The Legislative Effort Continues

This week, naturopathic doctors from around Maryland came to Annapolis to talk with legislators about the importance of licensing and regulating the practice of naturopathic medicine. This is the fourth year that the MDANP has been at work in its legislative effort, and in honor of the effort, I'm posting a map showing the US states and territories that currently license naturopathic doctors (in green) and those that will be debating the issue in 2014 (in yellow). Currently, a third of states license naturopathic doctors, and many more will consider doing so in 2014. While I work in a profession characterized as fringe, I hope this map makes clear the fact that naturopathic medicine has moved into the mainstream. And really, why wouldn't it? With a clear focus on prevention, treatments that offer cost savings, and an extremely low incidence of malpractice or harm, naturopathic doctors offer the nation something important at a time when it's needed more than ever before. If you haven't before, take a minute this week to find out what the naturopathic professional organization in your state is up to; you might even pitch in!

Simple Pleasures

Simple recipes are often the most difficult. While large ingredient lists are imposing and can offer the logistical challenge of managing a massive number of ingredients and preparation, a long list of spices often brings with it a strong-enough flavor that it can cover up sub-par technique and preparation. It's ironic, but true. It's easier to get results with complicated recipes. In contrast to that, I'm offering a simple but sublime recipe adapted from Claudia Roden's The Food of Spain. Rather than a curry with a list of 15 spices alone, this is a simple dish prepared from a few ingredients and spiced only with garlic and paprika, and yet the results are fantastic.

1 cup dried chickpeas soaked overnight or 1 15 oz can chickpeas
Salt
1/4 cup olive oil
A whole head of garlic
1 cup dried raisins, soaked in water for 20 min
1 teaspoon sweet paprika
5 cups chicken stock
2 1/2 cups arborio rice

Drain the chickpeas, and bring to a boil in fresh water. Reduce heat to low and simmer for 1 hour, adding 1 tsp salt.
Preheat your oven to 400 degrees.
Peel and chop the garlic cloves, and drain the raisins.
Heat the oil in a medium size pot or casserole that can go in the oven. Stir fry garlic and raisins in the oil for 2-3 minutes, until the aroma arises from the garlic. Add paprika and stir well, then add chickpeas, stock and another teaspoon of salt. Bring the mixture to a boil and add the rice. Stir well to achieve a consistent mixture.
Bake in the oven for 30 minutes, until the rice is al dente.

Simple, yes. Wholesome, yes. Sublime, yes as well. This is a great, filling Spanish delight that will surprise you with its fantastic taste and elegance. It's as well suited to a dinner party as it is a simple family meal. Enjoy.

The 50th Anniversary of an Important Moment

Fifty years ago this week, the Surgeon General of the United States, Luther L. Terry, released Smoking and Health: Report of the Advisory Committee to the Surgeon General, an important milestone in the effort to control tobacco as a public health hazard. While studies from the early 1950s had already indicated that smoking caused lung cancer, and prior studies had shown correlations between smoking an risk of premature death, the report of the Surgeon General made it the opinion of the United States government that smoking was a significant health hazard, and should be controlled by legal means. In that time, we've seen efforts to restrict the purchase of tobacco, the act of smoking, and many, many taxes levied on tobacco, all in an effort to reduce smoking and tobacco consumption.

I won't belabor the point here, so I'll simply point out that the Journal of the American Medical Association has devoted its entire issue to the anniversary of this important event, and also note two studies published in JAMA this month.

The first study found that since the publishing of the Surgeon General's report in 1964, an estimated 8 million smoking-related premature deaths have been prevented in the United States. While lifespan has increased overall since 1964, smoking restriction has added 2.3 years to life expectancy for men, and 1.6 years to life expectancy for women. My own conclusion is that it's been no small potatoes.

The second study found that global smoking rates have decreased for men from 41% in 1980 to 31% in 2012, and for women from 11% in 1980 to 6% in 2012. While this is excellent news - it means that global smoking rates have decreased by over a third - the total number of smokers has actually increased as the global population has increased, so we still have lots of work to do.

As we move forward into the second 50 years of tobacco restriction, and especially as we now see the rise of legalized marijuana consumption, let's not ignore the important work that still must be done, while we celebrate that this global effort has had excellent success.

Vitamin E Surprises Me

Most of the articles written here are meant to be free-standing, so that anyone who happens across them will be able to benefit, but regular readers of my blog will benefit from their experience in reading my blog post today.

To set the scene: Three weeks ago, I made an off-hand comment about the rise and fall of vitamins, mentioning specifically vitamin E. Vitamin E was the focus of a lot of attention many years ago, when it was believed that use of high doses of the antioxidant vitamin might prevent cardiovascular disease. Since then, however, it has fallen out of favor, and is now believed by many to have been over-hyped. Further studies of vitamin E have failed to verify the benefit, and so I tend not to recommend it much, or at least not to patients with cardiovascular disease. In my most cynical moments, I dismiss vitamin E as a fad of a prior time.

Then, two weeks ago, an editorial in the Annals of Internal Medicine came out slamming vitamins in general and vitamin E in particular. I deconstructed that article and argued that it was riddled with problems, but as it relates to today's posting, the editorial suggested that vitamin E was ineffective for, just about anything, and was also probably unsafe.

It turns out that I was wrong to dismiss vitamin E, and so was the Annals of Internal Medicine. Just two days ago, an article was published in the Journal of the American Medical Association that found that vitamin E may provide benefit as an adjunct treatment in Alzheimer's disease. Further confirmation is necessary, but the findings were significant and worthy of attention because of their clinical utility - researchers posited that vitamin E delayed progression of symptoms by about 19% per year in Alzheimer's patients. Additionally, no ill effects were noted over a mean follow-up time of about two years.

I'm not going to discuss the results of the study here, however. Rather, I'm going to make an important point about research. The editorial published in the Annals of Internal Medicine was rash in its suggestion that physicians stop recommending supplements, consumers stop buying supplements, and researchers stop investigating supplements. I argued that broad, blanket statements like this one rarely, if ever, hold up to scientific scrutiny, and less than two weeks after publication, we've already started chipping away at the editorial by way of a peer-reviewed study published in a major medical journal. Broad statements that do not take into account nuances, or indeed evidence, are bound to fail, though they may be partnered with major media campaigns.

The second point is this - clearly I was wrong too. Medicine, despite its attempts to pursue neutrality and evidence, is subject to fads - treatments of all kinds come in and out of favor, and it's not uncommon for clinicians to discount older therapies in favor of newer ones. And lo, I was guilty as charged. Though the evidence for vitamin E in cardiovascular disease remains weak, I was wrong to dismiss the supplement altogether as a fad that lost favor. Vitamin E may indeed hold promise as an effective treatment for other conditions, and I'll now continue to keep an eye out for research.

The point is this: It does no one any favors to close doors in medicine. When we do so, we're inevitably proven wrong. While evidence may lead us away from going to a certain treatment for a certain condition, we should never discount that treatment entirely. I hope we've all learned our lesson today.

Brewing Black Tea (Improperly)

It's the day after Christmas, and whether you celebrate the holiday or not, I hope you're finding some downtime today to spend with friends or family. In fact, I hope you're not spending your day reading my blog! But even so, I'll give you a short piece to read. We've been alternating between posts on health issues and recipes, and it's been a few weeks since we had a recipe. I'll keep today's entry short, and so I'm just going to explain how to brew black tea the 'right' way.

There's some discussion on how to brew black tea, with the British having a very specific procedure involving warming the pot and specifications on the temperature. The truth, however, is that this is only correct for certain kinds of black tea. Black tea is more variable than many know, and some types will require differing preparation methods. Here, then, is a general procedure, with variations noted.

1. Add black tea to the pot. Generally, this is accepted to be 1 teaspoon per 8 ounces, but those who like it strong will add a bit extra - I usually use 1 1/2 teaspoons per 8 ounces. Some of the fuller, leafier black teas, such as high-end Darjeelings, will necessitate slightly more tea, because they are not as tightly packed as traditional black teas.

2. Boil the water. Tea must always (always) start as cold water and be brought to a full boil.

3. Pour the water over the tea. Most black teas must be given water at a full boil in order to bring the best flavor out. Green teas take slightly cooler water, but black teas generally need absolutely boiling water. Again, one exception is Darjeeling; some high end Darjeelings should be given cooler water, which prevents bitter flavors, and allow floral elements to fully express themselves, though for most black teas, the cooler water will result in weak, unstructured tea.

4. Steep the tea, and then either fully decant or remove the leaves from the pot. Of course, the question is on timing, and again, this is variable. Some British-style black teas grown in India and Sri Lanka will take 7-8 minutes to gain full flavor, but other will need only 5 minutes. Chinese black teas generally need only 4-5 minutes to steep. Darjeelings will not only take cooler water, but also shorter brew times. Some experimentation with brew times will be necessary to get optimum flavor.

5. Add milk if desired. Milk, while anathema to green and white teas, is regarded by many as part of the black tea experience. I generally add a small amount, enough to give the tea a rich texture and dark caramel color only. But again, this depends on the specific tea. Many black teas have been bred and processed to take lovingly to milk, though others will not. Generally speaking, Indian and Sri Lankan teas will do well with milk, whereas Chinese and Darjeeling will not, though this is not a hard and fast rule.

6. You may add sugar, but do this at your peril. Remember, you're drinking tea, not eating candy.

And finally, on the topic of re-steeping. If you've brewed using a high quality tea, it should be able to take a re-steeping. Though black tea should be re-steeped at the temperature you brewed at initially, you will have to increase brew time. Again, experimentation is key, and while an extra minute will suffice in some cases, in others you may have to add far more time. Milk may or may not treat your tea favorably on a second steeping. My experience has been that second steepings lack the tannins present in the first steeping, and so do not tolerate milk well. But again, this is only my opinion - I don't even warm the pot, so what do I know?

I hope you are enjoying your winter holiday and find time for a bit of black tea in the process. While I'm a daily drinker of green tea for both flavor and health benefits, a little black tea now and again really hits the spot, especially in the cold winter months, where the heat and heft of black tea is exactly what the doctor ordered.

Thoughts On Multivitamins

The Annals of Internal Medicine, a well-respected medical journal, recently published an editorial titled "Enough Is Enough: Stop Wasting Money on Vitamin and Mineral Supplements." The piece was then widely disseminated to the news media both home and abroad. The editorial claims that the research indicating the uselessness of multivitamins is now so overwhelming as to condemn their use on a vast scale.

It is with sadness that I have to critique this piece. Naturopathic physicians such as myself, both individually and as a profession, have long strived to further research into nutritional approaches to disease and complementary therapies, not to mention furthering the cause of research generally. It is rare that I have to describe an article as unconstructive, but this editorial is such a piece. As I'll argue, this editorial is poorly conceived, poorly intended, and does not engender constructive scientific dialogue.

But before I go further into discussing the particulars, I'd like to discuss a point of irony. The point of irony is that I am not a big advocate for the use of multivitamins. In working with patients, I am far more interested in fostering good eating habits than recommending a multivitamin to "cover the bases." It is perhaps ironic therefore that I might criticize a piece whose point I do agree with. So given that, why argue with it?

Well, there are two big reasons I'm forced to differ with this editorial. The first is that despite claims of overwhelming evidence, the editorial is based on imperfect evidence. It took into account only about 32 studies, some of which are older (a colleague of mine called them "academic leftovers"). While that's no small number, compare it to the article I discussed last week, which examined nearly 300 studies in an effort to understand the role of vitamin D supplementation in disease.

The editorial was written in specific response to two studies published in the Annals of Internal Medicine this month, which bear attention.

The first article found that multivitamins did not appear to provide protection against cognitive decline. This piece suffered from significant limitations, including the fact that it was performed on physicians, who in general eat above average diets and may not need additional nutritional supplementation. Additionally, the use of a multivitamin to prevent cognitive decline is unorthodox, even in complementary medicine, and slowing of cognitive decline is not an outcome that could be reasonably expected from the use of a multivitamin. The most authoritative reference I know of, Nutritional Medicine by Dr. Alan Gaby, includes no references to the use of multivitamins in cognitive decline; this is an exhaustive reference book that draws on published medical literature as far back as the 1940s. This study then, is a prospective study examining a completely novel use for multivitamins, but has been misrepresented as a refutation of the use of multivitamins for a given condition.

The second article discusses the use of multivitamins in prevention of cardiovascular events (such as heart attack, stroke, chest pain, or death) in patients who had previously had a heart attack. Patients who were taking part in the study were also undergoing conventional medical therapy. Here also, the use of a multivitamin in preventing a second cardiovascular event is not common practice. This study is not a refutation of an accepted practice, as it is presented in the editorial, but a prospective study that failed to find a positive effect. Though individual nutrients have been studied in regards to various cardiovascular risk factors, including some with positive results, it would not have been reasonable to anticipate that a multivitamin would have the effect of preventing a second event. Additionally, this particular study was confounded by low levels of compliance with treatment, and the study authors themselves admitted that firm conclusions could not be drawn.

A weak rationale for the editorial is one reason that I have to object to the argument.

The second reason I have to object is that the tone of the editorial, especially when taken in light of the evidential basis, leads me to strongly suspect that the authors were writing with substantial bias against the use of nutritional supplements. While attitudes are changing to an extent within the medical profession, there nonetheless remains a strong undercurrent of bias against nutritional medicine and other complementary therapies. As a provider committed to integrative medicine, which incorporates the use of conventional and complementary therapies, recommended on an individual basis, I find it disappointing that the authors did not check their biases at the door. Scientific method has been developed to decrease the influence of bias in research, and it does no good to bring bias back into the equation when interpreting results.

Of course, the editorial itself is not the entire problem. Of greater frustration is the fact that this editorial was then widely disseminated via the news media, during which it received an additional level of distortion. Given that the articles that incited this process found that multivitamins did not engender an additional benefit on top of a balanced diet or conventional treatment, and for conditions that would not be expected to benefit from use of a multivitamin, it is incomprehensible that the subsequent news articles bore titles such as "Should We Toss Our Vitamin Pills?" and "Vitamin supplements are a waste of money, say scientists." It is difficult to know whether the blame lies at the feet of the journalists or the publicists, but it is clear that limited evidence was spun dramatically out of proportion as this made its way from the lab to the public. While the information gained in the clinical trials is valid and deserves to be incorporated into clinical practice, it does not warrant a massive news campaign intended to convince the public to stop taking vitamins.

Finally, experience and an understanding of scientific progress has taught me that it never pays to close doors, as these authors are suggesting. Statements of absolute certainty rarely hold up under scientific scrutiny, and the broader-reaching they are, the faster they tend to succumb to criticism and new evidence. In the final analysis, this editorial was unconstructive for this reason. It offered little new knowledge, and proposed a radical departure from well-established norms. Had the editorial been limited and stuck to concrete information, I would probably have been chiming in my agreement, because after all, we've learned that multivitamins are unlikely to prevent cognitive decline, though they may have other benefits, and that they are also not a helpful addition to conventional medical therapy immediately after a heart attack. But to take that evidence and then goad the news media into publishing articles that deride vitamins as useless is not helpful, not constructive, and frankly, bad science.

New Information About Vitamin D

Vitamin D has gotten unending amounts of press lately. It's been touted for a whole number of health conditions, including cancer, immune conditions, heart disease, and diabetes. That said, research into the therapeutic effects of vitamin D supplementation have been inconsistent, and there's been some discussion of the importance of blood levels of vitamin D as a test. The version of vitamin D tested by health care professionals is not the active form of vitamin D, but is a 'pre-hormone' that acts as a reservoir and is converted into vitamin D for use by the body. Researchers are asking themselves what exactly this test measures, and whether raising those levels has a therapeutic effect.

Enter into this a paper that was recently published which suggests that serum vitamin D levels are the result of chronic disease, rather than the cause of it. The authors postulate that during chronic disease, vitamin D levels fall, rather than inadequate vitamin D levels being the cause of the chronic disease. The paper is a review of hundreds of individual studies of vitamin D, some of which looked at serum levels of vitamin D, while others looked at the effect of vitamin D supplementation on disease. While I think it's of limited clinical use to assess the effect of vitamin D on health generally, rather than on specific diseases (consider the results we'd get if we were to assess the benefits of a statin cholesterol drug on human health over a variety of conditions), the study nonetheless deserves enormous plaudits for the sheer scope of the study. With 290 studies to draw from, the information they generated should have some weight.

In summary, the findings were this: Low blood levels of vitamin D appear to be the result of chronic diseases, rather than their cause. The researchers noted many, many associations of low vitamin D with conditions such as cardiovascular disease, multiple sclerosis, mood disorders, and weight gain, but did not find strong evidence that vitamin D supplementation resolved these issues.  As stated previously, there are some issues with applying this information - reconciling the broad conclusions of this study (that vitamin D supplementation does not affect disease generally) with the specific conclusions of others will be a challenge for clinicians.

The primary concession the authors make is that among the elderly, vitamin D supplementation has a clear beneficial effect on reducing overall mortality. They were hesitant to discuss why this was, but agreed that vitamin D supplementation was an important intervention for the elderly, who are susceptible to a number of ailments.

Nonetheless, the idea that the body responds to chronic disease by lowering serum levels of vitamin D is not without precedent - it does similar things with iron. However, the reason that the body appears to do this is still unclear. Stay tuned as we continue to learn more about vitamin D.

Vitamins have risen and fallen in the past, be they vitamin C or vitamin E. This study will likely not prove to be a nail in the coffin of vitamin D, but it will certain shape our understanding of vitamin D in the future. Consumers should still note the fact that this study will not change recommended supplementation guidelines. The Institute of Medicine increased the recommended amount a few years ago from 400IU to 800IU for healthy adults, and that number still stands. Supplementing with vitamin D, despite the findings of this study, is still strongly recommended.