Fibromyalgia, and Chronic Fatigue are diagnoses that trigger emotional reactions from doctors and patients for many reasons, chief among them the lack of understanding of why people are thus afflicted. Unfortunately, this problem is seen to one degree or another in practically ALL diseases, for it is our lifestyles, diets, stresses and polluted environments that are causing our health to break down at the cellular level. Check out this article:
“Fibromyalgia and Obesity, The Association Between Body Mass Index and Disability, Depression, History of Abuse, Medications, and Comorbidities.”[1]
Yes, even the pharmaceutical treatments inflicted on Fibromyalgia and CFS patients perpetuate their problems since their detoxifying capacities are compromised. It turns out that most of these patients have intestinal and liver issues.
Why don’t we tell our patients they need to change their diets and lifestyles? You know the answer.
Hugo Rodier, MD
On unnecessary testing
For the most part doctors wish to cover themselves so that they cannot be sued due to a missed diagnosis. The US Preventive Task Force is beat up each time it points out that we are testing too much, so, the system is unlikely to make any changes any time soon. So, let’s go for the low hanging fruit: cholesterol testing. It seems that each month some enterprising soul tries to show how their fancy new lipid testing is better than the old, cheaper testing we have had for years. I have not bought into their marketing, or their studies. I feel they are most likely tweaked to sound better than they really are. Besides, cholesterol is really not the problem as we have discussed several times in this newsletter.
So, if you are going to get tested, insist that they focus on the old LDL particle and that they aim for a percentage of reduction of the LDL, and not so much on an absolute reduction of LDL to reach a goal determined by statistics.[2]
The AMA on Drugs
Don’t take the title literally because the AMA has finally decided to oppose Direct to Consumer Pharmaceutical advertisement.[3] If successful, a big IF since the pharmaceuticals are already spreading so-called “research” saying that drug ads are beneficial to patients, New Zealand would be the lone country allowing drug ads. It doesn’t take a big stretch of the imagination to wonder if these ads have contributed to the increase in pharmaceutical use in the USA (see the article below). The question should be asked: are we healthier for it?
“Trends in Prescription Drug Use Among Adults in the United States From 1999-2012.”[4]
“In this study, researchers retrospectively analyzed the National Health and Nutrition Examination Survey database to determine if the prevalence of prescription drug use changed from 1999-2000 to 2011-2012. Household interviews with approximately 38,000 people were included. During the interviews, people were asked if they had taken prescription drugs over the prior 30 days and, if they answered yes, were asked to show the medication containers.
The main findings include:
- The percentage of adults reporting use of any prescription drugs increased from 51% in 1999-2000 to 59% in 2011-2012.
- The use increased as people became older. For example, for those aged 40-64 years, the use of one or more prescription medications increased from 57% in 1999-2000 to 65% in 2011-2012, whereas the use increased from 84% to 90%, respectively, in those older than 65 years.
- Polypharmacy (use of five or more prescription drugs) increased from 10% to 15% among those 40-64 years old and from 24% to 39% for those over 65 years.
- There was increased use of antihypertensives (from 20% to 27%); antihyperlipidemics (6.9% to 17%), primarily driven by statins; and antidepressants (from 6.8% to 13%), especially selective serotonin-norepinephrine reuptake inhibitors and selective serotonin reuptake inhibitors.
- Narcotic analgesic use increased from 3.8% in 1999-2000 to 5.7% in 2011-2012.
- Among those interviewed, 4.6% took antidiabetic agents in 1999-2000, which increased to 8.2% in 2011-2012, mainly due to greater use of biguanides, insulin, and sulfonylureas.
- Prescription proton-pump inhibitors increased from 3.9% to 7.8% and anticonvulsants from 2.3% to 5.5%.
- The 10 most commonly used individual drugs in 2011-2012 were simvastatin, lisinopril, levothyroxine, metoprolol, metformin, hydrochlorothiazide, omeprazole, amlodipine, atorvastatin, and albuterol.
All of the reported increases from 1999 to 2012 were not explained by changes in the age distribution of the population.
Viewpoint
Any physician working in a hospital has likely noticed that many of those admitted for inpatient surgery are taking multiple prescription medications. This study confirms the suspicion that a greater number of patients are on more medications than ever before. For example, the authors found that almost 40% of the US population over 65 years of age is on five or more prescription medications. This percentage was established in the general population and is not specifically for patients undergoing surgery or those who are hospitalized at any moment, as such data were not available to the investigators.
Sometimes, the number of daily medications taken by a single patient can be bewilderingly high (eg, more than 10). An aspect of these patients’ perioperative management involves their anesthesiologist or surgeon assessing the medications and any potential interactions. The more medications, the more questions arise preoperatively. Should the oral anticoagulant be stopped; and, if so, for how long? Should the oral antidiabetic agent be taken the morning of surgery? What about the antihypertensive? How should the analgesia plan be modified if the patient is on oral opioids?
The important finding of polypharmacy raises other crucial questions for policymakers and health systems, such as whether a primary physician is managing the patient’s multiple medications to ensure that each is warranted and that the combination is optimal.
The overall increase in drug use that was noted in this study may reflect several forces, including evolving medical practice patterns (eg, advances in treatment or new clinical guidelines), drugs entering and exiting the market, changes to drug marketing and promotion, modifications in health policy or payment systems (eg, implementation of Medicare Part D), or evolving health needs of the population. A possible example of this is presented in the finding that 8 of the 10 most commonly used drugs in 2011-2012 treat components of the cardiometabolic syndrome, including hypertension, diabetes, and dyslipidemia. As proton-pump inhibitors are likely to be prescribed for gastroesophageal reflux in overweight individuals, the increase in use of these four agents may reflect the growing prevalence of obesity.”
Why coffee
Since its inception this newsletter has published study after study on the health benefits of coffee, but not without warnings that coffee has diminishing returns. There is a point where one may drink too much, which is associated with cardiac and gut problems in addition to insomnia. Still, the cost-benefit analysis of coffee consumption is impressive. The latest and massive study on coffee leaves no doubt:
“People with a moderately increased intake of coffee—caffeinated, decaffeinated, or overall—have a significantly lower mortality risk than coffee nondrinkers, according to a pooled analysis of three large well-known cohort studies.”[5]
The main salutary effects of coffee are through its antioxidant effects which improve detoxification on the liver, increase bowel movements and improve insulin sensitivity-see below.
Diet and Depression
It never ceases to amaze how the pharmaceutical paradigm clouds intelligent peoples’ minds. Given the above article on the overuse of pharmaceuticals you will find the example presented below rather… amusing. In short, despite the great results seen in this study, the good doctor insists that the answer to metabolic problems including diabetes and depression is pharmaceutical. Sure, a bone is thrown to prevention, but, given who financed the study it is understandable that emphasis be placed on the drug pioglitazone,[6] rather than changing one’s lifestyle. Read for yourself….
“Adjuvant pioglitazone for unremitted depression: Clinical correlates of treatment response.”[7]
“The study is the result of 20 years of work examining insulin resistance and issues of the central nervous system and is based on the “hypothesis about underlying insulin resistance in patients who have mood disorders and cognitive complaints, as a potential link to neurodegenerative disease.” In addition to confirming the effect of pioglitazone on depressive symptoms compared with placebo, the investigators sought to correlate any potential antidepressant effect via increasing insulin sensitivity by distinguishing participants by insulin response.
Successful treatment of unremitting depression with pioglitazone is more likely when there is corresponding glucose metabolic dysfunction. Despite the very fascinating neurobiological interplay, there is a very simple and very easily generalizable impact of the findings, in terms of just educating providers who care for people with prediabetes, diabetes, obesity and who have depression. That there is this interplay between both conditions, and identifying each condition…and treating it aggressively is very important for overall well-being.
A greater understanding of the reciprocal links between depression and insulin resistance may lead to a dramatic shift in the way in which depression is conceptualized and treated, with a greater focus on treating and/or preventing metabolic dysfunction.
Earlier work showed that younger adults had an advantage in restoring cognitive performance. If depression and insulin resistance hit a person at a younger age, they have worse cognitive performance, and as you see [in this current study with active treatment], they fare better, which means the sooner we can identify these conditions in patients who have depression and the sooner we treat it, we have better chance at primary prevention.
Insulin has multiple functions within the central nervous system, insulin resistance is inherently a proinflammatory state, and depression and inflammation have been linked. As the current prevalence of Type 2 diabetes mellitus and related diseases grow worldwide and its associated metabolic consequences become more salient, it is increasingly critical to understand the role of IR [insulin resistance] in depressive disorders.”
- J. Clinical Rheumatology 2015;21(6):289↑
- JUPITER trial at the American Heart Association (AHA) 2015 Scientific Sessions ↑
- AMA 2015 Delegates meeting in Atlanta ↑
- JAMA 2015;314:1818 ↑
- “Association of coffee consumption with total and cause-specific mortality in three large prospective cohorts,” J. Circulation 2015; DOI:10.1161/CIRCULATIONAHA.115.017341 ↑
- Pioglitazone carries a warning of fluid retention and cardiac failure ↑
- J. Psychiatry Research Epub Oct 12 2015↑
