 cup white wine vinegar (red wine vinegar is also OK)
2/3 cup of tahini, approx.
1 clove garlic, crushed
1/2 tsp salt

Cut the cauliflower florets off from the head. Steam until stems can be easily pierced with a fork, but are not overly soft. Remove from heat, allow to cool slightly, and then chop into smaller pieces.

Meanwhile, combine all ingredients except tahini in a blender or food processor. Add the tahini in parts, until you reach a consistency you like. If you add the full amount of tahini, it will come out with a fairly thick consistency, similar to hummus, so smaller amounts will produce a more dressing-like consistency.

Toss the dressing and cauliflower while the cauliflower is still warm, and serve. The result is a tangy, creamy mix of cauliflower and sauce that is not entirely unlike macaroni and cheese (really). This should please even the most finicky of little eaters.