A Walmart ad in my local newspaper trumpets “75% of all Americans don’t get enough Vitamin D” and offers to sell me Maximum Strength Vitamin D3, 5000 IU capsules to “promote bone, colon and breast health.” Meanwhile, the Institute of Medicine (IOM) tells me that “the majority of Americans and Canadians are receiving adequate amounts of … vitamin D” and that no one should take more than 4000 IU a day. Apparently Walmart and the IOM aren’t talking to each other.
The media have been giving the impression that vitamin D is a new wonder drug. They have told us that we aren’t getting enough sunlight, that a large percentage of us suffer from vitamin D deficiency, and that low levels of vitamin D are associated with cancer, multiple sclerosis, peripheral vascular disease, diabetes, rheumatoid arthritis, Parkinson’s and Alzheimer’s disease, and other conditions. Low levels of vitamin D have been linked to higher overall mortality (but so have high levels of vitamin D!). The anti-vaccine folks have been telling us (without any controlled studies) that vitamin D supplements are better than vaccines for preventing influenza. There’s no good evidence that raising vitamin D levels with supplements actually prevents any of these conditions, but many people think it should, and doctors have increasingly been measuring blood levels and prescribing high dose supplements. Is this just another passing fad like the enthusiasm for vitamin C, or are we belatedly recognizing a serious deficiency problem?
I’ve had a lot of inquiries about “is this information trustworthy?” and “how much vitamin D should I be taking?” I’ve been telling people that I didn’t know, that recent findings will soon result in new recommendations, and I’ve been eagerly awaiting the new guidelines. Now we have them, thanks to the IOM. They are not what most of us anticipated. Since so many doctors had been advocating higher levels to prevent things like cancer, I thought official recommended intake levels would go up; instead, they went down.
The Accreditation Council for Graduate Medical Education (ACGME) has released proposed new standards to limit working hours for medical residents. Bus drivers are allowed to drive for 10 hours and then are required to have 8 hours off duty. Airline pilots can be scheduled for up to 16 hours on duty — being at work, ready to fly — and up to eight hours of actual flight time in a 24-hour period, with a minimum of eight hours for rest between shifts. Physicians in residency training work 80 hours or more a week (compared to 75 hours a month for airline pilots) and are regularly on duty for more than 24 hours at a time. If adequate rest is an important safety measure for drivers and pilots, isn’t it important for doctors too?
When I was an intern and resident, my hours were a little better than some. Instead of every other night, I was on call every third night. I had to work from about 7 AM one day to 5 PM the following day (34 consecutive hours). I stayed in the hospital: there was a call room with a bed, but if we got to lie down it was never for very long. When I got off duty, my sleep-deprived body demanded that I go home and crash. It was only every third day when I worked “only” a 10 hour shift, that I could devote an evening to all the other activities of my life like laundry, grocery shopping, and trying to read medical journals. One memorable weekend I worked from Saturday morning to Monday evening and only got to lie down for about 20 minutes. I don’t think I made any fatigue-induced mistakes that hurt patients, but by Monday afternoon I was groping my way through brain fog and running on fumes. (more…)
Bill Clinton loved hamburgers from McDonald’s. He used to eat a typical American high calorie, high fat, meat-based diet. No more. He had a heart attack and a quadruple bypass in 2004. Recurrent blockages required placement of two stents in February 2010. This got his attention and he went on a strict new diet, losing 24 pounds to get back down to what he weighed in high school.
He is now a vegan.
I live on beans, legumes, vegetables, fruit. I drink a protein supplement every morning — no dairy, I drink almond milk mixed in with fruit and a protein powder so I get the protein for the day when I start the day up.
I did all this research, and I saw that 82 percent of the people since 1986 who have gone on a plant-based, no dairy, no meat of any kind, no chicken, no turkey — I eat very little fish, once in a while I’ll have a little fish — if you can do it, 82 percent of people have begun to heal themselves.
On October 19, 2010, the FDA approved a long-awaited new drug, dabigatran, expected to replace warfarin (Coumadin) as a better way to prevent blood clots in susceptible patients. This provides an opportunity to re-visit several issues that we have addressed before, including Big Pharma tactics, drug approval by the FDA, deciding what is adequate evidence, applying science to clinical practice, and making individual health care decisions based on evidence that is sometimes incomplete.
Patients with atrial fibrillation, artificial heart valves, deep vein thrombosis, pulmonary embolism, antiphospholipid syndrome, and people undergoing certain types of surgery are at risk of blood clots, embolism, and stroke. They are currently being treated with rat poison. Warfarin (Coumadin) is an anticoagulant originally intended to kill rats. It inhibits the vitamin K dependent synthesis of several clotting factors. It saves human lives but is a mixed blessing. It takes several days to achieve therapeutic levels. Patients must be monitored with frequent blood tests to ensure that their prothrombin levels stay between an INR (international normalized ratio) of 2 and 3. When starting out, this means blood tests every couple of days. For some patients, dosage fluctuates and requires frequent adjustments; others can eventually drop down to a monthly blood test. Warfarin interacts with a long list of other drugs that raise or lower its blood levels. It interacts with many foods, and patients have to modify their diet. It can cause serious bleeding complications; while preventing thrombotic strokes it can cause hemorrhagic strokes. It is taken once daily. There is an antidote, vitamin K, that can reverse its effects promptly.
Warfarin is the 11th most prescribed drug in the US. Its benefits clearly outweigh its risks, but we wish the risks were fewer. We have yearned for a better option: something safer, something that would not require monitoring with blood tests, something that foods wouldn’t interfere with, something that would not interact with every other drug in the book. And now it seems we have it: a direct thrombin inhibitor called dabigatran.
Melanie Thernstrom has written a superb book based on a historical, philosophical, and scientific review of pain: The Pain Chronicles: Cures, Myths, Mysteries, Prayers, Diaries, Brain Scans, Healing, and the Science of Suffering. Herself a victim of chronic pain, she brings a personal perspective to the subject and also includes informative vignettes of doctors and patients she encountered at the many pain clinics she visited in her investigations. She shows that medical treatment of pain is suboptimal because most doctors have not yet incorporated recent scientific discoveries into their thinking, discoveries indicating that chronic pain is a disease in its own right, a state of pathological pain sensitivity.
Chronic pain often outlives its original causes, worsens over time, and takes on a puzzling life of its own… there is increasing evidence that over time, untreated pain eventually rewrites the central nervous system, causing pathological changes to the brain and spinal cord, and that these in turn cause greater pain. Even more disturbingly, recent evidence suggests that prolonged pain actually damages parts of the brain, including those involved in cognition. (more…)
American Family Physician, the journal of the American Academy of Family Physicians, has a feature called AFP Journal Club, where physicians analyze a journal article that either involves a hot topic affecting family physicians or busts a commonly held medical myth. In the September 15, 2010 issue they discussed “Vaccines and autism: a tale of shifting hypotheses,” by Gerber and Offit, published in Clinical Infectious Diseases in 2009.
The article presented convincing evidence to debunk 3 myths:
- MMR causes autism.
- Thimerosal (mercury) causes autism.
- Simultaneous administration of multiple vaccines overwhelms and weakens the immune system, triggering autism in a susceptible host.
A salesman is demonstrating a new product at a sports store in the local mall. He has a customer stand with his arms extended horizontally to the sides; he presses down on an arm and the customer starts to fall over. Then he puts a bracelet on the customer and repeats the test; this time he is apparently unable to make the customer lose his balance. He has the customer turn his head as far as he can without the bracelet, and shows that he can turn his head a few degrees more after he puts on the bracelet. (Try this yourself: if you turn your head, wait a couple of seconds and try again, you will always be able to turn it further on the second trial). He similarly shows that the customer is stronger when he wears the bracelet. The customer and the onlookers are mightily impressed by the demonstration, by the salesman’s testimonials, and by the endorsements of famous athletes: they buy the bracelets to improve their athletic performance.
These so-called energy bracelets (also pendants and cards) allegedly contain a hologram embedded with frequencies that react positively with your body’s energy field to improve your balance, strength, flexibility, energy, and sports performance; and they also offer all sorts of other benefits (such as helping horses and birds and relieving menstrual cramps and headaches). The claims and the language on their websites are so blatantly pseudoscientific it’s hard to believe anyone would fall for them. Here are just a few examples from the Power Balance website:
- We react with frequency because we are a frequency.
- Your body’s energy field likes things that are good for it.
- Why Holograms? We use holograms because they are composed of Mylar—a polyester film used for imprinting music, movies, pictures, and other data. Thus, it was a natural fit.
- A primitive form of this technology was discovered when someone, somewhere along the line, picked up a rock and felt something that reacted positively with his body.
Dr. Novella has recently written about this year’s seasonal flu vaccine and Dr. Crislip has reviewed the evidence for flu vaccine efficacy.
There’s one little wrinkle that they didn’t address — one that I’m more attuned to because I’m older than they are. I got my Medicare card last summer, so I am now officially one of the elderly. A recent review by Goodwin et al. showed that the antibody response to flu vaccines is significantly lower in the elderly. They called for a more immunogenic vaccine formulation for that age group. My age group.
I have frequently said that science can only provide data to inform our decisions but can’t tell us what we “should” do; that it can determine facts but not values. I stand corrected. A persuasive new book by Sam Harris, The Moral Landscape, has convinced me that science can and should determine what is moral. In fact, it is a more reliable guide than any other option.
Several recent books have looked at morality from a scientific viewpoint. Animals have been shown to exercise altruism and to appreciate fairness. Human cooperation has been shown to offer a survival advantage to individuals and groups. Game theory has demonstrated the success of the tit-for-tat strategy. In The Science of Good and Evil, Michael Shermer argues that evolution has produced in us a moral sense that is not a reflection of some “absolute” morality but that constitutes a worthy human project that transcends individuals. He posits a pyramid of morality that becomes more advanced as it is applied to larger in-groups, from self to family to community to all living creatures. He amends the Golden Rule to specify that we should treat others not as we want to be treated but as others want to be treated. (more…)
I write a lot of critical articles. It’s nice to be able to write a positive one for a change. I received a prepublication proof of The Mayo Clinic Book of Home Remedies: What to Do for the Most Common Health Problems. It is due to be released on October 26 and can be pre-ordered from Amazon.com. Since “quackademic” medicine is infiltrating our best institutions and organizations, I wasn’t sure I could trust even the prestigious Mayo Clinic. I was expecting some questionable recommendations for complementary & alternative medicine (CAM) treatments, but I found nothing in the book that I could seriously object to.