Tag Archives: health

Lost Posture: Why Indigenous Cultures Don’t Have Back Pain.

Lost Posture: Why Indigenous Cultures Don’t Have Back Pain : Goats and Soda : NPR.

I see a lot of people with back pain in my office. There are times I think it’s the common cold of pain. Though I don’t consider things like the radio, newspapers, TV  my main source of medical information (I prefer journals like “The Annals of Internal medicine” and “The New England Journal of Medicine” and things like grand rounds [a form of continuing medical education for doctors]), sometimes I come across things like this are interesting.

Often times if something is common one might forget to ask why it’s so common.   With a lot of people developing  back pain finding ways to prevent it or treat it before it becomes chronic is important. If this theory holds up, It’s worth pursuing.

Motion is Medicine

If there was a medication that you could take that would help reduce weight, reduce the chances of developing disorders such as diabetes, dementia, and  osteoporosis, I think most people would take it. If the side effects of this medication (even in the absence of dementia, depression, fatigue, etc) were a better mood, a better ability to concentrate, less fatigue, even more people would probably clamor to take it.

There is such a medication: exercise. Some medical societies, such as the American College of Sports Medicine state that “exercise is medicine”. The current recommendations for the minimum amount of exercise is 150 minutes a week of moderate exercise. This comes out to 20 minutes 7 days a week or 30 minutes 5 days a week. Walking is an example of moderate exercise often used to give people an idea of what the effort level of moderate exercise is. One should be walking slowly enough that one could talk and not be out of breath, but fast enough that one couldn’t sing. When my patients state they can’t find the time to do 20 minutes a day, I encourage them to find 10 minute periods through the day to walk. Obviously for some forms of exercise (swimming, playing a game of basketball, etc), this would be impractical to do.

Some research indicates that exercise has an anti-inflammatory effect in the body. Other research seems to indicate increased sensitivity to insulin, increases in various other hormones (or decreases in others), it is likely the mechanism for the beneficial effect of exercise is due to more than one pathway. That is to say that rather than, say deceased inflammation is the cause for improved mood or a decreased risk of dementia, it is likely that improved insulin sensitivity, anti inflammatory effects, etc all act in concert to improve health in people who exercise regularly. When talking with my own patients I tend  to avoid talking about why it works  and prefer to talk about the kinds of exercising they could/should be doing.

Though I encourage people to do weight bearing exercises such as walking, jogging, basketball, etc, I also realize that there needs to be some accommodation. For someone who’s morbidly obese or has severe arthritis that limits, at least initially, how much they can walk I might suggest stationary bicycles, water aerobics or something like tai chi (which is a weight bearing exercise, but because one isn’t jumping around as much as with things like basketball) the stress on joints is lower. I also realize that if someone doesn’t like a particular form of exercise, that person’s less likely to do that than a form of exercise they enjoy doing. Prescribing exercise isn’t a “one size fits all” solution to promoting health.

For people who’ve read many of my earlier posts, have probably noticed that I’ve focused less on medication and more on lifestyle issues such as diet. This post is no different. Many of the most common diseases I see in the office are most commonly caused by, for lack of a better word, poor lifestyle choices.By this I mean having a poor (read “western”) diet and not exercising enough. Once one has hypertension, type two diabetes, obesity, etc, lifestyle changes might not be enough to totally reverse  or cure a particular problem in a specific patient. However even if one needs an antihypertensive, diet and exercise don’t become less important.

The Pantry Prescription

With this blog post, I realize I run the risk of sounding like one of those people that touts a new food every day or month (drink pomegranate  juice for it’s high anti-oxidant content. You’ll live to 100!! it’s the next superfood!!!!). As I’ve pointed out, when evaluating health claims for foods/pills/etc it’s probably better to evaluate the claims as how they relate to endpoints such as decreased risk for disease, death, etc. rather than take something just because it’s a good antioxidant or has other reputed health benefits.

Anyhow, if someone were to ask me what kinds of foods should I eat/have handy, here are a few things I’d probably suggest. It is not an exhaustive list by any means. Of course if one has allergies to any of these foods, then they shouldn’t be on that person’s list of foods to have:

#1) Olive Oil. This makes my list because of the health benefits associated with intake. There is an inverse relationship with olive oil intake and the risk of dementia (that is, the more you take, the lower your risk of developing dementia). I has a lot of anti-oxidants in it as well as healthy fats. It’s good for heart health as well. It is important to mention that it’s important to use it IN PLACE of other fats, not just add it to a bad diet. That is, use olive oil in place of animal fats, coconut oil and other saturated fats.

#2) Canola oil. It’s high in Omega-3 fatty acids which are associated with lower risk of death due to heart disease, dementia, etc.  It has a higher flash point than olive oil so can be used to cook at higher temperatures (and has a less strong taste which can be important with some foods).

#3) Flax seed/flax seed oil/ground flax. Flaxseed is also a good source of omega-3 fatty acids. However these are medium chain omega-3 fatty acids (as opposed to the long chain omega-3 fatty acids which are found in fish. It is the longer omega-3 fatty acids which have been shown to have health benefits). Not all of the fatty acids are converted to long chain omega-3 fatty acids in the body, but any little bit helps, and any that takes the place of fully saturated fatty acids or trans fatty acids is a good thing. Fish such as tuna, salmon, and sardines, to name a few, are better sources for long chain omega-3 fatty acids.

#4) Legumes, any combination of them you might want (legumes include peanuts, lentils, any type of bean). In combination with a cereal (e.g. rice or wheat) will provide all the essential amino acids (make up a “complete protein”). The health benefits get even better if it’s a whole grain you pair the legumes with.

#5) Tree nuts such as almonds, walnuts, cashews, etc. Though relatively high in calories – they  tend to be high in fats – they are healthy. They contain some fiber. The fats they have tend to be the healthier types of fats and tend to be high in fat soluble antioxidants. Using a handful of nuts such as almonds to stave off hunger pains can help keep someone from consuming even more calories at dinner due to hunger. And they’re better for you than sugary/starchy foods such as crackers.

#6) Eat many different fruits and vegetables. The greater the variety the better. One study showed that blueberry intake reduced the chance of developing diabetes by 40 % (however this is only one study. Whether this is close to the “real number” blueberry intake reduces risk would be determined by looking at/doing more studies). Other fruit intake also reduced risk of certain diseases, for example,  apple intake is associated with a lower risk of developing emphysema.  Rather than relying on one “super food” or whatever fruit is the fad of the day, having a variety of fruits is probably better. Each fruit and vegetable has a different mixture of antioxidants and phytochemicals. The different phytochemicals probably have different affinities for different tissues (this is my supposition here. I have no proof to back it up other than a feeling it might be the case) and by having a variety of foods, it’s likely that more parts of the body will be protected.

#7)  A variety of spices. I would put turmeric high on the list of spices to have as it appears that the curcumin (a substance found in turmeric) is a rather potent anti oxidant and anti inflammatory agent. However, I would make the same argument about spices that I make about fruits and vegetables above. The greater the variety the better.

Notice I have not put on the list meat, poultry, milk or other sources of animal protein.I wouldn’t say avoid them, unless you have a  particular cultural or moral stand on eating animal products. I only mention fish because of the healthy fatty acids some fish contain. Limiting the amount of meat one has is important for maintaining health.  However the amounts of each, frequency of using these in diet is a topic for another time.

 

The Prevention Prescription, part 3

In my previous two posts I’ve written about different kinds of prevention (eg, primary, secondary, etc as well as vaccination which is a form of primary prevention). In this post I am going to talk about a couple of different things relating to prevention.

The first is that there are preventative measures which sometimes fall into more than one category. By this I mean that if we counsel someone to change their diet and exercise more because they’ve had a heart attack, give them aspirin, a statin, etc. that we’re engaging in tertiary prevention. However if they are on their way to becoming diabetic but because of the change in diet and increase the amount of exercise they do, and therefore lower their risk of Diabetes Mellitus, then one could argue that’s primary prevention (or secondary if they have metabolic syndrome…).

I’m a firm believer in using medication to lower cholesterol, blood pressure, etc when and if appropriate. However, I think we give short shrift to diet, exercise and sleeping enough as preventative measures to prevent or delay multiple medical problems.  Even if someone needs to be on medication, lifestyle changes are important to keep up. Exercise and diet do not become less important just because someone’s started medication. One recent study published in the New England Journal of Medicine comparing intensive lifestyle changes+usual care as compared to usual care did not reduce death. However there was evidence for a better quality of life and less need for medication, at least early on. There is a lot of evidence that enough exercise and good dietary practices can prevent and delay Diabetes. And for those that are cost conscious, a half an hour a day of walking is a lot cheaper than most medications!

There is a push by some physicians to actually prescribe exercise the same way we prescribe medications. Books have even been published on the matter!!

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The Prevention Prescription, Part 2

In my last post I talked about vaccination, which is a form of primary prevention: it is the prevention of disease. There is also the concept of secondary prevention. In the case of secondary prevention, one has already has a disorder and doesn’t know it. Secondary prevention prevents the disease from getting to the point where it causes symptoms or complications (this is paraphrasing the definition on the CDC website). The example the CDC website uses is excising/taking a biopsy of a suspicious skin lesion before it becomes cancerous. Colonoscopy could also be put in the category of secondary prevention if pre cancerous polyps are found and removed before they become cancerous.

Sometimes it can be difficult to convince people to do some secondary prevention. Colonoscopy is one such item it is sometimes challenging to convince people to do. It is inconvenient as one needs to take a day off from work (if one is of working age and is working), has to have someone who’s willing to drive them home and requires taking things to clean their colon out so the colonoscopy can be done. When someone has a problem that can only be diagnosed by colonoscopy (eg: weight loss, fevers, and blood in the stool which could be a sign of inflammatory bowel disease, for example) people are worried enough about their health to get it.

Tertiary prevention is when one is trying to prevent complications or side effects of a disease which is already present. Examples of this are anticoagulation in people with atrial fibrillation, use of ACE inhibitors to prevent or slow kidney disease in diabetics.

In my next post I’ll take more about prevention and why it’s important.

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The good old days?

Medical Knowledge and technical savvy are biodegreadable. The sort of medicine that was practiced in Boston or New York or Atlanta fifty years ago would be as strange to a medical student or intern today as the ceremonial dance of a !Kung San tribe would seem to a rock festival audience in Hackensack. – Lewis Thomas

When in medical school (and after) a common quote is that 50% of what you learn in medical school will be obsolete in 5 years. Sometimes it even feels like things come and go out of fashion however. I’m old enough to have seen theophylline come in and out of the lineup for treatment of asthma/reactive airway disease (at least to some degree) a few times. When I come across quotes like the one above, several thoughts come to mind.

One thought is what my grandfather would think of medical practice in the twenty first century. He went to medical school in the 1930s and got interested in Urology while serving in the Army during World War II. He retired in the mid 1970s. He lived until the 1990s, long enough to see me graduate medical school. When he started, there essentially no antibiotics, no antihypertensives, no real way of treating cancer other than surgery (I would have to check to see when radiation began to be used for treating certain tumors). Some early antihypertensive medications actually had to be started in the hospital for patients’ safety. Vaccination for smallpox and for Rabies were the only (or two of the few) vaccinations available. Diseases such as Polio, Measles, Mumps, Rubella, Influenza and  tetanus killed/disfigured/disabled thousands of people if not tens of thousands or millions worldwide yearly (this is something people who are anti-vaccination seem to forget as Smallpox has been eradicated, Polio, Measles, Mumps and are thankfully rare. I have never seen someone affected by pre natally affected by Rubella).  I have a whole host of medications to treat hypertension, diabetes, varicella, bacterial infections and so forth that my grandfather’s generation of health professionals could just dream about.

Secondly, the business of medicine has changed drastically as well. I have heard stories as to how patients paid him with vegetables they grew in their own gardens. Though I won’t say much more here (it’s not germane to this particular blog post).

Thirdly,  sometimes people will say that we can’t seem to make up our minds as to what’s good for people or bad. For example, for years eggs were made out to be bad for us because of the amount of cholesterol in them. Now, they’re ok to eat as part of a balanced diet (though like many things, you can have too much of a good thing…). It’s just that as we learn more, the message about things gets more nuanced. Eating fats in your diet isn’t bad, though you can have too many of the ‘bad’ kinds of fat. Not all carbohydrates are bad: Too much refined sugar is bad, complex carbohydrates (as in FIBER) are good. This also can be seen in what medications are considered first line for treatment of certain diseases, sometimes a new(er) medication is better to start with than an old, more established medication. Other times, an old medication can treat a disease just as well as a newer one.

Secondarily to this several thoughts come to mind. One is that with all the
medications available for almost every conceivable disorder, we  – and I mean both doctors and patients – forget that we shouldn’t rely on a pill to fix everything. In the case of things like Type 2 Diabetes, prevention by diet and exercise will do far more than pills or injections can. Of course there are people who’d still develop Type 2 Diabetes, so for those who’d say “well my uncle/father/neighbor/etc did everything right and still developed DM-2 (or hypertension or whichever disease you’re talking about that can be prevented/delayed or modified by diet)…” I would use this analogy. We lock our car doors when we park them. When we leave our homes we lock the doors. In both cases peoples’ cars and homes still get stolen or broken into. Sometimes we  forget that some of the tools available to my grandfather’s generation are still just as valid and useful today: it’s that  we know more about how diet and exercise  work than they did. I think, however, doctors and patients sometimes miss that for the allure of taking a ‘new or improved’ medicine because its “more modern” than the old fashioned way of doing something or that it’s just easier to take a pill than it is to count calories and exercise more or do some exercises to help reduce a symptom such as back pain.

When I was in medical school my grandfather remarked how everything in the New England Journal of Medicine was about immunology and antibodies. As I read the the New England Journal, I am beginning to get the same feeling, though  now I’d say it’s all about genetics as there are more articles about DNA and genetic mutations. In several cancers, specific mutations and chromosomal changes have been targeted as they lead to a gain in function (or lead to a protein being produced constantly rather than being produced in a regulated fashion). Knowledge of this has led to some medications being developed that are less toxic than what’s usually used for cancer. How this will affect the treatment of other diseases remains to be seen. Will Asthma, Hypertension and Rheumatoid Arthritis be treated someday with medications that block whatever the root cause is, or perpetuates the disease? Only time will tell.

If someone were to ask me if I’d rather be a doctor now or when my grandfather started his practice, I’d have to say now. I can do a lot more for my patients than he could when he started. It also means however, that keeping up with changes in what we know or think we know about how best to treat patients I think is harder because of the sheer volume of things to read and keep up on is larger. Even if it means I’m accused of ‘flip flopping’ because new recommendations and papers seem to point in a different or opposite direction from what was said before. This is why physicians keep up with what’s new in whatever specialty they’re in. It’s the price we pay for 50% of our knowledge becoming obsolete every few years.

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Four of the best things to do for your health.

Correlation between smoking and lung cancer in...

Correlation between smoking and lung cancer in US males, showing a 20-year time lag between increased smoking rates and increased incidence of lung cancer. (Photo credit: Wikipedia)

Four of the best things to do for your health.

1) Don’t start smoking. Stop smoking if you’ve already started.

 If someone asked you to pick up a habit that increased the risk of all of the following (and would cost you roughly $33-77 dollars a week depending on where you live, brand, etc), would you do so? Here are some of the things that smoking increases the risk of: lung cancer, colon cancer, bladder cancer, esophageal cancer, kidney cancer, pancreatic cancer, cervical cancer, vascular disease including aortic aneurysms and strokes. It increases the risk of fractures in post menopausal women. It increases the risk of low birth weights in infants. There is an increased chance of developing cataracts. For men in their 30s and 40s, it increases the risk of erectile dysfunction by 50%.

According to the CDC, smoking contributes to 443,000 deaths annually in the U.S.

2) maintain a healthy weight.

obesity raises the risk of multiple diseases: Diabetes Mellitus – type 2, high blood pressure, colon cancer (though the mechanism isn’t known how). It increases the risk of breast cancer (adipose tissue has an enzyme that converts testosterone to estrogen), osteoarthritis and more. There are no easy ways of doing this. At its simplest it means taking in the same amount of calories you expend. Granted if you’re overweight, you need to expend more calories than you take in.

3) Exercise

On top of helping maintain a healthy weight, excercise has many beneficial effects. Exercising reduces the risk of alzheimer’s disease, some cancers, it can improve mood, helps reduce blood pressure and can help prevent and treat diseases such as type 2 diabetes.  The suggested minimum is 150 minutes of moderate physical activity a week, which comes out to approximately 20 minutes a day. It can be something as simple as walking. The what of exercise (what kind) is less important than the regularity of actually getting exercise.

4) Have a healthy diet.

Potential health benefits of apple consumption...

Potential health benefits of apple consumption. (See Wikipedia:Apple#Health_benefits). Model: Mikael Häggström. To discuss image, please see Template talk:Häggström diagrams (Photo credit: Wikipedia)

Diet is the mainstay treatment in a lot of diseases. Whether it’s DM-2, high cholesterol, coronary heart disease (even if you’re on medication for any of these, maintaining an appropriate, healthy diet becomes no less important). In one study coming out of Lydon, France (known as the Lydon Study), people who were put onstandard treatment and who were switched to mediterranean diet with N-3 fatty acid supplementation (as opposed to just the  standard treatment) decrease their mortality after a heart attach by 66% (their mortality went from 17% down to 10%). This was independent of weight loss, decrease in cholesterol, etc. A dietary/lifestyle program promoted by Dr. Ornish which uses lifestyle changes, exercise and a vegetarian low fat diet (10-20% of calories from fat rather than the 20-30 used in the AHA step II diet) has been shown to reverse Coronary Heart Disease and is covered by medicare. A mediterranean style diet is also associated with decreased death from heart disease, a decreased risk of certain cancers as well as a decreased risk of dementia. At this point I won’t go into a huge discussion about diet (I’m likely to blog more about this in the future on multiple occasions).

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resiliency

Resilient:

(of a person or animal) able to withstand or recover quickly from difficult conditions.

DERIVATIVES:resilience noun, resiliency noun, resiliently adverb

It’s taken me a bit longer to do this post than I originally had hoped it would. Given the events in Boston this past  few weeks, this word resilience has been going through my mind a lot. Though it did also go through my mind due to other recent events as well (Newtown CT, Aurora CO among others). I do not want to sound as if I am medicalizing whatever caused the people who killed and maimed over 170 people. However, being the optimist that I am, I think people’s basic makeup is to be nice to other people and have a “live and let live” attitude to others that they disagree with or have no particular connection to.  I sometimes wonder what happened to people that would drive them to commit such acts of horror, that overcomes whatever resiliency that would otherwise keep them functional, reasonably happy people.

As a practicing physician I often get to see a side of people that they don’t often show others. There are the people who have gone through whatever traumas life has presented them and are married, have children and work. Others don’t seem as lucky, as if somehow given the same number and intensity of  shocks to their system used up whatever resiliency they have. They seem to go from moment to moment as if their lives are going to collapse. Anxiety seems to seep from their pores when they come into my office.

I have no answers as to why some people are more resilient than others. Often people who grew up in tough situations (few resources at home, single parents, drugs/violence in the neighborhood) make the news for getting into Harvard, Yale or some other school and “made it”. Was it that their parents and teachers helped them stay resilient. What about the people who are mirror images … they have caring parents who model being nice, giving to others, tolerance, don’t have  to worry about where if they are getting their next meal and where it’s coming from but somehow end up being unable to say no to whatever demon (now I’m speaking figuratively here, not literally) overwhelms whatever their resiliency can handle and they end up having issues (for lack of a better word) with drugs, violence or whatever.

Perhaps this will be my only foray into making any sort of commentary on society or sounding like I’m living in left field (or perhaps the peanut gallery) but: perhaps in addition to the three ‘Rs that are taught in school, Resilience should be added as a fourth R. Does it need to be  separate class? Probably not, life doesn’t happen in discrete blocks (I don’t spend one hour doing math, another hour ‘doing’ history, another ‘doing English’  i.e. reading writing, explaining things to people either verbally or in writing, and so forth)  and some things in school shouldn’t  either. Just learning that a bad grade in one test or class doesn’t mean the end of the world. Nor does having difficulty with one class or multiple subjects if given the skills/help in figuring out what helps someone learn. Ideally it’s something people should learn at home.

For something that affect health and quality of life, resilience is probably underrated. It is not the cure for all ills (if one is resilient, it doesn’t make one immune to getting cancer, diabetes, hypertension, etc). I suspect those who are more resilient are more able to deal with any chronic illness they might have and are more likely to take medication (if needed), follow up with any lifestyle changes that would affect their health (diet and exercise don’t become less important in diabetics once they start medication).  Would someone who’s resilient be less likely to do something that the  bombers did, that I don’t know. The answer to that, I leave to the psychiatrists, public health officials, philosophers, and those who actually do research in the area.

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Evaluating health care claims

In some ways this post is a continuation of my previous one titled “…because it’s natural”. In a lot of diseases such as DM-2, Alzheimer’s, and heart disease, there are multiple mechanisms that contribute to either the disease itself or to it’s complications. Two mechanisms of disease that seem to get a lot of space on TV, print and on the internet is that of inflammation and oxidation. Whether it is someone promoting a “super food” that has a lot of antioxidants in it (or a lot of anti-inflammatory activity), or a pill that has plant extracts in it that reduce oxidation or inflammation, the claims should be  taken with a grain of salt. For example in some cases, there may be multiple good studies that show taking said supplement does act as good antioxidant. However this doesn’t mean that the supplement will improve one’s health or lengthen lives. This is a problem with using what’s called a surrogate endpoint. Don’t get me wrong, using surrogate endpoints can be useful when the more significant and relevant endpoints are things to be avoided (death or disability for example) or might not happen for years  – I don’t think a study that would take 30 years to start showing something works would get funding – or finding enough people to study would be practical. It helps if a change in the surrogate endpoint has already been shown to be related to reduction in a particular disease’s morbidity or mortality.There are also observational studies that show certain things (high vitamin A levels, higher beta-carotene intake) are associated with lower levels of a particular disease state. Sometimes using a surrogate endpoint  (or  noticing an association between two things such as high levels of vitamin A and lower rates of a particular disease) ends up leading to people doing negative studies. For example, many deaths after a heart attack are related to arrhythmias. A study called the CAST (short for Cardiac Arrhythmia Suppression Trial) showed  higher mortality in people who were on anti arrhythmia drugs. It doesn’t mean that the drugs didn’t have a role in other disorders. I have a feeling it means that we were just asking the wrong question (even though it needed to be asked and answered) about treating arrhythmias after heart attacks. I use the example of the CAST study to make the point that showing something changes the level of something (either up or down) that is thought to be involved in causing disease – be it inflammation, oxidation, arrhythmia or otherwise – doesn’t mean it affects the disease it is said to. It may be that to treat a disease with anti-inflammatory medications (or substances), one also needs to block other pathways of that disease as a well for any to be effective. This is why most cancers are treated with more than one drug. This is why people are often on more than one blood pressure medication. As I mentioned in my last post, any claims should have data supporting that they work. The results should be reproducible, hopefully other by other researchers. Getting back to my original assertion from the start of this particular blog post, if someone is touting a “superfood” for health, It is appropriate to ask if it actually improves health, decreases complications, etc. In my opinion, just to say something is a “super food”  because it is a ‘super anti oxidant’ is blowing smoke.  That isn’t to say that anti-oxidant rich foods don’t promote good health. There are too many studies that are negative that to look at one thing and say “this is the holy grail of food”. This also undersimplifies things too greatly. It’s better, in my opinion, to say “these are the types of foods/eating (or habits if one is talking about other aspects of lifestyle) that are associated with good health. For examples, many of the studies that show that olive oil intake is inversely related to cognitive decline are more agnostic about what role each component in olive oil plays, despite showing benefits. Is it the kinds of fatty acids in olive oil? Is it the polyphenols that act as antioxidants?  Is it the anti-inflammatory chemicals in olive oil? I suspect the answer is yes, it is all three. Is it the answer to everything: just have olive oil and you’ll live to 100? I doubt it. My bottom line on health care claims:

Be critical but open minded: ask the following questions: “Does it actually affect or prevent disease? Does it decrease complications of the disease and not just something thought to be associated with disease or complications thereof?”. If the answer is “yes, it does reduce _fill in the blank_ and there is a proportional reduction in the amount of deaths/strokes/people going on dialysis/etc then you have a winner. IF the answer is “it does reduce _fill in the blank_” but there is no reduction in _fill in this blank as well_” it may mean that the answer is more complicated than we think. It may mean that the wrong question(s) were asked, or the right ones hadn’t been asked.

Also be wary of claims that make a product or procedure seem that it’s THE ANSWER for a particular disease. It may be a piece in the puzzle, but in order to be considered as such, the answer to the question ‘where’s the proof’ should be along the lines of “here are the studies…”

If the person makes statements like “doctors are in the pockets of ‘big pharma’ and aren’t interested in curing disease”, then be wary. I think most doctors get into this business to make people better. If there was a pill that taken once or twice cured someone of his or her type 2 diabetes (and did not cause some other severe life threatening disease), I think most doctors would use that pill.

Also ask if this the first study of something? Often a treatment is found in a study to be helpful. The numbers of people may be small. Due to the nature of studies, the participants are typically more homogenous than the population as a whole. Once larger studies are done, the benefits of a medication/procedure, etc may not be as large as initially thought.

Another question ot ask is this better than what we have now? Though it could be asked of a new medication, I’m primarily thinking here of new surgical procedures (eg, robotic surgery for certain things). If offered ask: is the rate of complications less with the new procedure? Is mortality less? Is the recovery time quicker with the new procedure?

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… because it’s natural.

I think with this post I am going a bit off topic (or at least getting on a soap box for a bit). Occasionally a patient will say that they don’t want to take a medicine because they want to try other treatments first, like loosing weight or exercising, if,  for example, they were just diagnosed with adult onset diabetes (also known as Diabetes Mellitus, type 2). Now if their numbers (eg, a glycosylated hemoglobin) that is at or near goal for a treated diabetic, that might not be an unreasonable approach. After all, even if someone is put on a diabetes medication, anti-hypertensive, etc, diet and exercise don’t become less important in treating whichever disease they have.  What concerns me at times is if the reason someone doesn’t want medication for a treatment is because the medication is “not natural” and that they want to try something that is derived solely from natural products.

Now on one hand this might not be totally unreasonable in that many common medications are derived from natural products. Think of aspirin and penicillin (the latter produced by fungi known as penicillium).   Streptomycin is another drug initially derived from a natural source. Digoxin/Digitalis is produced by the Foxglove Plant (which was used to treat what we now call congestive heart failure.  Digoxin and digitalis are still used at times). Morphine is derived from Poppies. The list goes on. As I don’t work for a pharmaceutical company, I don’t know how many of these medications are 100% man made vs being derived from plant sources. Given that a pill has a known quantity of a known medicine, I’d rather take that than risk a stroke or some other complication. My biggest issue is someone wants to take a  supplement to treat a disease “because it’s natural” and because “it’s safe”. I want to see the proof that it works before I’d recommend it. Note, if we’re talking about a disease that won’t kill you tomorrow, or next week, I try to be open minded if a patient wants to try something else first.

Having said that, when someone’s reason for wanting to use an herbal treatment, a supplement, etc to treat a disease because natural products are safe/safer than medications, I am apt to give them a list similar to this: Carbon Monoxide, Snake venom, Radium, Ricin, Atropa Belladona (nightshade), Botulinum toxin, etc. Aside from being toxic, they are all natural products as well. It is my way of hopefully, and gently, pointing out that natural doesn’t always mean safe or non toxic.  If someone is hawking a natural product as a “cure” for something, it’s reasonable to ask the following questions:

1) Is it safe?

2) Does it work? What is the proof that it works? For medications it’s multiple trials that are reproducible and show (usually) a clinically significant difference in cure/length of disease/significant decrease in morbidity or mortality. In some cases it is a change in a surrogate end point. Do the natural products have the same level of proof? Of note, a celebrity spokesperson or the fact an infomercial exists isn’t proof. In my mind if someone is saying that “studies show…” then they should be able at some point to tell you where to find the studies, or provide the references themselves. Obscure or non peer reviewed journals don’t count. Nor should there only be one study showing benefit (it should be a really compelling article if there is only one).

3) What are the alternatives?

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