There are many problems with our broken Health Care System.[1] Chief among them is the use of ACUTE care tools like pharmaceuticals to treat CHRONIC health problems (See Article “Too Much Medicine” at the end of newsletter.) While we should use Prilosec IV yesterday when we have an acute bleeding ulcer, those drugs are not a good idea to stay on indefinitely without regards to their side effects.
No doubt we have the best acute health care system in the world. Rush Limbaugh so proclaimed as he waddled out of the ER after being treated for a heart attack. Fortunately, many people are becoming aware of this dissonance. Many now hope that by the year 2020 the system will have switched to TLC, Therapeutic Lifestyle Changes for Chronic health problems.[2] This newsletter was dedicated to that worthy goal at its inception in 1999.
Even before 1999 the data supporting the use of non pharmaceutical tools has been there. But, many skeptics have not bothered checking it out. Rather, they take the word of those who, having an interest in perpetuating acute care treatment with drugs, write articles belittling TLC and supplements: “It would behoove us to apply the same tenants of evidence-based medicine,” writes the good doctor about acupuncture, noting that its salutary effects have been dismissed as “alternatives” not as effective as drugs.[3] We would do well to apply the same sound reasoning in regards to the evidence for non drug tools.
Hugo Rodier, MD
Environmental Estrogens
It is sad to hear women still blaming their own native sex hormones like estrogen and their genes for many of their chronic health problems. They have been “educated” to do so by those who continue to ignore environmental toxins that have an estrogen-like effect, generally known as Endocrine Disruptors (ED), or Xeno-estrogens. This omission is compounded by a lack of education on how poor diets compromise these chemicals’ elimination or detoxification from our body by burdening the liver with fatty deposits and altering our gut flora. These two organs are further compromised by commonly used antibiotics and acid-blocking drugs like Prilosec (see above.)
Fortunately, the evidence on ED affecting the health of both men and women is now surfacing in better medical journals. For example, pesticides are affecting men’s semen quality.[4] Soon, said evidence is likely to make it to the cover issue of the best of them. The latest article on ED highlights the problem of premature menopause in women most exposed to these “foreign estrogens.”
“These EDs were associated with a mean age of menopause 1.9 years to 3.8 years earlier in women with high levels than in women with lower levels. Women exposed to EDs were up to six times more likely to be postmenopausal than women who were not exposed to EDs.“[5]
Unfortunately, the data associating ED with breast, uterine and prostate cancer has not emerged from the lesser journals, yet. I leave you to ponder why this is the case. Let us focus on minimizing exposure to ED (pesticides, plastics, heavy metals, fluorinated and chlorinated products, dioxins, etc.) and maximizing their elimination by optimizing our diets, gut flora and liver function.
To that end this newsletter has highlighted in the past a handful of supplements you may wish to add to the above: probiotics, fiber, alpha lipoic acid, indole-3-carbinol, sulpharanes and herbs found in the brand name Myomin. There are many more supplements to consider; they are generally classified as Glutathione precursors. But, I advise to start with the above simple approach.
Antidepressants update
The following facts have been repeatedly made known, but, they don’t gain much traction in our society. Again, I leave you to ponder why.
“Reporting Bias in Clinical Trials Investigating the Efficacy of Second-Generation Antidepressants in the Treatment of Anxiety Disorders:”: JAMA Psy EPUB March 25 2015
“FDA deemed positive [trials] were five times more likely to be published compared with trials deemed not positive. Furthermore, they found evidence for study publication bias (P < .001), outcome reporting bias (P = .02), and spin (P = .02). The findings, investigators say, provide a skewed view of antidepressant efficacy. ‘Antidepressants have value in treating anxiety disorders, but they are not ‘miracle drugs,’ and there is less evidence to support their efficacy than what appears from the published studies.'”[6]
Translation: Studies showing no efficacy for these drugs are less likely to be published. If all studies, both positive and negative were to be lumped together the efficacy of these drugs would be considerably watered down. This is not to say we should not use them. But, that we do well to stick to using older, well-vetted antidepressants that are much cheaper, anyway.
Remember also that these drugs have side effects; the latest to be documented is an increase risk of first time seizures.[7]
Putting these facts together points to a more conservative use of antidepressants. Many doctors feel they should be prescribed for only severe depression. After all, they have been shown not to work for mild to moderate depression. Sadly, pressure from patients who feel the usual ups and downs of life should be medicated leads to significant over prescribing. This is often fueled by commercials showing happy people popping these pills. Doctors who treat with antidepressants when confronted with puzzling symptoms would do better to refer out for a more thorough investigation, especially if said symptoms persist despite antidepressants.
Review of non pharmaceutical treatment of depression: Diet, exercise, Tai Chi, Yoga, meditation, counseling, improving relationships, career changes.
Supplements: Folic acid MTHFR, SAMe, GABA, lithium orotate, Omega oils, Vitamin D, tryptophan.
Related brain news:
“Association of maternal Diabetes with autism in offspring,” JAMA 2015;313;1425
“Vitamin D low in psychosis,” 15th International Congress on Schizophrenia Research
Complete Article Report: Too much medicine[8]
“Overdiagnosis means different things to different people, say S M Carter and colleagues in their exploration of the social and ethical dimensions of too much medicine. Born out of the Preventing Overdiagnosis 2014 conference in Oxford, their article and others in this special collection (thebmj.com/specialties/digital-theme-issue-overdiagnosis) serve to presage the next conference in Washington, DC, in October 2015, for which registration is now open (www.preventingoverdiagnosis.net). There is much to discuss: how should we define overdiagnosis and its ugly siblings overtreatment, medicalisation, and disease mongering; what do we know of their causes; and what evidence based solutions are available, both general and specific? Above all, who gets to judge when care is inappropriate in any individual case? Pulling this theme issue together, Helen Macdonald and Elizabeth Loder conclude that decisions on what constitutes “just right” medicine are best made by individual patients in true collaboration with their doctors, armed as far as possible with relevant, reliable, and independent information about benefits and harms (doi:10.1136/bmj.h1163).
Therein lies the rub. How good is the available evidence base? When it comes to new drugs entering the market, not very, say Michael Köhler and colleagues (doi:10.1136/bmj.h796); but new legislation in Germany may help and should be adopted internationally, they add. Drug companies wanting to market their drugs in Germany must now provide a standardised dossier containing all available evidence of the drug’s benefits, with special emphasis on outcomes relevant to patients and how the drug compares with existing competitors. Köhler and colleagues found that, in comparison with conventional sources of publicly available information about new drugs (such as journal articles and registry reports), the information in the dossier was far more complete and clinically relevant.
This sounds like progress, even if, as Peter Doshi and Tom Jefferson say in their linked editorial, it’s odd that clinical study reports aren’t included (doi:10.1136/bmj.h952). We know from the Tamiflu saga, on which Doshi and Jefferson worked, that these long and complex documents that drug companies submit to regulators provide invaluable information that should be in the public domain. Excluding them because content is “commercially confidential” seems out of date, they say, especially since the European Medicines Agency has pledged to release all clinical study reports in its possession.
Even so, Germany and its Institute for Quality and Efficiency in Health Care are setting an international standard for other countries to follow. The same might have been said of the UK’s Quality and Outcomes Framework (QOF), the world’s largest pay for performance scheme. As Grant Russell says in his editorial, this grand experiment has been closely watched around the world (doi:10.1136/bmj.h1051), but Evangelos Kontopantelis and colleagues have now provided what Russell believes to be the best evidence on its lack of effect in terms of population health (doi:10.1136/bmj.h904). They found no significant relation between practice performance and either all cause mortality or cause specific mortality. Social deprivation remained the main predictor of mortality.
Whether QOF’s financial incentives to investigate and prescribe have also caused harm and waste from too much medicine is work for another day.”
[1] NIH Report 2001 “Crossing the Quality Chasm.”
[2] “Health Care 2020: reengineering health care to combat chronic disease,” Am J. Med 2015;128:337
[3] “Acupuncture for chronic pain” Am J. Med 2015;128:331
[4] Eating F&V with pesticides lower semen quality, online March 30, 2015 in the journal Human Reproduction
[5] “Persistent organic pollutants and early menopause in US women,” J. PLOS One 2015;10(1):e0116057
[6] MedScape April 2015
[7] European Psychiatric Association (EPA) 23rd Congress
[8] BMJ 2015; 350 :h1217
