Naturopath challenge--follow up

I almost stopped reading at "I recheck his vitals and his BP is lower, 140/82, which is okay for now." But I did read on.

What troubles me is that PalMD's approach is exactly what should be done, and the diagnosis and treatment is, if I can say this, kind of easy to outline. That the ND failed to even get the basics right kind of proves the point.

And I keep scratching my head about these "dietary change" recommendations that are so common with CAM pseudoscience. Setting aside the patient's adherence to these diets (I'm not holding out much hope that a 65 year old overweight smoker is going to change), the difference that diet can make to blood glucose and hypertension is relatively small. Both need to be treated aggressively (with the caveats you stated above).

These type of stories are just so frustrating. I'm going to scream.

It's scary to think that anyone with a disease as serious as either type of diabetes would actually take a naturopath's advice over a real MD's.

Dr. Bernstein and his recommendations are VERY controversial in the diabetes world, FYI. Here's a sample thread from a popular diabetes forum:

http://www.diabetesdaily.com/forum/food-diet/1158-dr-bernstein

Yes, he's had type 1 (as do I) for 65 years, but his recommendations on A1C--in the 4% range--are extremely low compared to the AACE/ADA standards (6.5-7%). He also advocates eating no more than 30g carbs per day and thinks the occasional ketones in urine are acceptable (um, no...!). Fruit and bread are also 'banned' substances according to his book.

Oh, and is there any such thing as a 'diabetologist'? I thought D-specialists were always endocrinologists...

Well done sir - I've sent this to a few people in my class as a quick and dirty review...
Just a couple of quibbles

By the way, a CMP includes LFTs

Is that standardized? Beacuse when I was on family practice, the CMP included ALT/AST but not T/D bilirubin, total protein or albumin.

drug-eluding stent

I realise its silly - but isn't it drug-eluting?

What I love about this post is that PalMD is so methodical. I hate seeing scatter brained, disorganization in medical thought. It's that kind of sloppyness that leads to problems.
Kudos on the awesome example!

Yes, it's "eluting"

A key to the acronyms would be helpful. I know some of them but not all of them.

I perhaps somehow missed this in the discussion here and on SBM, but is there actual legislation pending somewhere that would classify naturopaths as PCPs?

Good point, MM.

yes, there is in several states a movement to license n-paths to allow them to function like PCPs.

Certain acronyms:
PCP--primary care physician/provider
CMP--comprehensive metabolic panel, a set of labs that usually includes electrolytes, kidney function, and liver tests (LFTs)
BMP--electrolytes plus kidney function

HbA1C--glycosylated hemaglobin---a reasonable snapshot of diabetic control over a 3 month period, assuming a reasonably healthy population of red blood cells.

LDL--Low density lipoprotein, or "bad" cholesterol.

BTW, i'd like to echo some of the commenters' praise for the n-paths who have commented. It does take guts to knowingly walk into the fire.

I teach this stuff for a living. It's my job to know it cold, to know the data.

--and perhaps, depending on the details of his stent, Plavix.

The questions I kept wanting to ask include what sort of drug eluting stent was it? Taxane eluting stents require a longer time on plavix, if I remember correctly. Also has he bled? Or thrombosed? Either might change your management.

I'm not at all convinced about the value of a PSA. The current guidelines are category I for a 65 year old man. Unless there were a particular symptom (in which case it becomes case finding not screening) I'd be inclined to forget the PSA. However, if you want a PSA done, you should get it before the DRE since DRE can increase PSA values.

An attempt to license NDs in Florida (again, they were licensed until 1959) was defeated in 2006. I hope they don't try again. Unfortunately, Florida licenses acupuncture, which is defined as "a form of primary health care, based on traditional Chinese medical concepts and modern oriental medical techniques . . ."
Chiropractors are allowed a scope of practice that is about as broad as that of a primary health care MD, except that they can't do obstetrics or prescribe medications.

Agree with all you say, with one small modification:

dilated eye exam done by an ophthalmologist or optometrist

I make sure to specify to all my diabetics to see an ophthalmologist rather than an optometrist.

Any particular reason?

Optometrists are terrific at measuring people for corrective lenses.

For people in whom I suspect serious medical problems, i like them to see an MD who can diagnose and treat diseases, and can catch things I miss.

I've had ophthos catch occult carotid disease, giant cell arteritis, etc. They have more of a big picture.

"By the way, the drug regimen which he will likely need will cost him approximately (minus the plavix) $18/month."

And what would the naturopath's regime cost him? All those vitamins, minerals, fish oils, herbs, and accessory nutrients (whatever those are) aren't free.

First some disclosure: I'm an optometrist in Australia.

Saying that optometrists are terrific at measuring people for corrective lenses is a bit like saying saying general physicians are terrific at measuring blood pressure - it's the truth, but nowhere near the whole truth.

There's a solid evidence base for optometrists' involvement in the detection of diabetic retinopathy. Here in Australia our national diabetic retinopathy guidelines (prepared by the National Health and Medical Research Council) recommend screening by optometrists. This recommendation was based on the evidence for accuracy, as well as better accessibility & cost, partly due to insurance arrangements here (ie. optometrists were just as accurate as ophthalmologists in detecting DR, and were more accessible). There wouldn't be a day when I don't examine a couple of diabetic patients referred by their medical practitioners.

As for carotid disease & giant cell arteritis, I've picked both up in patients plenty of times. I'd encourage you to talk to some optometrists - you might be surprised to find that they do a lot more than you thought.

I'm not at all familiar with the Australian system.

Tsu Dho Nimh wrote:

"and what would the naturopath's regime cost him? All those vitamins, minerals, fish oils, herbs, and accessory nutrients (whatever those are) aren't free."

Much dinero. All sold out of the NDs dispensary, most likely. Don't forget a homeopathic remedy as well.

But, rest assured, according to the CAND [the Canada ND org.], two of the best reasons for ND care is that their Tx. is

(see http://www.cand.ca/index.php?38 ):

"safe and effective [..and] research conducted in the United States on the cost-effectiveness of naturopathic medicine has demonstrated the significant savings to be realized by individuals, insurance companies and the health care system in general."

Of course, they are the same people that state that a figment and a scientific fact are the same thing.

So, did they make up that blurb or what?!?!

-r.c.

I'm pretty sure I could have done better than the ND and that's kind of sad considering I'm a third-year undergrad. At least I knew all the medications the patient needed to be put on.

I'm not at all familiar with the Australian system.

You should become familiar with the American system, in which Optometrists do a whole hell of a lot more than 'measure people for corrective lenses'. The OD I am married to sees about 200 patients a month, and during a 40 minute exam can conduct a number of assays on vision, general ocular and systemic health. He probably refers 6 patients per month for ophthalmological follow-up of some kind, and a subset of those are sight-saving calls on his part. His diagnoses and referrals are often the first indication the patient has any kind of systemic disease. He also regularly co-manages post-operative patients in his practice, in concert with ophthalmologists, and is certified to write prescriptions. All of this falls under the Optometric bailiwick--the scope of his practice, is not unusual, by any means.

You are absolutely correct that DR should be treated/managed by an ophthalmologist, but your insinuation that a well-trained optometrist couldn't or shouldn't be trusted to catch health problems that affect vision or retinal anatomy in some way is uncharacteristically dismissive, and smacks just a tad of medical elitism.

respectfully,
JBP (I'm converting from the Danio handle)

My question is, what do ND's think they offer that an MD doesn't? Why should this hypothetical 65yo man even consider seeing an ND, if the best he can hope for is that the ND might give him the same standard of care as an MD? (Especially if the ND visit may not even be covered by his insurance!)

Is it really just for the extra recommendation of supplements? Any ND's willing to explain?

Thanks, Jennifer, you've given me something to think about and investigate.

While I agree with your recommendations regarding DM treatment in this case, it is also important to acknowledge the role of nonpharmacological interventions which you did not mention. Pick any oral medication for DM2 and if you are lucky you might get a drop in a1c of 2% (1% is more likely). If your are treating an obese junk-food couch potato, you could get a much bigger drop in a1c with changes in diet and exercise than with any pill.

One valid complaint most patients have about MDs is their tendency to use their prescription pad first. Certainly many people would rather take a pill every day and continue their less-than optimal habits. In the short term it is easier for both parties.

There is plenty of evidence about life style interventions that work (e.g., the DASH diet), in properly motivated individuals. Naturalists are simply trying to take credit for lifestyle interventions MDs sometimes fail to emphasize...their so-called "wedge" strategy.

Pal wrote "BTW, I'd like to echo some of the commenters' praise for the n-paths who have commented. It does take guts to knowingly walk into the fire."

It really should not take guts if one already claims 20+ years of experience. Lots of NDs should have posted (except, I don't know how many would even look at a medical blog such as this).

qetzal asks a great question. I have heard of chiroquacks who ask their customers inane questions and then inquire "Has an MD ever asked about that?" In order to make a case that they go beyond medicine.

My question regards the following:
"For this patient, his goal systolic blood pressure is less than 130 mmHg, his goal LDL less than 70, and his goal A1C less than 7.0"
I am neither a naturopath nor a physician so my may seem ignorant but how well based are these targets in EBM?
Is it possible that "evil pharma" is influencing these targets in order to get more people on their drugs than necessary?
For example, how big are the benefits of lowering LDL from 90 to 70 if we consider the side effects of the drugs as well?
I have heard these claims several times but never had the time to look into this.
How can I answer to this claim with EBM?

beebeeo, your question depends on what is your goal of treatment. If you seek to maximize length of life with minimal serious problems, PalMDs recommendations are the way to go. But there are always people for whom the side effects and risk outweigh the benefits....that's the art of medicine

The evidence for these goals is very, very well supported.

"As a naturopathic diabetic expert"

Upon what does "Mona" base this? She is, as usual, a self-proclaimed "expert". Delusional thinking.

As you have already stated, she could not even sit for the board exam in Internal Medicine.

Run away, fast, if you value your health.

If you want to see an example of evidence based guidelines, with ratings of evidence by quality, go here.

This is frustrating to me. From a pure economic consideration, Mona's naturopathic recommendations will not effectively treat the patient, which will lead to real physicians employing more expensive treatments and procedures to help this patient. What if it were a 50 year old presenting with these symptoms? What's the long-term cost to the patient and to his insurance plan if he delays proper treatments for years?

Attacking hypertension and Type II diabetes early has a huge long-term benefit in economic costs, let alone an improved life.

I hate saying this, but how moral is it for a naturopath (I will not use the term "doctor" with these individuals) to be involved in real health care? "Do no harm" seems to be lost here.

"Do no harm" seems to be lost here.

As understood by many, primum non nocere ignores opportunity cost.

"We don't want to expose you to the risks of those evil Big Pharma drugs" is not a justification for refusing immediate effective care to a cyanotic asthma patient.

NB: should Our Most Excellent Host ever wish to do this again, I'd love to see some not-quite-ER cases. Or another: a patient's orthopaedic surgeon send hir to you for a pre-surgical clearance. What do you need to do to make a decision?

"One valid complaint most patients have about MDs is their tendency to use their prescription pad first. Certainly many people would rather take a pill every day and continue their less-than optimal habits. In the short term it is easier for both parties." (from delaneypa's comment)

It is not really a valid complaint, though. MDs do prescribe drugs, and they also advise on changing "less-than optimal habits" of their patients. Altmed philosophy has infiltrated culture so much that there is a popular notion that it is one or the other, either Rx OR "lifestyle changes" (which often, ironically, include lots of supplements). But evidence shows that medicine has FAR more impact on lowering morbidity and lengthening life than does changing your diet and moving your ass more at middle age.(I don't assume that delanypa meant this, but it is a good example of the "argument" common in altlandia.)

And even if it IS "easier" for the patient "in the short term", what the heck is wrong with that!? At least SBM gives the patient a much better chance at getting to have a long-term now. Altmed, especially naturopathy, is philosophically stinky with puritanism, with tacking on a moral dimension to illness. I fail to see what's wrong with a person taking the meds, maybe tweaking "lifestyle" factors and getting on with their lives.

I know this is a simplistic question, but it's food for thought: Would I rather take some well-tolerated, well-studied RX and play with my great-grandchildren or follow a grueling, boring regimen of extreme diet and exercise (and supplements!) and die before even my grandkids can know me? Call me lazy? BFD sticks and stones.

Move your ass and your fork moderately and - most of all - take your meds.

I really don't understand the charge that MDs "just prescribe pills," rather than what woo-meisters supposedly do (treat the patient, increase wellness, practice holistic medicine, yadda yadda yadda).

I only have my own anecdotes to go on here, but literally *every* doctor I've ever seen has asked about and encouraged the following: don't smoke, don't drink to excess, don't do drugs, don't have unprotected sex, get lots of exercise, and eat well. I'd even say they sometimes do this to a fault! Once, I was in the ER waiting to get stitches over my eye, and they took the time to ask these questions TWICE because the new computer system crashed. I was stemming the blood loss from my face with my softball teammate's sweaty jersey, and those "non-holistic" MDs made me doubly insist that I was exercising and using condoms before they sewed me up.

Am I just lucky to have had good doctors? Or, is this yet another straw man from pseudoscientists? I like the comment that emphasizing this treatment is CAM-proponents' "wedge strategy," but I think it's ultimately just as vacuous as the ID-proponents' claims.

PalMD,

Good job with listing the typical MD treatments for cardiovascular indicators. If pharmaceutical medicine, in the absence of good nutrition and regular exercise, were so effective, why is heart disease still a leading killer in America? This is despite almost everyone with CVD being put on a regimen such as yours.

There is a reason that more and more patients are becoming interested in non-drug approaches. It doesn't take a genius to realize that eating a balanced, nutrient rich diet and exercising regularly can improve majority of acquired health problems like CVD. The alternative field did not invent this approach, nor do they claim to -- they have simply taken up the slack where MDs have left it in favor of prescription meds.

Yes, presciptions are easier and cheaper to prescribe. But often, they are an attempt to undo the damage that the patient constantly inflicts upon themselves. It seems that a growing number of patients are realizing this, and are becoming more interested in actually learning how the body works, and how to approach disease using this knowledge. This is why they are turning to NDs, acupuncturist and doing more personal reading about health then ever.

Naturopathic doctors (sorry, MDs don't have a copyright on the designation) are thoroughly trained in nutrition and physiology. And guess what, they are very successful at treating the most common chronic diseases, such as CVD. Part of it is that patients who go to NDs are extremely motivated and are more likely to be compliant with lifestyle adjustments.

For patients who don't want to change, or cannot for whatever reason, pharmaceutical medicine is great, and even lifesaving. But it is not the only way to correct disease.

#26 Could you please cite the research that supports lowering LDL from 90 to 70 as increasing length and quality of life?
Mona at least bothered to cite some references for her treatments. If this is a forum about evidence, it would be nice if all sides (especially the host) followed suit, making this more than an opinion site.
Thanks.

Thanks PalMD
looks like an excellent paper.
I'll be more confident fro now on to declare that recommendations are sufficiently based on evidence and not a desire to make more and more people eligible for pharmaceuticals even though benefit is getting less and less and the evidence gets more and more unconvincing.
As I am doing a PhD in basic science and I am not a medic I had never actually seen publications like this one.
I do have to note however that more than half of the authors have research grants from, are advisory board members of or get speaker honoraria from at least one but usually several big pharma companies.
Especially as my exapmle 70 vs 90 mg/dl LDL-C is concerned, I am not convinced.
In both references that are cited to support 70 vs 100, the authors conclude that the further reduction had no significant impact on overall survival (death from all causes) The p values are p=0.92 and p=0.81. Not even a trend. I personally would be skeptical if there is not even a slight reduction in overall survival.
Thanks again

Okay I just posted my thoughts in the original and I missed beta blockers and was wondering if plavix was eluted from the stent or if it was something else. Oh and I said opto when I meant Optho, not bashing on optometrists, but I meant optho.

A question for you, how likely is Abdominal Aortic Aneurysm in smokers (or past smokers) over 65 with 40+ pack years?
Thanks for the great post PalMD. I am bookmarking you as one of my daily reads along with Orac

Grow, you're making the assumption that doctors don't prescribe balanced diet advice along with drugs.

If pharmaceutical medicine, in the absence of good nutrition and regular exercise, were so effective, why is heart disease still a leading killer in America?

So in your perfect world, what would the top ten causes of death be? Gunshot wounds? Falls from horseback?

There are four million kids born in the USA every year. Over time, that many will also die, and there will always be a top reason for it, and there will always be someone making political points about how shameful it is that we haven't done anything about the #1 killer.

Well, have a look at the top ten from a century ago and get back to us.

#30 "Do no harm" seems to be lost here.

It has long amused me that NDs claims usually include "First, do no harm" as the second or third item in their creed.

Something many people seem to be missing in this case is that (per the original post) the patient is not obese. His weight is only about 145 lbs. As such, there is precious little weight loss can do to help mitigate his diabetes and cardiac issues. The guy NEEDS drugs, stat!!!

(Always wanted to say that. ;))

First, the Pharma Shill Gambit is not welcome here. Just because someone has received some support from [insert perceived evil source of support here] does not mean that the results are tainted. When results are repeated over and over from multiple studies and authors, it lends them legitimacy. Yes, there have certainly been abuses, but that is why we insist of reproducible results. Also please not that the avg cost to a patient for a statin is about 4.ooUSD/month.

Anyway, intensive lipid lowering for secondary prevention (and even primary prevention per the JUPITER trial) in those with CAD or CAD-equivalents such as diabetes were at first controversial among physicians, but has now been pretty well validated by numerous studies.

doi:10.1016/j.jacc.2005.02.080
doi:10.1016/j.jacc.2005.04.064
http://content.nejm.org/cgi/content/abstract/352/14/1425

It is not that one single biased source has produced data, it is that the totality of the evidence shows this.

Another question regarding the 100 vs 70 LDL-C is the number of patients needed to treat. From what I see you need quite high doses of statins to achieve that and a small percentage of patients does not seem to tolerate such doses. How many patients do you need to treat in order to save one patient from death from CHD.
I am definitely not on the side of the alternative "doctors" but I am really interested in how such recommendations are decided on and how they decide whether it is class I, Class IIa or class IIb. The same is true for the level of evidence (A,B or C) in the recommendation. From a non-expert understanding of reading the guideline, the classification does seem a bit arbitrary.

On the other hand I could understand that in some cases it might be unethical not to use treatment, even if there is disagreement on its usefulness. As long as the weight of evidence tends to support a treatment then that is the best evidence we have and we should use it.

We also need to take into account that there have been enough incidences where pharma companies have tried to suppress knowledge of side effects (it might not be the rule but we shouldn't pretend it doesn't happen at all) and that more favorable trials are more likely to be published. We should also note that broadening the criteria to make more patients eligible for statins means millions of people taking those drugs almost permanently and this translates to billions of dollars for the drug companies.

I am still overall in favor of EBM and remain convinced that CAM is dangerous but we should still remain skeptic, both on CAM but also on pharma companies.

I really don't like getting into a fight about this but lets review the papers you cited:

doi:10.1016/j.jacc.2005.02.080
This paper only uses surrogate markers (LDL-C and CRP), not
overall survival

doi:10.1016/j.jacc.2005.04.064
In this paper the p value for the outcome DEATH is p=0.56 (far away from being significant)

http://content.nejm.org/cgi/content/abstract/352/14/1425
This is the one that I had looked at earlier. quote from the paper: "The risk of death from any cause also did not differ significantly between the two drug regimens (hazard ratio, 1.01; 95 percent confidence interval, 0.85 to 1.19; P=0.92)"

Using surrogate markers/outcomes instead of the arguably most important one (Death) is not necessarily always wrong but it has to be justified and subsequent trials with longer median followup have to prove the benefit.
IMHO, the publications you cited are not conclusive on this.

I concede that it was most probably wrong to say:"this translates to billions of dollars for the drug companies". It is probably quite exaggerated. However, they do make a lot of money with it.

If you think that the speaker fees and advisory board money given is irrelevant, then please read this
http://scienceblogs.com/ethicsandscience/2009/04/sniffing_out_bias_in_a…

I will continue to be a fan of your blog.

I'm not sure it's appropriate to compare best case scenario medical care with some random naturopath off the street (er, internet). I'm pretty sure a minority but still not good percentage of the practicing PCP population -- the ones who really wanted to do something else and were last in class, the ones who really wanted to do something else but are FMGs, the ones who are totally ground down by whatever assembly-line integrated health care delivery system in which they practice, the ones who've been ground down into a "they're dumb and self-destructive so why should I care?" attitude by negative patient interactions -- would not do the thorough job you describe.

With respect to the glycated hemoglobin goal, I wonder if you have read the editorial by Richard Lehman and Harlan Krumholz in BMJ, Tight control of blood glucose in long standing type 2 diabetes, BMJ 2009;338:b800. They discuss the ACCORD, ADVANCE and VADT trials and conclude that "Taken together, the three trials show that no reduction of clinically meaningful adverse outcomes occurred in patients with long standing type 2 diabetes treated to a glycated hemoglobin below 7.0% in the time periods studied. Moreover, intensive treatment is accompanied by substantial costs and an increased risk of hypoglycemia and perhaps mortality."

I am a third year naturopathic medical student and from our pharmacology classes, I understand your reasoning for your treatment protocol based on the current ACC/AHA and National Institutes of Health guidelines.

Please help me understand why you would not follow ALL the current guidelines especially the class 1 recommendations for this particular patient scenario?

Class 1 recommendations based on http://circ.ahajournals.org/cgi/content/full/113/19/2363

Smoking: Why not address complete cessation of smoking? Why not urge to avoid exposure to environmental tobacco smoke at work and home?

Blood Pressure Control: Why not increase physical activity (medically supervised program), alcohol moderation, sodium reduction and an emphasis on increased consumption of fresh fruits, vegetables, and low-fat dairy products?

Lipid Management: Why not start a diet therapy and reduce intake of saturated fats, tans-fatty acids, and cholesterol? Why not add plant/sterols, viscous fiber and promote daily physical activity (medically supervised program)? Why not encourage increased consumption of omega-3 fatty acids in the form of fish or in capsule form (1 g/d) for risk reduction? Is it because EFAs are only a class 2(B) recommendation?

Physical Activity: Why not advise a medically supervised program for your high risk patient?

Diabetes Management: Why not begin modification of other risk factors?

Antiplatelet Agents/Anticoagulants: Why not also manage warfarin with this patient since he has a drug-eluding stent?

Based on your logic and not following ALL of the class 1 recommendations, would you also receive a failing grade from an internal medicine board?

Other thoughts and questions:

Patientâs first office visit: Why wouldnât you AUTOMATICALLY be looking for symptoms of dsypnea, effort intolerance or atypical chest and abdominal pain? You would call 911 immediately if the patient had any of these presenting symptoms right?

Medications: Why recommend a statin if his LDL-C of 98 has met the lipid management goal? Wouldnât it be more helpful to know his triglyceride numbers before prescribing a statin? Would you give all these pharmaceuticals on the first visit? Why would you not first start off with a thiazide with this patient? How would you personally monitor the effectiveness and side effects of all these medications?

Disclosures of the conflict of interest at the end of the guideline recommendations: Does it concern you that the authors of these guidelines have disclosed a significant conflict of interest as being consultants and board members of major pharmaceutical companies?

The beauty of naturopathic medicine is that it treats the whole person/tolle causam. Physical, emotional, mental, social, spiritual and environmental healths are treated naturally and with pharmaceutical drugs when needed. But our philosophy and treatment protocols are not dictated by pharmaceutical companies.

I went to medical school to be trained to make the best decisions for my patients and not have my hands tied by pharmaceutical and insurance companies. I will question every treatment protocol whether it is from orthodox medicine or naturopathic medicine and will look at the entire, whole picture of the patient. If there is a solid, non-biased guideline that my patient would benefit from then wonderful, but if there is a better option for my patient then it is my duty and obligation to safely explore that treatment.

Dr. Mona Morstein is a brilliant physician, just follow the results of her patients and then maybe you will see why she is an expert with diabetics. She is the true definition of a doctor!

Thank you for the entertainment, but I really wish there were âevidence-based guidelinesâ to treat arrogant douchebags. :)

I went to medical school to be trained to make the best decisions for my patients and not have my hands tied by pharmaceutical and insurance companies

Is the implication that I'm going to medical school because all I really want is to be a pawn of the pharmaceutical and insurance companies? Or is it that I'm powerless to stop the all powerful insurance and pharma industries, but you, pure-of-heart naturopathic doctor can defeat them!

Both implications, and anything else you can really throw out to justify that OUTRAGEOUS comment are horribly offensive.

All this "holier-and-purer-than-thou" stuff is utter bilge. Yes yes, we're all pharma shill's and you are valiant Galileo, forging ahead with a new and brilliant medical paradigm.

Why not also manage warfarin with this patient since he has a drug-eluding stent?

Why would you put this patient on warfarin? Is he in atrial fibrillation? Atrial flutter? Does he have an LV thrombus? What's his CHADS2? Whats his outpatient bleed risk index?

Had you said this on rounds, my attending would probably have told you to go home before you kill someone.

You appear to have literally just googled the guidelines and typed out whatever PalMD didn't put into his answer.

Thats disappointing. When I read that post, I thought maybe you used these guidelines to improve patient care. Clearly you aren't even vaguely familiar with them, or why they are important.

Doug in sunny Arizona said "Blood Pressure Control: Why not increase physical activity (medically supervised program), alcohol moderation, sodium reduction and an emphasis on increased consumption of fresh fruits, vegetables, and low-fat dairy products?"

What if the blood pressure was genetic? Perhaps caused by a structural problem like hypertrophic cardiomyopathy with obstruction. Would you prescribe exercise before finding out the cause of high blood pressure?

Does Dr. Morstein get those with Type 1 diabetes off of insulin?

At least with science we can settle our disagreements by appeals to rules of evidence. But no such luck with cults. Mud, blood, guts, and the killing bite.

The in-group/out-group thing was boring ten thousand years ago and it's still terribly, terribly, tedious. Were it not for the jokes I'd have to off myself.

BTW, Doug in sunny Arizona is a douchebag. I have it here in these herbal tea leaves.

Dr. Mona Morstein is a brilliant physician, just follow the results of her patients and then maybe you will see why she is an expert with diabetics.

I'd love to look at her results. Alas, she has not published any of her data. At least not anywhere that pubmed recognizes. Therefore, I can not follow the results of her patients. If I had a method for treating diabetics that was producing brilliant results, I'd be writing articles as quickly as possible. Why not share your results with the world? Yet she doesn't. It's almost as if she doesn't want her results analyzed rigorously.

I'm pretty sure a minority but still not good percentage of the practicing PCP population ...would not do the thorough job you describe.

I agree that this can be a problem. I've seen PCPs--and specialists--make thoughtless errors with consequences ranging from tragic to hilarious. But at least an MD or DO who has completed a primary care residency (internal medicine, family practice, etc) has the tools to do a good job. Some may not do their job well, for whatever reason. Certainly, all will sometimes screw up: it's unavoidable with people. But NDs don't have the training, neither the details of what best current practice is nor the mindset of how to continue to learn what the evolving standards are, they need to be good primary care physicians. So they are being set up to fail. No matter how brilliant, dedicated, and compassionate you are, you can't be a good doctor if you don't know what good medicine is. And I pity both the ND and his or her patient when they find that diet and exercise aren't panaceas and that, for example, starting a person with hypertension on an exercise program without considering their cardiac condition, the etiology of the hypertension, other co-morbid illnesses, and the severity of the disease can have deadly results. Same with telling a diabetic to stop their drugs because the miracle diet will cure all and so on.

Whitecoats: The AHA/ACC Guidelines states âManage warfarin to international normalized ratio_2.0 to 3.0 for paroxysmal or chronic atrial fibrillation or flutter, and in postâmyocardial infarction patients when clinically indicatedâ. Go look it up if you need to http://circ.ahajournals.org/cgi/reprint/113/19/2363

The patient has a drug-eluding stent so he fits the post-myocardial infarction. Are you saying these guidelines are inaccurate? Or did you just have a bad experience with your attending?

And yes, naturopathic medicine is a brilliant medical paradigm, but it definitely is not new.

HCN: I was again stating the AHA/ACC Guidelines for recommending fresh fruits, vegetables etc.. that PalMD conveniently left out of the ârequirementsâ.

As he stated âNot adhering to these recommendations puts you very far outside the mainstream of evidence-based practiceâ. If you are going to make a statement like that then you better preach using ALL the AHA/ACC Guidelines and not just pick and choose.

Physical activity could simply mean walking, hence why I said a medically supervised program.

Strenuous exercise would be CI in hypertrophic cardiomyopathy. Remember Reggie Lewis dropping to the floor? Unfortunately, he didnât listen to the 12 cardiologists who told him to play no more basketball.

I would have Dr. Morstein speak for herself, but she is probably busy with patients. But no, she does not get Type 1 Diabetics off insulin â nice try though.

Dr. Brenway: Glad to hear you are drinking herbal teas these days. I will admit I am a douchebag at times, but I am never arrogant. After all, I am only in medical school.

Dianne: You will have to ask Dr. Morstein that question. I totally agree, publishing her results would be great. Seeing is believing right? But if you are really sincere (which I highly doubt) in wanting to know what she does then setup a visit with her and follow here around for a day. You will at least enjoy the weather here.:)

Doug,

Why do you say, "medical school" like a pharma schill? Are you no different?

OMG it's a religion, isn't it? Following the charismatic leader, reality be damned.

And, no, white coat was right. It would be very unusual for someone with CAD alone to be on warfarin. Very unusual. Maybe if they have an LV thrombus. Maybe (but only maybe) if they have very severe LV systolic dysfunction.

Dr. Bengay: I have no idea what a pharma schill is and I am not interested in knowing, but thank you.

Ha-ha looks like you have a little following of your own PalMD â sheep following other sheep.

The real reality is that âthe reign, but not the perpetuation, of conventional medicine is coming to an end, not because of any inherent malevolence, but because all paradigms must come to an end. The challenge is to help this paradigm end gracefully, as we would a dying patient.â

My final goodwill plea is to go out and meet a ND in your area (www.naturopathic.org). Find out exactly what they are doing for their patients so you wonât have to make wild assumptions from behind the comfort of a computer. Heck, maybe they will even offer you a job.

Hey Dork, errr, Doug -

Lern too spel, m'kay?

STFU and learn something about the subject at hand, but then to you ignorance is bliss.

None so blind than fundies or alties.

I am not saying that all recommendations are wrong or not sufficiently based on evidence. Further I do not think that lowering cholesterol from 100 to 70 is dangerous. It does seem to bring about fewer myocardial infarcts (quite significantly so).
But, an improvement in overall survival has not yet been reported and some skepticism might be appropriate. I do not doubt the recommendation for 100 mg/dl LDL-C.

As far as the usefullness of naturopaths is concerned, they should definitely not replace primary care physicians. If some people want to seek out further advice on lifestyle changes that have been proven to work, then they do not need a naturopath. Their doctor should be able to give them the same advice and if they are motivated to pursue them, their doctor should not discourage them.
However, lifestyle changes do not work all the time and in most cases medication will be just as or more efficient and compliance will be easier to achieve.
What role can there be for naturopaths?
A limited role for giving advice on lifestyle might be all. But if the only thing they can do better than a real doctor is to subscribe vitamins and recommend books then there isn't really any role for them left.

when clinically indicated

Yes Doug. When Clinically indicated. It is clinically indicated in Afib, Aflutter, some LV thrombus, and very rarely besides that.

Thats my entire point. You don't understand what clinically indicated means.

Doug,

The current "paradigm" is science. It's not dying any time soon.

Naturopathy might have joined science-based medicine a hundred years ago after the Flexner report. But the naturopaths told science to fuck off.

Why you hate science, naturopaths? Oh wait, I remember: vitalism.

The public are being mislead by naturopaths who claim to have completed "medical school" and residencies in "family practice." "Naturopathic science" is also misleading, as vitalism is indefensible scientifically.

Popularity, political advocacy, money from supplement manufacturers --none of these things establish what is true.

Why do I hear Cartman's voice when reading Dougie's tantrums??

"Respect ma a-thor-a-tay!! I'm a wanna-be ND!!"

I looked up Mona Morstein, and her website is typical, complete with the glaring "Lose Weight Now" banners.

Her specialties .... more than any one M.D. ever handles, or even thinks they can handle.
# Diabetes and Endocrinology
# Gastroenterology
# Women's Health
# Nutrition
# Weight Loss
# Pediatrics

Her therapies:
# Diet/Nutrition and Supplementation
# Botanical Medicine
# Homeopathy
# Hydrotherapy
# Vertebral Manipulations

And, she sells things straight from the clinic to the patient, for their convenience of course. And if you order from her recommended source, there's a special ID code to enter to make sure she gets the credit.

"Through properly applied supplementation, prescribed in an ethical and moral protocol, patients can see their health return quicker than they ever imagined, and they can also notice that following their health regimen is easier.

Supplements include vitamins and minerals, amino acids, enzymes, glandulars, essential fatty acids, antioxidants, cleansing powders, fiber, specialty products to enhance various organs of the body such as to stop food cravings, to stimulate the thyroid or adrenals, to heal up the intestines, and so forth.

"Dr."Morsteinâs clinic contains a full dispensary to ensure where patients are able to obtain the highest quality nutrients in a convenient place, bypassing all the confusing and at times untruthful hype and hyperbole which patients face seeking help in various Health Food Stores and on the internet.

And she's straddling both sides of the medical fence, willing to prescribe those nasty "Big Pharma" drugs when needed. My question is, does she know when they are needed and does she prescribe them correctly, or does she piddle around with her nostrums and cleansing agents and hydrotherapy until the patient is much worse.

9) Prescription Drugs:
There are times when regular prescription drugs are necessaryâwhen an acute infection is more than the body can handle, or when some chronic condition has progressed enough that at least temporarily, body health needs a prescription to get it back on track. Dr. Morstein has full prescriptive rights in the state of Arizona, and judiciously prescribes medications only on an âAs Neededâ basis.

Dr. B., with the SWOOSH!

a) Joe wrote [#39]:

"it has long amused me that NDs['] claims usually include 'first, do no harm' [but] as the second or third item in their creed."

You are right.

Man do I have quite a collection of NDs stating their essential principles - what I call the 'ND sectarian creed.'

I've been wanting to do a paper on it for a while, in terms of word usage.

This creed actually establishes their standard of care [S.O.C.]: which is, specifically, 'you must treat within a vitalistic & supernaturalistic context' AND claim this nonscience is scientific fact.

If you go to the trunk of their consortia, the National College of NATURAL Medicine [see "Principles of Healing"], the mother ship so to speak, you'll see that this belief set places:

vitalism first [see "promoting health through stimulation of the vital force"];

do no harm third {bound to vitalism};

supernaturalism second, forth, and fifth

[out of six principles].

Such is stated as objectively "in fact" and able to survive scientific scrutiny: Nobels soon to be awarded, express mailed to Portland, Oregon - something is what it entirely isn't.

b) sND 'Doug in Sunny Arizona' wrote [#46]:

"I will question every treatment protocol whether it is from orthodox medicine or naturopathic medicine [...] if there is a solid, non-biased guideline that my patient would benefit from then wonderful [...] if there is a better option for my patient then it is my duty and obligation to safely explore that treatment."

So, 'Dr. 2B' Doug, have you questioned the above ND S.O.C. 'nonsense survives scientific scrutiny'? I don't think so. A new aphorism regarding naturo., not 'first do no harm' but:

first, 'vomit up the sectarian irrational malarkey'.

I think there's a douche for that, science & critical thinking. It requires you to, in your own words, as someone with live neurons in your cranium {espero}:

"question", support "solid non-biased guidelines", and "explore" per "duty and obligation".

-r.c.

@26 "If pharmaceutical medicine, in the absence of good nutrition and regular exercise, were so effective, why is heart disease still a leading killer in America? This is despite almost everyone with CVD being put on a regimen such as yours."

Why...because americans going to NDs rather than seeing regular doctors and staying on their meds. I have your cause-and-effect right here....

Dr. Bengay

I see what you did there. How the good doctor will ever show his face here again after such a stinging rebuke, I don't know. Certainly, questioning the sexuality of your critics is a far better use of your time than, say, defending your position in any substantive way whatsoever.

Whitecoat Tales: Why do you keep leaving out âpost-myocardial infarctionâ in you post? It is clearly stated by the AHA/ACC Guidelines so leaving it out of your post doesnât mean it isnât clinically indicated.

The American Heart Association even states the clinical effectiveness of warfarin for acute myocardial infarction. http://content.onlinejacc.org/cgi/content/full/41/9/1633

If you feel so passionate that it isnât âclinically indicatedâ then I highly encourage you to write to the American Heart Association and the multiple pharmaceutical makers of warfarin and tell them to change their guidelines and âwell-designed clinical trialsâ. You might even want to add to your letter that your âattendingâ would tell them to go home before they killed someone.

I will cut you some slack Whitecoat Tales because you are in medical school like me so you are still learning.

But you know what is scary, even more than me speaking in âCartmanâs voiceâ?

Some well meaning medical doctors have no clue about their own drugs that they are prescribing to their patients. Pharmaceuticals are your bread and butter so you absolutely have to know them in and out! Not stating âmaybeâ three times as PalMd did in defense of his little Whitecoat Tales. It is either clinically relevant or not, no MAYBES!

Dr. Bengay: You make me laugh so thank you.

This will be shock to most of you, but naturopathic medicine is more in line with science then what the current paradigm claims to be. Orthodox medicine has had its place and has benefited mankind in more than one way. But overall, the current paradigm has made their own distorted âscienceâ and the science gods would be absolutely ashamed. Your made up scientific creeds were spawned from greed and is not truth. Far from it!

BTW, why use the different names to post? Yourmama and Duckdroppings obviously come from your own blog www.tuftedtitmouse.blogspot.com (âDr. Bengayâs occasional droppingsâ) with absolutely lovely pictures of ducks, I might add.

Are you ashamed to use the post as Dr. Bengay with the nooby comments you make?

Tsu Dho Nimh: Obviously my plea is not going to be heeded to actually go and meet with a naturopathic doctor instead of hiding behind a computer and making insults about them and what they actually do.

Daijiyobu: I am not a doctor, but I did laugh at âDr. 2Bâ so thank you.

âvomit up the sectarian irrational malarkeyâ â that statement definitely made me vomit. You make it sound like your âscienceâ is your religion.

You also act like you are an âexpertâ and can speak for naturopathic medicine. Your paper you plan to write will only show you know how to take quotes out of context and interpret them to your own agenda. You will not understand the philosophy of naturopathic medicine because you have absolutely no sincere desire to understand it.

You mock what you donât understand so my only suggestion is to keep your day job and not venture off to write a âpaperâ on the philosophy of naturopathic medicine.

Speaking of day jobs. Why arenât you doctors seeing your patients right now? Oh thatâs right, they have appointments with naturopathic doctors.

Man, I am feeling the love from this blog that âwelcomedâ us. Anyone want to be my friend on facebook? :)

Doug, two things:

First, that paper that you linked is a general paper on warfarin, not a position statement.

Second, the appropriate post-MI guidelines are to be found here. It's important to understand your references thoroughly. Warfarin anticoagulation post-MI is a very uncommon intervention.

Doug said [#68] of me:

"you also act like you are an 'expert' and can speak for naturopathic medicine [...] you will not understand the philosophy of naturopathic medicine because you have absolutely no sincere desire to understand it."

Well, I know a lot about it. I did go to ND school for four years in CT [I stopped due to its wackoness] and I've read thousands of ND web pages.

But, I never speak for naturo. I let them speak for themselves, 'from the inside' -- and how do YOU know my motivations?

Perhaps I meant "2B" as a rating. With 1A being the kind of physician I myself would see.

-r.c.

If you are talking ratings, shouldn't his be 4F?

Doug,

You're suffering from ideas of reference. It happens a lot on the Internets. The mind is a pattern-creation and sometimes illusion-creation machine.

I don't do sock puppets. I have no idea who "yourmama" or "duckdroppings" are.

I suspect we're not defining "science" in the same manner.

Perhaps you might explain the scientific evidence for vitalism?

PalMD: Just a paper? Really? The âpaperâ as you call it, says it âwas approved by the American Heart Association Science Advisory and Coordinating Committee in October 2002 and by the American College of Cardiology Board of Trustees in February 2003â.

Is this how it works in your medical community and in your office? You pick and choose what fits your argument/belief the best?

You have already shown that you discount class 1 recommendations (diet, fruits, vegetables, tobacco smoke, alcohol moderation, viscous fiber, EFAs and etc. ), but then preach to everyone by stating âNot adhering to these recommendations puts you very far outside the mainstream of evidence-based practiceâ.

If this doesnât fit the definition of an arrogant hypocrite then I donât know what does.

Daijiyobu aka Rob Cullen: Four years of medical school and then one day you decided naturopathic medicine was âwackyâ? Seriously?

Correct me if I am wrong, but it sounds like you didnât pass your clinical boards so you became very bitter and decided to make it your âmissionâ to fight against naturopathic medicine.

I didnât us telepathy to know your motivations. You clearly state them in your own blog. http://www.blogger.com/profile/14987563840947860899

Enjoy your âtestifyingâ "Dr" Bob Ironic.

DPSisler: The joke was already made and it was only funny once so your lofty aspirations as a comedian just went up in a flame of smoke.

Dr. Bengay: You are boring, be gone with you.

Doug, do you even know what hypertrophic cardiomyopathy is?

And why did you ask "Daijiyobu aka Rob Cullen: Four years of medical school and then one day you decided naturopathic medicine was âwackyâ? Seriously?"

When he said "Well, I know a lot about it. I did go to ND school for four years in CT [I stopped due to its wackoness] and I've read thousands of ND web pages."

Ummm... ND is not the same as medical school. Do naturapathic schools have clinical boards? And if they do, how well would you do based on the questions asked by PalMD?

I see what the problem is Doug.
Reading comprehension.

Whitecoat Tales: Why do you keep leaving out âpost-myocardial infarctionâ in you post? It is clearly stated by the AHA/ACC Guidelines so leaving it out of your post doesnât mean it isnât clinically indicated.

Your source says

and in post-myocardial infarction patients when clinically indicated (eg, atrial fibrillation, left ventricular thrombus)

So the article says, in a post MI patient, you use warfarin IF it is clinically indicated. It goes on to say It is clinically indicated IF a patient has A-fib, or LV thrombus.

This does not imply that it is clinically indicated in every post-MI patient. It says, WHEN it is clinically indicated, THEN you can prescribe warfarin.

Reading comprehension often helps when reading papers.

In your next post, you took a paper published in a journal, and then stated its findings as if that was a proffesional organization's official stance. This is gibberish. You appear to not understand the how to read a paper.

More importantly, you didn't even read the paper!
You cited
http://content.onlinejacc.org/cgi/content/full/41/9/1633

You imply that this paper says we should have prescribed warfarin. However this paper discusses warfarin only in the context of ACUTE MI, or as primary prevention. It recommends AGAINST using warfarin in primary prevention. The patient in question did not have an acute MI. The patient has a drug-eluting stent placed about 1 year ago. This is not acute.

See what we do in Evidence Based Medicine, is read papers before we cite them.

Your arrogance is only surpassed by your ignorance.

Cor blimey, Dork, you're a fuckwit.

Bzzzzt, wrong. I'm not affiliated with Dr. Benway in any way, shape, or form.

Im reposting my comments from the other forum:

Let's approach this from a biochemistry point of view. So this guy has diabetes type 2 and HTN. He has developed CAD due to plaque formation and now has a stent. What is the best way to tx? You guys go for the statin, Ace inhibitor, HCTZ, metformin "at least" which is fine for a short while. You'll likely tell the patient to exercise and eat healthier (DASH diet) but nothing really specific (you may even start with this first x 3 months). You go on your way as if you changed a life. Again what is the best way to tx? This guy is diabetic which has led to his CAD. His diabetes is the MAJOR contributing factor to his elevated lipids. How? HMG COA reductase is the enzyme in our liver that produces the major blunt of our cholesterol. It is turned on by insulin which spike due to high carbohydrate meals. This guy has high insulin levels due to his diabetes along with hyperglycemia. His pancreas continues to push out insulin which does not address the hyperglycemia in his blood. This excess insulin in the blood turns on his HMG COA reductase leading to elevated lipids. If you get the insulin levels, blood sugar under control the lipids will fall, period. Some feedback inhibition is lost due to the continuously elevated insulin levels. (excess cholesterol will feedback inhibit HMG COA reductase in healhty person). The best way to accomplish this is to put the patient on a very, very low carbohydrate diet. This will prevent glucose spikes in the blood which will prevent insulin spikes which will prevent HMG COA reductase from being turned on which will decrease cholesterol production. Once hyperglycemia and high insulin levels drop his body will begin gluconeogenesis, glycogenolysis, and lipolysis for energy. Glucagon will inhibit HMG COA reductase. Put him on high psyllium fiber which will remove bile and prevent enterohepatic recirculation. Prescribing statin should be reserved for patients who refuse to make the diet change to avoid carbs. Also, statins inhibit isoprenoid formation which inhibits COQ10- ubiquinol formation as well as hormones. The fatigue, cramps, and weakness is b/c without COQ10 we cannot donate electrons via the electron transport chain. Our cells become deficient in ATP and we get fatigue and malaise. I know you have heard of rhabdomyolysis. Hypothesis: Possibly combining cellular toxicity (due to low COQ10 which results in low ATP) and we all know that people process drugs at different rates via the liver cytochromes. Basically, if someone gets too high a dose of statin and they have lower than average cytochrome activity (phase 1,2), equals mitochondrial toxicity = cell apoptosis = rhabdomyolysis. His blood pressure is elevated but as long as he doesn't have signs of end organ damage (eyes, kidneys) I would try other methods before jumping into the diuretics. I know you are not interested in actually learning how inept you are (prevention-wise) so I will not go into tx since you obviously have no care in actually helping your patients to stop the progression of disease. But, I have a challenge for you Doc if you are man enough to take it. Go shadow via an accredited ND clinic and then talk your bull, if you still feel the way you do. This is a challenge to all MD's who read this by the way. Ignorance does not become you.

John Williamson

This response is to Whitecoat Tales.......Practicing medicine via Biochemistry is the only clear way to bring health to patients. It is the foundation of human health.

Clinical trials?

How long was it known that folic acid prevented abnormal folding of the neural tube? Well, they had evidence since the 50's. How many children have had to suffer because of morons in the science community who failed to recognize the importance of folic acid? The importance of folic acid by the FDA wasn't actually instituted till the 90's. Thousands of lives destroyed. I would be pretty upset if my child had spina bifida which could have been prevented, wouldn't you? Besides there are lots of clinical trials, RCT's, on CAM on countless herbs, and supplements. Look for yourself.

"signifying nothing"?

I have signified everything actually that food, nutrients activate enzymes in the body which can be manipulated via simpler, safer, more long term tx's rather than drugs. Drugs are great accomplishments of science but should rarely be firstline therapy. It is well known that nutrients are coenzymes that are absolutely essential for enzymes to function.

On the otherhand, I am happy that you have made the effort to shadow an ND. But before you proceed make sure they have graduated from an accredited school and optimally it should be in a licensed state. You would be gladly accepted to shadow at one of the accredited school's clinics. We have had several MD students rotate via. Also, you could attend the AZNMA, tx's centering around naturopathic medicine.

As for your colleague, PalMD, he is lost and will succomb to the common diseases of lifestyle and will ultimately be on > 10 drugs before his demise which will be long before the average lifespan.

John Williamson

What, no comment on folic acid? Anyone?

Do you MD's ever consider the origin, cause of disease before people have markers, or values, or symptoms? How do people develop diabetes in an MD world? Have you guys ever ever thought of why and how it could have been prevented? I know you have never questioned how your medicine works but since you are too busy to look for alternative medicine which is loaded with positive information and signifcant values,

Do Low-Carb Diets Help Diabetes?
Small Study Shows Restricting Carbohydrates Reduces Need for Medications
By Salynn Boyles
WebMD Health NewsReviewed by Louise Chang, MDMarch 15, 2006 -- Should people with type 2 diabetesdiabetes follow very low carbohydrate diets? The American Diabetes Association (ADA) says "no", but a small study from Sweden suggests such a diet may be one of the best ways to manage the disease and reduce the need for medication.

In the study, 16 obese patients with type 2 diabetes followed a calorie- and carbohydrate-restricted diet for 22 months. Most showed continuing improvements in blood sugar that were independent of weight lossweight loss; the average daily dosage of insulin among the 11 insulin-dependent patients was cut in half.

"Many people are essentially cured of their [type 2] diabetes by low-carbohydrate diets, but that message is not getting out," says low-carb proponent and biochemistry professor Richard Feinman, PhD, of the SUNY Downstate Medical Center in Brooklyn, N.Y.

While agreeing that carbohydrate restriction helps people with type 2 diabetes control their blood sugar, ADA spokesman Nathaniel G. Clark, MD, tells WebMD that the ADA does not recommend very low-carb diets because patients find them too restrictive.

Okay, back to me, your own colleague here Clark MD completely writes off all diabetics, says its too hard to eat right to be healthy. That's it, write off everyone, prepare for blindness, kidney failure, neuropathy, CAD, chronic infections, and amputations b/c its just too hard! Oh yea, decreased carbs equals decreased cholesterol, too! Go shadow someone, learn what you can to help people to the fullest. Use drugs when you need them, integrative medicine first.

John Williamson

John Williamson: A wall of text is not easy to read.

I noticed that you did use paragraphs later, but that must have been just from a cut and paste.

Wow, John Williamson, you are so full of...information. And, so far, completely devoid of any sources for your rather incredible claims. Surely someone who can pile information so high and deep would have no problem supplying references for the unenlightened hoi polloi. How 'bout it?

Chris and Jennifer,

These are my original responses from the original post. I wanted more people to read what I had written. Oh, and actually read them before you respond. You will learn something. And I don't really need references for biochemistry which is pure fact. What claims do I have by the way? I have made no claims other than why you address diabetes and hypercholesterolemia with a very low carb diet. Oh and I did include an article from webMD. Read it and dont respond if you have nothing to bring to the table. I report facts, nothing more.

John Williamson

John Williamson

HCN: Yes and yes. According to PalMD I would fail. We were taught the same guidelines in our pharm classes so that is why I was questioning why he wouldnât recommend all the class 1 recommendations and why he was picking and choosing. How well I would do on my clinical boards? I will let you know in a year and a half.

Whitecoat Tales: I see what you are saying and you are correct. Is that arrogant enough for you? You are still more than welcome to come out for a visit.

It is the John Williams show now. Good luck naysayers! :)

Sad, all of this is sad. The topic is valid and important. I am a practicing Naturopath in a very busy practice. I love what I do because it works. My patients get better, they tell their friends, their MD's see the results, I get referrals and build on my success. My point is this: forums like this can easily devolve into mental masturbation and quickly become devoid of value.
In the grind of day to day practice vitriol has no place. Results, research and care reign. While you argued and deliberated on my right to exist today, I continued to build my practice and consolidate on my success. I called a few of my MD friends and collaborated on patients. I saw 2 MD's as patients and further rooted myself into the medical system. I did this regardless of your opinions and indeed in spite of them.
My point is this- the tenner of the debate here needs to change or it will be even less relevant than it is now.
I am going nowhere but to work tomorrow. You need to figure out how we can co-exist, and you need to do it in a respectful manner.

I'm trying to sort through this wall of text. Most of it seems to be a verbatim regurgitation of half a biochemistry textbook, with the assumption that the simple layed out interactions of biological molecules hashed out in vitro apply directly to clinical practice. This simply isn't the case, we could have AP Biology students practicing medicine straight out of high school if it were. Scary thought.

Did you just call cytochromes Phase 2 metabolism?

Folic Acid has been in pre-natal vitamins since... at least the 1960s

Loading the body with cofactors, vitamins and coenzymes isn't really going to clean up this sort of mess. Your average American gets pretty much what they need unless their diet is has fallen apart completely. Unless you've got some spectacular revelation sitting in peer review somewhere, I doubt the nutritional guidelines are getting rewritten any time soon.

The study you mention involving low carbohydrate diets I cannot find online. However, a study of n=16 is nowhere near what you need to even suggest the widespread adoption of a clinical practice. This sort of study is grounds for a larger scale, more powerful investigation perhaps, but not widespread adoption of its intervention. In relation to this patient, he was 66kg, not obese by any standard. Likewise, Nathanial Clark of the ADA did not condemn health eating, he dismissed low carb diets. If an intervention is too restrictive, or too unpleasant, be it drug or behavioral, most patients will have a great deal of difficulty adhering. It doesn't matter if it's a drug that must be taken six times a day, or a complete exclusion of a major food group that must be adhered to with perfection. If people won't do it, it doesn't work.

And while biochemistry may be 'pure fact' as you put it, the application of biochemistry to medical practice does need a great deal of support. It's one thing to characterize the behavior of enzymes in a spectrometer or cell culture. It is quite another to use those principals to devise a medical intervention

I'm still trying to decipher John Williamson folic acid rant. At what point is he suggesting that we had the knowledge about folic acid, but didn't act on it because of the nature of MDs?
Here's a brief history of the folic acid supplementation issues:
http://www.foodsafety.gov/~dms/wh-folic.html

That article clearly explains the challenges of not just figure out where/how to add something like folic acid as a standard supplement, but also the challenges of figuring out the correct levels to help pregnant women without hurting others. Perhaps we could have acted on the research a few years sooners, but do you have any hard evidence that people knew about the direct link between folic acid and spinal bifida in the 1950's and there was absolutely no response? (Also note that the method for adding folic acid to flour didn't even exist in the 1950's)

We don't know enough about biochemistry to confidently reason from basic science to clinical practice.

Vitamin X may be needed to create substance Y, involved in building structure Z, which makes us feel peppy. However, vitamin X might also serve to up-regulate production of not-yet-discovered substance A, which makes us feel tired.

It is useful to make predictions based on biochemistry. Then when our predictions fall flat --which they often do at the bleeding edge of research-- we can see the incompleteness of our model.

Biochemical plausibility is a necessary component of any proposed therapy. It is, however, an insufficient justification.

Doug:
Dr. Bengay: You are boring, be gone with you.

Of course I am easily dismissed. I'm a mere titmouse, likely to be eaten by a cat soon.

Yet the question still stands for all who read this thread:

You claim naturopathy is based in science. Please explain the scientific evidence in support of Vis Medicatrix Naturae.

To Erik Jackson,

Last time I checked AP biology does not include biochem. I have a B.S. in biology as well as in Natural science. Trust me, you are wrong. Again, I have shown via biochemistry that manipulating the diet via low carb supplementation directly influences not only insulin resistance but also HMG COA reductase (chol production). There are plenty of studies on low carb diets, go look for them. YEs, Clark MD, did dismiss low carb diets for everyone. Hey, maybe some people would rather have both their legs in the future. You cannot ever speak for everyone on anything, period. I don't care who you are.

To Dr. Benway,
Drugs work on the biochemistry level. They inhibit enzymes. MD's basic line of tx is on the biochemistry level. Why can't you try to manipulate the enzymes rather than complete inhibition?

On folic acid, the fact is it was well known long before prenatal institution of its importance. Thousands upon thousands of birth defects that could have been prevented held back by likely your colleagues.

To all who respond, at least read what I write, some of your arguments are getting weak and your assumptions weaker.

John Williamson

Funny. My AP bio had basic biochemistry, and that was nearly ten years ago now.

You cannot treat biochemistry like a mathematical proof. There are too many confounding factors in the real world. As Dr. Benway states, you will find more often than not that predictions based on pure biochemistry just flat out fail in the real world. Real biological systems do not behave with the perfect clean interactions drawn out on paper. They're flat out messy in fact.

The raw biochemistry drawn out from a textbook is a lovely place to start. But if you want an idea to get anywhere you're going to have to show it working in the real world.

Oh, and there are dozens upon dozens of categories of drugs that act primarily by allosteric modification, induction, partial inhibition, reversible inhibition and even modifying of the expression of the genes themselves. Even implying that all pharmaceutical manipulation of biology is done by enzyme inhibition is flat out provably false.

To Eric Jackson,

What is the goal of allosteric modification, competitive inhibition, etc............Remember when a substance binds to a ligand receptor initiating a second messenger system activating transcription of a gene initiating translation forming a protein product which in many cases is an enzyme. Blocking receptors blocks transcription. Blocking an enzyme receptor inhibits the enzyme. In most cases drugs will inhibit an enzyme. I highly doubt your AP bio class involved biochemistry by the way, but who knows, if you say it did then maybe you had an eccentric teacher. Manipulating the genetic expression of the body via diet is the most idealistic way to tx patients. Otherwise, patients are on drugs for the rest of their lives which is not okay. You need to question how this guy ended up with diabetes and high cholesterol. I have tried to explain it to you MD's but you refuse to accept the biochemistry which is interesting considering this is the rational of your tx's. very interesting, indeed.

John Williamson

John Williamson

On folic acid, the fact is it was well known long before prenatal institution of its importance.

Well if it's so bloody well known, it should be the easiest thing in the world for you to provide a reference, right? Or at least to address the specific questions posed by bsci @87. Repeatedly impugning our reading comprehension and professional competency with occasional interjections of 'Think of teh babeeez!', all in lieu of providing evidence to support your claims, suggest that you are, to put it bluntly, just making shit up.

Manipulating the genetic expression of the body via diet is the most idealistic way to tx patients.

Mmm-mmm, what a golden nugget of woo-filled goodness that was! My favorite so far. Keep 'em coming. OMNOMNOMNOM

To jennifer,

I am going to assume Jennifer is not an MD or MD student b/c she is completely devoid in biochemistry and genetics. How can I make this hoi poi up? You dissapoint me very much if you are a conventional MD student, very much.

From the FDA.gov: "Scientists first suggested a link between neural tube birth defects and diet in the 1950s. The incidence of these conditions has always been higher in low socioeconomic groups in which women may have poorer diets. Also, babies conceived in the winter and early spring are more likely to be born with spina bifida, perhaps because the mother's diet lacks fresh fruits and vegetables--which are good sources of folate--during the early weeks of pregnancy"

So it took nearly 50 years to decide folic acid is good? Millions upon millions of miscarriages + birth defects avoidable. Sorry patient, there just wasn't enough evidence to prevent your child from having spina bifida.

John Williamson

To BSCI,

FDA.gov: Scientists first suggested a link between neural tube birth defects and diet in the 1950s. The incidence of these conditions has always been higher in low socioeconomic groups in which women may have poorer diets. Also, babies conceived in the winter and early spring are more likely to be born with spina bifida, perhaps because the mother's diet lacks fresh fruits and vegetables--which are good sources of folate--during the early weeks of pregnancy

John Williamson

Seriously, folks, when you have assertions about history, biology, medicine, etc, please try to provide a reference. Google can be your friend.

Point #2: are you suggesting that the fact that there is a lag time between hints of an association and a clinical application is nefarious? Back in the 50s was someone shouting this from the rooftops, "Get teh folaytz!!!!"

"What is the goal of allosteric modification, competitive inhibition, etc............Remember when a substance binds to a ligand receptor initiating a second messenger system activating transcription of a gene initiating translation forming a protein product which in many cases is an enzyme. Blocking receptors blocks transcription. Blocking an enzyme receptor inhibits the enzyme. In most cases drugs will inhibit an enzyme."

I'm sorry. Since when did say, a ligand binding an allosteric site necessarily result in the inhibition of an enzyme, or necessarily a decrease in expression? The direct opposite is perfectly capable resulting in an enzyme catalyzed reaction that proceeds faster, a receptor that is active more, or increased gene expression. Moreover, the same compound is capable of inhibiting the behavior of one enzyme and inducing others. As an example I'd cite antidepressant inhibition of monamine reuptake transporters, which at the same time appear to induce expression of BDNF (PMID 19170396 is a good review). Or the action of benzodiazepines in binding allosterically to GABA-A receptors and resulting in increased frequency ion channel opening (Brody's Human Pharmacology 3rd Ed.)

" Manipulating the genetic expression of the body via diet is the most idealistic way to tx patients. Otherwise, patients are on drugs for the rest of their lives which is not okay. You need to question how this guy ended up with diabetes and high cholesterol. "

Idealistic, but not established in to be effective. I'd point out the difference in taking a medication for a long period of time, which is well established to be effective in reducing morbidity and mortality, versus an extremely restrictive diet which is not established to be equivalent or superior, or even comparable. It is not as though merely assessing how his insulin resistance came about - it could be anything from genetic factors to simple age - this patient is in his 60s, not severely overweight.

I am not an MD, I have made no claim to be. The view you are presenting of the biochemistry in these conditions is incredibly simplistic, as though it can be adjusted without effort ignoring all the other pathways which go into regulation of these processes. You've presented the biochemical chain of events above as some sort of mathematical proof establishing some sort of treatment, when it's eminently clear that biology does not behave in this pure, straight and narrow pathway from point A to point B. How you've come to this conclusion escapes me, as even introductory college biology lab courses contain elements that demonstrate how murky the behavior of these systems in the real world.

From the FDA.gov: "Scientists first suggested a link between neural tube birth defects and diet in the 1950s..."
So it took nearly 50 years to decide folic acid is good? Millions upon millions of miscarriages + birth defects avoidable. Sorry patient, there just wasn't enough evidence to prevent your child from having spina bifida.

Exactly! Long ago, Some guys in white coats said 'hey, there might be a link between nt defects and diet'. Then they played golf for 50 years, stroked their beards for a little bit, and finally decided to dump some folic acid into a big vat in the flour-packing factory. Oh wait, no. That's not how science works at all.

I can visit the FDA.gov site too. I found a slightly different version of the information, and I'm going to bold the important words:

"Scientists first hypothesized in the 1950s that diet had something to do with neural tube defects."

and

"In addition, researchers discovered in the 1960s that folic acid deficiency causes birth defects in animals. "

and, [after citing a couple of positive European studies from the early 90s]:

"These studies led the U.S. Public Health Service in September 1992 to recommend that all women of childbearing age capable of becoming pregnant consume 0.4 mg of folate daily to reduce their risk of having a pregnancy affected with spina bifida or other neural tube defects."

In fact, It takes a long time to get from 'hypothesis' to 'specific public health policy'. 40-50 years is not all that outlandish, especially considering that it took approximately 10 years to get from 'something in the diet' to 'folic acid', and that the conclusive human studies did not appear until the early 1990s. Numerous in vitro experiments, tests in animal models, and clinical trials were required, not to mention significant discussion of the complex pros and cons of dosing the food supply of an entire population (see points raised by bsci, which, John, you have yet to acknowledge) to arrive at the final FDA recommendation. It's easy to say in hindsight that more children would have been spared neural tube defects if we had only known sooner, but I don't see anything inept or sinister about this timeline, and the fact that you do speaks more to your fanatical hatred of 'allopathy' than to anything inherently wrong with the system of evidence based medicine.

I am going to assume Jennifer is not an MD or MD student b/c she is completely devoid in biochemistry and genetics. How can I make this hoi poi up? You dissapoint me very much if you are a conventional MD student, very much.

After all the vitriol you've spewed in disparaging MDs and med students over the past few days, I can't tell you how delighted I am to have some showered upon me, too. For the record, and to enable you to target all future insults more precisely, your assumption about my letters is correct. I do not possess an MD degree, nor am I a student of any health science program. I do, however, have a PhD in molecular genetics and hold a full time research appointment at a large state university.

'"Do no harm" seems to be lost here.' -- Michael Simpson

"Statins
...
These are not "maybes". These are required, if tolerated by the patient. Not adhering to these recommendations puts you very far outside the mainstream of evidence-based practice." -- PalMD
-- Certainly quick to criticize here. Prescribing a medicine with a success rate of between 0.2% to 0.3%, with a side-effect rate over 10%. Nice science-based medicine.

Do Cholesterol Drugs Do Any Good?
http://www.businessweek.com/magazine/content/08_04/b4068052092994.htm
Statins - NNT 500+ to prevent death or serious medical conditions.

Crestor Info from wikipedia
http://en.wikipedia.org/wiki/Rosuvastatin#cite_note-3

Crestor Study â new study cited by Wikipedia article:
http://www.washingtonpost.com/wp-dyn/content/article/2008/11/09/AR20081…
17,802 - 31 heart attacks in the statin group vs. 68 in the placebo group

Note: that is 31 out of 8900 vs. 68 out of 8900
0.35% vs. 0.76%

Can a Drug That Helps Hearts Be Harmful to the Brain?
http://online.wsj.com/article/SB120277403869360595.html.html?mod=home_h…

http://en.wikipedia.org/wiki/Atorvastatin
"Adverse effects
Headache is the most common side effect, occurring in more than 10% of patients. "

*********
"I'm not sure how handing him a book qualifies as appropriate care, but if you're following him closely..."
...
"Why are you putting him on supplements? There is no evidence to support that practice. " -- PalMD

"Is it really just for the extra recommendation of supplements? Any ND's willing to explain?" -- qetzal

Here is a nice book by a guy who read hundreds of studies on diabetes, and cured himself. It is very heavy on information of the value of supplements for treating diabetes. It has dietary recommendations as well. You can read it online for free.

How an ex-diabetic engineer beat diabetes despite a coma and a 1337 glucose level
http://books.google.com/books?id=F2VxOD4gOBMC&pg=PA361&lpg=PA361&dq=lys…

I just like that he said that since those things were biochemistry, that meant they were "pure fact" and therefore didn't need to be referenced.

I'm gonna try that one in my next review article and/or grant proposal!! C'mon, NIH, it's pure fact that this biochemistry is occurring, so you should give me money to study it!

a) Doug wrote [73] about me:

"correct me if I am wrong, but it sounds like you didnât pass your clinical boards so you became very bitter and decided to make it your 'mission' to fight against naturopathic medicine."

Doug, you stand corrected - galore - I never sat for those boards, amadan.

I did pass the NPLEX Part 1, but the more I thought and thought about what actually is science, taught to me in those BMS courses and in my pre-med. courses, the more I realized that I was embedded in an 'unethical sectarian pseudoscience': naturopathy.

Any supposed profession that labels what is profoundly science-ejected scientific and takes money from the public under such a false pretense simply disgusts me...thus, I dissent.

It is not bitterness, it is disgust. It is an issue of ethics and integrity, not of the emotional pettiness you project upon it.

I also keep in touch with the appropriate authorities on this matter, and perhaps the situation is developing.

b) Dr. B. wrote [#89]:

"[Doug] you claim naturopathy is based in science. Please explain the scientific evidence in support of vis medicatrix naturae."

Ah, the life force. You know, I've seen the life force

http://naturocrit.blogspot.com/2009/04/i-have-seen-life-force.html .

-r.c.

To Eric:
Thanks for confirming the fact that most drugs are enzyme inhibiters with unknown side effects they are still confirming (MAO inhibitors, monoamine oxidase is an enzyme by the way which is inhibited to increase norepi, serotonin, and dopamine levels).

Thanks for agreeing that it is idealistic to manipulate genetic expression via diet. I'm glad someone recognizes the importance.

Your right that genetics (family hx) play a role in development of disease; however, you are wrong that it is okay and normal to develop diabetes ever. I may explain why it occurs later.

The biochemistry that I am suggesting is not merely biology at all. It is biochemistry, more specific. Specific pathways exist in the body which are influenced by diet. If you understand those pathways, their cofactors you can influence genetic expression period. I'm assuming you have never had biochemistry, things do go from point A to Point B as long as specific cofactors are present. How else do you think drugs work if biochemistry is so complex? Is that not the rational of drugs or is biochemistry a pseudoscience and drugs a mere optical illusion?

John Williamson

To Jennifer:

hmmmm....interesting. So it took 40-50 years to recognize folic acid as extremely important. Hmmmmmmmmm....name one drug that took 40-50 years to get on the market after initiation of testing?

Oh, and interesting that folic acid deficiency induced birth defects in animals in the 60's yet it took a EUROPEAN study in the 90's for the United States to say "hey we should follow the European's lead." It didn't have to take 30 years after animal testing had already been initated to institute folate as extremely important.

By the way, I do not hate allopathic medicine. However, it belongs in hospitals, emergency care. The only primary care MD's should be the ones who attempt to understand and practice integrative medicine. They are the MD elite in my opinion.

Oh, my attempts are not to disparage anyone. I am merely giving scientific explanations for the rational of naturopathic tx's which MD's should appreciate as long as they understand biochemistry of course.

John Williamson

To Arienna,

You suprise me. Why do I need to cite biochemistry facts? The last time I checked they were in every single biochemistry book you can buy. Go open one if your interested in actually learning something.

As for grant writing, the NIH would be delighted to fund your pilot study especially if you could explain where your experiment fits in the biochemistry pathway.

John Williamson

To PalMD:

For those of you who can actually read, Dr. Morstein actually passed with flying colors. Let's critique PalMD now in a similar way.

PSA is controversial? Doing a DRE and running a PSA in a 65 year old uncontrolled diabetic would be far from controversial. The last time I checked Prostate cancer FAR exceeded colon cancer not to mention the inflammatory process in his body likely which has contributed to BPH. Way to be hypocritical later on by saying you would run a PSA and do a digital exam.

You want to do an abdominal ultrasound? You forgot to listen for bruits and to measure the width of the abdominal aorta. Im not sure you can even go straight into ordering an ultrasound without reason for doing so. You know what, why dont we order a cerebral angiogram CT of the circle of willis while were at it? Who knows he may have aneurisms.

Thyroid panel is usually not required? If a type 2 diabetic has hypothyroidism it will be exacerbating his hyperglycemia and lipids by decreasing cellular metabolic activity. It is well know that hypothyroidism is associated with elevated lipids.

Let's look at the drugs now. You want to put a 65 year old uncontrolled diabetic on a beta blocker and a statin at the same time? Does anyone see a problem with this picture? The patient won't even be able to get out of bed or walk down the road due to his reduced cardiac output and COQ10 deficiency. If you didn't already read my first comment, statins inhibit COQ10 ubiquinol production which is an electron acceptor in the electron transport chain which is essential for ATP production. Also, COQ10 levels are highest in the heart. Why? The heart's main fuel is lipids which require an abundance of mitochondria. However, if the electron transport chain is deficient it will decrease heart health. Oh yeah, and studies have shown that COQ10 is efficacious in many heart conditions from angina to CHF. Mayo clinic also recognizes that people with low serum COQ10 levels tend to have HTN.

Beta blocker before any other diuretics? What? I didn't see any signs of end organ damage. Does anyone see the problem other than reduced CO? We have a type 2 diabetic, a beta blocker is likely to induce orthostatic hypotension. IF the patient falls, well, then were looking at an open wound. But wait, you covered that with the tetanus shot didn't ya. With his uncontrolled blood sugar and brilliant ADA guidelines we'll just tell the patient after we cut off his leg to be more careful next time.

Fibrinogen is insane? This patient has a hx of plaque formation. LDL cholesterol oxidizes which contributes to plaque formation. Oxidation increases in the presence of inflammation and free radicals. If the patient has high fibrinogen levels and plaques throughout his arteries he is at risk for developing ischemic disease of multiple organ systems especially if platelets adhere to the plaque. This patient should probably also have a CRP. You should monitor inflammation b/c getting inflammation under control will decrease LDL oxidation.

John Williamson

Rob Cullen: No need to speak Gaelic to me. Just come straight out and call me an idiot in English.

Yeah, I definitely would be disgusted too. Four long years of medical school as you âthought and thoughtâ really hard and bam -200 thousand + dollars in student loans to pay off. Talk about bitterness!

With all the mumbo jumbo on this blog of what âscienceâ is, it is interesting you call my profession âpseudo-scienceâ, but also describe the school courses as science. Confusion runs rampant on this blog.

âI also keep in touch with the appropriate authorities on this matter, and perhaps the situation is developing.â

What does this mean? Is this in regards to your future âexposeâ paper on naturopathic medicine? Or are you trying to have me arrested? Because as I type, I can hear a helicopter in the distance and it is making me very nervous. Okay, I really donât want to know that answer so never mind.

Trying to explain vis medicatrix naturae to the apostates of real science would be like explaining calculus to a tribe of confused monkeys. The only difference would be that monkeys would not be throwing their own poop at me.

John Williamson is da man!

Doug:

Thank you for explaining how damaging ND miseducation is, in terms of student debt - quite a yoke, but no need to remind me.

Stop representing ME; I'll speak for myself and I don't need directives from you about how I should communicate, and what I should say.

If you can look up the word "amadan" so easily, it proves a point: you can look up the scientific status of vitalism just as easily at the National Center For Science Education

(see http://ncseweb.org/book/export/html/3200 ):

"[1995] nonscientific notions such as geocentricism, flat earth, creationism, young earth, astrology, psychic healing and vitalistic theory, therefore, cannot legitimately be taught, promoted, or condoned as science in the classroom."

Great company vitalism keeps on that trash heap of scientifically-rejected ideas.

Per: "you describe the [ND] school courses as science," I never said such a thing. You commented earlier that I misquote. No, you misquote - it's quite slimy.

I wrote about how the basic medical sciences courses made me think about the contents of science due to their contents: there was no vitalism in anatomy, physiology [very important!], microbiology, pathology [very important!] and biochemistry [very important!]. There is obviously no vitalism or supernaturalism in modern biology, the basis [does that ring a bell, in terms of "basic"] of medical knowledge.

Wine + mud is not wine: a handful of basic science courses overlain with vitalistic & kind nonsense doesn't magically make the larger vitalistic nonsense scientific -- perfume on a pig and all; id est, it's still a pig.

Not sure why you are so paranoid, either: no veiled threat was mean in your direction. I only speak for myself and my experience per these "education robbers."

And per "trying to explain vis medicatrix naturae to the apostates of real science would be like explaining calculus to a tribe of confused monkeys. The only difference would be that monkeys would not be throwing their own poop at me."

Nice. Your a gentleman and a scholar.

There is a reason I call the ND claims of science "the science that ain't science". But [sigh], in your bizzaro world, "real science" is the science-ejected naturopathic vitalistic, and discourse is obviously no more sophisticated than a elementary school playground.

Susan Jacoby's phrase for such kind, per "The Age of American Unreason":

"a pseudo-intellectual universe of junk thought."

-r.c.

As there is some debate about supplements for Diabetes, and some mention of Folic Acid. Here is some more information.

http://lpi.oregonstate.edu/infocenter/vitamins/fa/index.html
"The results of more than 80 studies indicate that even moderately elevated levels of homocysteine in the blood increase the risk of cardiovascular diseases (4)."
...
"Folate-rich diets have been associated with decreased risk of cardiovascular disease. A study that followed 1,980 Finnish men for ten years found that those who consumed the most dietary folate had a 55% lower risk of an acute coronary event when compared with those who consumed the least dietary folate (18)."

Doug,

Easy fella. We all have our faith to maintain. I have met and know a number of NDs. They are generally earnest, intelligent and dedicated folks. Most (at least all that I know) practice within their capabilities - in other words, they are in CAM and IM practices usually supervised by a CAM friendly MD. Many take on the MOSM degree to dispense dubious concoctions from their onsite dispensary.

Here's the rub, there is no standardization, reliable quality control or oversight in almost all of these Chinese medicines or supplements. A quick review of FTC, FDA and other regulatory sites will reveal the extreme danger of providing "substitute" medication to patients. And we must be clear, with the exception of homeopathy, these substances affect the body pharmacologically.

Thus they are drugs.

I like my ND friends, they are interesting, committed to helping people and aware of their limits. I would NEVER visit them for medical advice. My spouse, a PA-C, who is very CAM/IM friendly occassionally tells me "near miss" horror stories of having to correct diagnosis or treatments of her ND colleagues. She has sat for her boards and recerts and proven herself in residencies from neuro, OB/GYN to FP. Her ND colleagues are usually sound and fury, signifying nothing.

Her I trust.

(PS - just reread this and it's a bit pompous, but it supports my view and feelings)

Doug, as you go into practice - know your limits and gather around yourself capable mentors.

hmmmm....interesting. So it took 40-50 years to recognize folic acid as extremely important. Hmmmmmmmmm....name one drug that took 40-50 years to get on the market after initiation of testing?

'Drugs' routinely take years, sometimes decades, to develop from concept to R&D to clinical trials to availability at your local drug store. And, here we're talking about pharmaceutical compounds which an *individual* would need a prescription to obtain-- prescription obtained from a doctor subsequent to examination, diagnosis and consideration of the patient's health and any other medications already in play. Does this not seem quite a different scenario than dosing the entire population through the food supply?? Can you not imagine that the decision to do the latter might (and, in fact, did) involve considerable, additional testing to determine the optimum additive dose that would confer protection against nt defects without unduly risking other health problems on a population scale (i.e. masking of B12 deficiencies)? A smart guy like you couldn't possibly be this obtuse.

By the way, I do not hate allopathic medicine. However, it belongs in hospitals, emergency care. The only primary care MD's should be the ones who attempt to understand and practice integrative medicine. They are the MD elite in my opinion.

*shudder*

I am merely giving scientific explanations for the rational of naturopathic tx's which MD's should appreciate as long as they understand biochemistry of course.

No you fucking aren't. You are proposing HYPOTHESES based on your understanding of biochemistry. The above quote is just the latest glaring example of your gross misapprehensions of how science works, although I am no longer surprised after our folic acid discussion. Truly, John, it takes lots of time and effort progress from an idea--however well informed it might be--to a useful therapy. If you are so convinced your theories are true, get yourself into a lab and demonstrate how, and why. Otherwise you're just talking smack and sounding like an arrogant berk.

To Jennifer,

Name one drug that took 40-50 years to make it to the market? I'll continue to wait b/c I believe in you.

Oh yea, and by the way folic acid is a naturally occuring compound that is high in fruits and green vegetables. It is not a drug at all. Im going to assume you know that, right? All chemists had to do was extract and isolate it from the food. They did not need to think up an entire compound out of the blue based on a single functional group.

Here's a question for you? When did obstetricians actually decide all women should be taking folic acid before pregnancy?

Masking of B12 deficiencies? Your kidding right? Since I know your not an MD student I will pretend I did not hear that.

John Williamson

I have no clue exactly what your point is with this constant harping about folic acid and the pace of medical references, but here's a timeline and more references I got from a review/commentary article: The Role of the case-control study in evaluating health interventions" Journal of Epidemiology Rhoads & Mills, 1984.

Just to sum up in the beginning, the process of medical science is slow with some good hypotheses not panning out over the 15 years it took to go from a clear hypothesis regarding folic acid to a positive large-scale population study. Eventually the link was found and policy was actually implemented quite quickly.

In the 1950's, there was an understanding about a link between nutritional deficiencies and neural tube defects. (i.e. Eichman E, Gesenius H. Die missgeburtenzunahme in Berlin und umgebung in den nachkriegsjahren. Arch Gynak 1952;181:168-84.
Aresin N, Sommer K-H. Missbildungen und umweltfaktoren. Zbl Gynak 1950;72:1329-36.

NOTE, that at this point, we didn't know that it was folic acid, just that people who had some time of malnourishment had more neural tube defects.

Warkany J, Beaudry PH, Hornstein S. Attempted abortion with aminopterin (4-aminopeteroyl glutamic acid). Am J Dis Child 1959;97:274-81.
Showed that failed abortions with an anti-folate caused neural tube defects. Perhaps, at this point it would have been possible to start consider advocating folate supplementation, but hindsite is nice.

Smithells RW, Sheppard S, Schorah CJ. Vitamin
levels and neural tube defects. Arch Dis Child 1976;51:944-50.
Linked neural tube defects to several possible vitamin deficiencies including folate.

The following three studies directly tested folate supplementation either in multi-vitamins or special pills. All had some positive evidence but suffered from biased population samples due to compliance or limitations based on human subjects concerns.
Smithells RW, Sheppard S, Schorah CJ, et al. Possible prevention of neural tube defects by
periconceptional vitamin supplementation.
Lancet 1980;l:339-40.
Smithells RW, Nevin NC, Seller MJ, et al. Further experience of vitamin supplementation for prevention of neural tube defect recurrences. Lancet 1983;l:1027-31.
Laurence KM, James N, Miller MH, et al. Double-blind randomised controlled trial of
folate treatment before conception to prevent recurrence of neural tube defects. Br Med J
1981;282:1509-ll.

The original review paper proposed a case-control study using outcomes based on whether women were taking multi-vitamins based on folic acid. The study resulting from that research actually produced a NEGATIVE. A review of negative results in the late 1980's is at:
Vitamins, folic acid and neural tube defects: Comments on investigations in the United States, Joe Leigh Simpson, Prenatal Diagnosis Volume 11 Issue 8, Pages 641 - 648

The study that finally gave strong evidence was:
MRC VITAMINS TUDYR ESEARCGHR OUP1. 991. Prevention ofneural tube defects: Results
of the Medical Research Council Vitamin Study. Lancet 338: 131-137.

A review paper of the plans of turning that study into US policy is:
Effects of Recent Research on Recommendations for Periconceptional Folate Supplement Use, Mills & Raymond Annals of the New York Academy of Sciences
Volume 678 Issue Maternal Nutrition and Pregnancy Outcome, Pages 137 - 145, 1993

Rob:âNice. Your a gentleman and a scholar.â

I didnât come here to be a gentleman or a scholar so get over it. Go read my other posts to find out why I am here.

On a scholarly note: It is âyouâreâ.

Thanks for the correction and clarification, Dug.

Oops, I meant Doug.

-r.c.

Name one drug that took 40-50 years to make it to the market?

Thalidomide.

...and it turns out that thalidomide is a pretty rockin' drug. Just a reminder...it was never used in the states the way it was in Canada/Europe. But we sure use it now.

@bsci:
Thanks very much for elaborating on my timeline in #99. I still don't think John's going to get the point, but it's been an interesting exercise for me.

I'm at home without institutional access to journals, but I did find an overview of the folic acid fortification saga from the FDA, which discusses not only time it took to collect the scientific data, but the protracted debates at the government level as the results of the human studies were coming in.

John asks:

Here's a question for you? When did obstetricians actually decide all women should be taking folic acid before pregnancy?

I would guess around the time the results of the Lancet study were made public--1991 or so. Isn't this generally how any standard of care gets modified? You know, waiting for convincing research to illuminate the best treatments and preventions?

Masking of B12 deficiencies? Your kidding right? Since I know your not an MD student I will pretend I did not hear that.

Nope, not kidding. It seems quite well documented that the risk of masking B12 deficiency was discussed extensively when the decision to fortify was being considered. I'm not sure why this merits condescention from you, but as your opinion means less than shit to me, it doesn't really matter.

I'm now morphing into a soccer mom for the rest of the weekend. Happy debating, all.

it turns out that thalidomide is a pretty rockin' drug. [...] But we sure use it now.

Tell me -- I know someone who was diagnosed last year with advanced multiple myeloma (as in, the tumors were holding his long bones together.) He's well enough now to consider returning to practice -- not working is, shall we say, not good for him.

Thalidomide is one of those "how good does it get?" drugs, too -- as chemotherapeutic agents go, it's very well tolerated.

PalMD:

By the way, the insanity is still going hot and heavy on the original challenge thread. Our boy Doug has been writing Walter Mitty scripts where he's a hero because he miraculously does everything right (sort of) in an emergency and manages to always ask just the right questions without ever heading down a ruled-out direction. (He doesn't seem to do "rule out," which isn't exactly a surprise, is it?)

I'm about to go into a grade-A EMT rant on him but know you could do a much better job of "you don't get to write the script for this show" than I can. If I don't see one from you I'll have a go at it.

Going to go OT for a moment and ask Jennifer Phillips if her handle used to be "Danio" 'cause she does research on zebrafish, or if she just thinks zebrafish are AWESOME (which they are), or if I am completely off in my own little Danio-dominated undersea imaginary paradise?

It's nice down here. We use science-based medicine and everyone has coffee!

To: bsci and all the other folic acid naysayers

Exactly bsci, you have no clue why I am harping about folic acid do you. I have a hidden agenda which is to make you readers question things which is failing obviously. So let me spell it out for you all since it is so difficult.

Warkany J, Beaudry PH, Hornstein S. Attempted abortion with aminopterin (4-aminopeteroyl glutamic acid). Am J Dis Child 1959;97:274-81.
"Showed that failed abortions with an anti-folate caused neural tube defects. Perhaps, at this point it would have been possible to start consider advocating folate supplementation, but hindsite is nice."

Exactly my point, 1959 antifolate drugs caused neural tube defects. We have cause and effect. Lets fast forward a MAXIMUM of 20 years, that means folic acid should have been a mandatory pre-pregnancy recommendation to all women of childbearing age by ALL obstetricians by 1979.

Where do I get 20 years from?
"new drug development and approval is a costly process. It can take between 3 and 20 years for a drug to be approved for marketing" (http://www.medscape.com/viewarticle/406736_2. By the way, medscape is a premier - well recognized MD and ND associated site.

I am not talking about fortification of a nations food supply here, I'm DEMANDING obstetricians mandatory rx of folic acid pre-pregnancy in 1979 at the latest. Since a cause and effect relationship was found in 59 that should have warranted further testing immediately. If folic acid were a drug then it would have been rushed into testing. Are you understanding?

If it weren't for the EUROPEANS then folic acid would be a Naturopathic recommendation and MD's would still be yelling "there's no evidence".

Oh yea, for a final piece of information. The World Health Organization ranks the USA Healthcare system at 37th right in front of Slovenia and Cuba. Hey, at least were in front of CUBA right?

Thanks for reinforcing my argument. If you do not understand by now then Im sorry friend.

John Williamson

To D.C. Sessions,

Thalidomide was synthesized in the 50's and approved for marketing within 10 years. Nice try, though.

John Williamson

We have cause and effect

One study does not cause and effect make. Hindsight is a beautiful thing, but one study it means little. One study is a start. Correlation is not causation.

If folic acid were a drug then it would have been rushed into testing

This is just speculative hyperbole, and some kind of weird reverse-pharma shill gambit.

To Jennifer,

Folic acid, according to drug timeline, should have been approved by all OBSTETRICIANS as mandatory in pre-pregnancy by (at the latest) 1979. The reason why I brought up obstetricians b/c I wanted to eliminate the fact that you're stuck on fortification of the food supply. Take that out of the equation and you have obstetricians making it mandatory to all their pre-pregnant females.

Fortification of a nations food supply is another matter. But I will tell you that any first year medical student should be able to provide a differential of B12 deficiency in the place of peripheral neuropathy without macrocytic anemia. Taking a thorough hx should rule out a B12 deficiency easily. Who is at risk? The elderly who develop pernicious anemia, an autoimmune attack against parietal cells, people with inflammatory bowel disease, people who have had terminal iliectomys, and theoretically people who have had bariatric bypass surgery to correct obesity. I don't see many physicians missing this.

John Williamson

Also, vegetarians.

To Whitecoat Tales,

I disagree with Doug. You will be less than a successful physician with your patients regarding the halting of the progression of disease. However, If you stay in a hospital you will be fine. But that's okay, you will merge in with the rest of your colleagues so do not fret. If one study establishes cause and effect then it should warrant further testing. As I said before, if the Europeans hadn't taken the initiative then folic acid would be a Naturopathic recommendation.

John,

Are you really this clueless? The 20 years is from the point when we have a drug and potential application in hand and when it reaches the clinic. Despite what you imply that was not the case in 1959 and it also ignores the fact that there's nothing magical about a 20 year maximum How long did it take from the first use of surgical gloves to their routine use? (And that was a VERY clear-cut case)

As for the 1959 case, perhaps the severe lack of folic acid (lower than typical in even deprived diets) caused a cascade of other things that led to neural tube defects. Attempted abortions might be a fairly messy population to study. Perhaps many people tried and failed to replicate this in other situations and also failed. Perhaps most low folate could cause neural tube defects but only in levels way below even malnourished diets, thus the supplement wouldn't actual help. Perhaps that original 1959 publication sat on a shelf for years before someone was looking into folic acid and realized it's significance.
What we do know is that since that 1959 study, the results were very mixed and there were real reasons not to push every possible supplement on everyone. You should also note that many of the challenges of the studies in the early 1980's (your time window) where complicated by the fact that so many women were ALREADY taking multi-vitamins with folic acid. While that was a good thing (and no study would tell people to stop taking vitamins), it definitely helped hinder good research on this topic.

As for your Naturopathic BS at the end. This was an example of a gray area of research. No one was saying not to have a diet rich in folate and many people were using supplements without criticism from MDs. When the evidence became clear enough that we knew the specific benefits of folate, how much was needed, and how to get it into the food supply, it was implemented rather rapidly.

I also want to add the extraordinary danger of John's conception of scientific progress. We see a single finding and we rush as fast as possible to implement it while ignoring all alternate hypotheses and evidence. What if it turned out that we rushed to implement a folic acid dose that was much too large and end up causing harm? What if the form of folate used had bad side effects? With your conception of science would it be possible to re-evaluate and correct?
In this specific case, it turned out that the original theory was close to the truth, but, in no way does that justify assuming that will always be the case.

If one study establishes cause and effect then it should warrant further testing

Between this, and "biochemistry requires no citation", and your "biochemistry as we know it is clearly adequate to immediately treat without further study" you have shown a profound misunderstanding of science.

You will be less than a successful physician with your patients regarding the halting of the progression of disease

I can only return to Dawkins.

If you are in possession of this revolutionary secret of science, why not prove it and be hailed as the new Newton? Of course, we know the answer. You can't do it. You are a fake.

If you think my methods will result in failure, then why not do the legwork to give some confirmation to your method? You can't.

Thalidomide was synthesized in the 50's and approved for marketing within 10 years. Nice try, though.

First approved for (extremely limited) use in the USA in 1998.

Sherri Finkbine ("Miss Sherry") was the headliner when I was on "Romper Room" in the 1950s and Bob Finkbine was one of my teachers in high school. Look them up.

Nice try, though.

John said, "But I will tell you that any first year medical student should be able to provide a differential of B12 deficiency in the place of peripheral neuropathy without macrocytic anemia.

Diagnosis not the issue. Excess folate masks the anemia until it's too late for B12 to fix the nerve damage, and may even accelerate the damage.

A "differential for B12"? Usually B12 deficiency appears in the differential for various symptom presentations. Few patients come in saying they need B12.

So your request, although not unreasonable, rings an odd note.

Anyhoo, here's my differential for B12 deficiency:
- not eating enough
- not absorbing enough

Updated Dawkins:

If you are in possession of this revolutionary secret of medicine, why not prove it and be hailed as the new Pasteur? Of course, we know the answer. You can't do it. You are a quack.

Romper bomper stomper boo!