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GSK Investigated for Bribing Doctors

The BBC reports that 11 doctors and a GlaxoSmithKline regional manager in Poland have been charged with alleged corruption. The apparent scheme was simple — GSK sales reps are given targets for new prescriptions for whatever drugs they are promoting. In order to meet those targets, it is alleged that one sales rep agreed to pay doctors £100 to give educational lectures to patients. The lectures never took place, and it was understood that in exchange for the payment the doctors would prescribe more of the rep’s drug.

The case is still under investigation but one doctor has already admitted guilt, stating that the £100 was simply too tempting.

Assuming the charges are upheld, such cases are very damaging to public confidence in the system. This is similar to cases of researchers faking their published research — I cringe every time I read about such cases.

There are some important questions, however: how common are such occurrences? And is this the isolated corruption of these individuals, or is it endemic in the system? The first question is difficult to answer. We can only know about exposed cases. Given the number of physicians and drug reps in the world, however, and the fact that the number of such cases that come to light are relatively few it would seem that such cases are the exception rather than the rule.

The second question is a bit easier to answer, but of course there can always be hidden corruption. GSK, for their part, states that such behavior is against their policy. I certainly hope this is true. GSK has been caught in scandals before. As the BBC reports:

In 2012, GSK paid $3bn (£1.9bn) in the largest healthcare fraud settlement in US history after pleading guilty to promoting two drugs for unapproved uses and failing to report safety data about a diabetes drug to the Food and Drug Administration.

These cases involved illegal activity at the corporate level. The current case most likely represents corruption at the level of the individuals directly involved.

While drug reps are certainly in sales, I have only personally seen a drug rep step over the line on one occasion. A new rep, who was clearly green, actually said to me and my colleague, “What would it take to get you to prescribe more of this drug?” I don’t think he was suggesting anything like bribery, but the statement was clearly inappropriate.

Our response was to end the encounter, and then call his company to report the incident and instruct them never to send that rep to Yale ever again.

There is no way to completely prevent isolated corruption. But we should ask about which policies would best minimize the incentives and opportunities for corruption. One approach, which is gaining favor, is to simply limit access of drug reps to doctors. This has already happened quite a bit. Drug company-sponsored lunches and talks have essentially vanished. Now my interaction is limited to signing for samples.

An even more draconian approach would be to eliminate the sales divisions of pharmaceutical companies. I am not suggesting this, but this would certainly eliminate any problems resulting from sales.

There is a potential downside to this also. There is benefit to be had from the flow of information between professionals and the private sector. Sometimes the goals of sales and good medicine align, when a new drug will improve health outcomes but is underprescribed because word has not penetrated the field yet. Companies can help get the word out and improve health outcomes.

The trick is to provide objective information, not information that is skewed in favor of the drug company. This can be accomplished by simply supporting education and outreach on the part of academics, who themselves will control the content. In my experience this is what happens most often, but obviously there are opportunities for drug companies to put their thumb on the scale, for example by their choice of academics — choosing those whose views happen to align with the company’s goals.

There are also advantages to academics advising private industry, to help them spend their research dollars in a way that is most likely to bear fruit and to meet unmet needs.

There are plenty of other measures that can be taken to minimize corruption short of a total ban on interactions between industry and practitioners and researchers. Perhaps the biggest measure is to manage the culture of the sales division. This flows from the top down — if companies want to keep their names out of the scandal pages and avoid big fines, they need to systematically train their sales reps to follow appropriate behavior, and swiftly and definitively discipline those who stray.

However, no matter what a company tells their employees during retreats and seminars, if the company sets up incentives that encourage corruption, it will still happen. GSK has already stated in response to the current episode that they will end direct payments to doctors for promotional talks, and also that they will eliminate sales goals for their reps.

Conclusion

No matter how a system is configured there is the potential for corruption. Even if the entire pharmaceutical industry were nationalized, there would still be a great deal of money exchanging hands, and this creates the incentive and potential for corruption.

It is critical, therefore, to identify and eliminate systemic corruption or any elements in the system that encourage or make it easy to hide corruption. This is especially important in vital industries, such as pharmaceuticals.

I do think we have been moving in the right direction in the last two decades. The tendrils of drug companies’ sales divisions have been slowly removed from academia and doctors’ offices. Gone are the previously ubiquitous drug lunches, branded gifts, and sponsored trips. There are further steps to be taken, such as those above, to maximize transparency and minimize both actual corruption and the appearance of corruption.

Exposing cases as they come to light, and shaming drug companies into taking corrective action, is an important part of this progress.

Posted in: Medical Ethics, Pharmaceuticals, Politics and Regulation

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165 thoughts on “GSK Investigated for Bribing Doctors

  1. Windriven says:

    First let me say that I have been away from the ‘retail’ side of the medical device business for almost 20 years. I sincerely hope that ethical standards have improved during that time.

    Back in the late 70s it was not unheard of for a cardiothoracic surgeon who implanted the ‘right’ pacemaker to wake up and find a new bass boat in his driveway. More often inducements like use of corporate vacation homes, junkets, and honoraria for ‘virtual’ services have been used.

    It is hard to explain how blurred the line between honorable business relationships and bribery can become. Physicians working with engineers and salespeople on new drugs or devices by definition spend a good deal of time with them. Friendships arise. The physician goes to a party celebrating a birthday. That leads to joining a bunch in the corporate box at an important football game*. The physician wants his friends to do well and shares in their excitement about the new drug or device. It takes a stout sense of ethics to prevent that from coloring professional judgment.

    The other side of the coin is that, as Dr. Novella pointed out, there is a useful exchange of information when salespeople bring new information and new technologies to physicians. The widespread adoption of important technologies is driven, in part, by well-coordinated marketing and sales programs. The stunning technical advances in clinical medicine would have never moved as quickly as they have without aggressive sales and marketing.

    Companies simply cannot afford a long, slow rollout of a new technology. Huge sums have been invested in bringing the product or device to the point of marketability. Those investments are made with the expectation of a profitable return and sales and marketing drive the speed. Absent profitability in a reasonable timeframe, resources will be invested elsewhere, technologies will not be developed, medical progress will slow.

    If finding the perfect balance was easy it would have been done long ago. It seems to me that the ethical balance is moving in the right direction.

    1. MTDoc says:

      I confess! In med school (1957), Eli Lilly Co. gave me a medical bag big enough to hold the few instruments we carried around in the hospital. In those days, we did not wear our stethoscopes around our neck. I’ve been hooked on their products ever since. Then I once received a corkscrew, purple, with KAON written on it, which I use more today than when the product was on the market. As for detail men, later detail persons, they gave me the only coffee breaks I ever had in my clinic, and they provided me with research papers and specific information I requested. And samples in quantities large enough to help many of my indigent patients. I still miss those brief visits. They also paid for seminars and visits to our area by specialists, such as infectious disease, who were otherwise unavailable to us directly.

      As for the TV ads for prescription drugs, I find them quite offensive; just another way to minimize the PCP’s role to that of corporate servant. Those resources could be so much better spent on R & D.

      Now a bassboat might have tempted even me.

      1. Windriven says:

        The early days of the pacemaker industry were absolutely wild. The guys that got bass boats implanted lots of pacemakers. But the idea was to establish brand dominance early. Market share is fungible – once you’ve built it you can easily turn it into cash.

        There used to be quite a few really ethical professional medical salespeople. Fewer now it seems. Back in the day there was a strong sense of medical salespeople as part of the continuing education process. But the sort of long term relationships that encouraged salespeople to be ethical and physicians to trust the information they provided aren’t rewarded anymore. Salespeople today live and die on a quarter’s performance. What’s right is not as important as what is profitable. Today there are plenty of salespeople who earn more than the physicians they call on. And that, my friend, is effed up.

        1. Spreza says:

          …and the scientists designing the therapy/devise.

  2. justsayno says:

    The public has been brainwashed into thinking drugs are good, the more the better. The TV news is interrupted about every 15 seconds for another drug ad, and these ads show people dancing ecstatically because they started taking yet another drug.

    The reality is that most drugs should be avoided if at all possible, because most of them do not improve overall health. Just the opposite is true — many drugs, in general, control the effects of disease rather than the cause.

    One typical example is cholesterol lowering drugs — high cholesterol is very often a result of artery disease, not a cause. The cause is very often chronic inflammation and type 2 diabetes. Statins happen to be anti-inflammatory, so they can have some benefit in decreasing artery diesease. But they also can have serious side effects, and there are much better ways to treat chronic inflammation. Mostly lifestyle improvements.

    But the public has been brainwashed by the drug industry into thinking cholesterol lowering drugs actually improve health. There is an unfortunate myth, which is believed by most Americans, that we are becoming healthier and living longer because of ever-improving drugs.

    These myths, and the barrage of TV ads, makes the public very accepting of prescriptions. If their doctor prescirbes cholesterol lowering drugs, they are not very likely to object.

    And many doctors are probably brainwashed by the myths and TV ads also.

    So even if there were no corruption, the problem would still exist.

    1. Harriet Hall says:

      No matter how much you wish it were true, lifestyle changes have not been shown as effective as statins in reducing mortality (both cardiovascular and all-cause). Statins may have been over-hyped and over-prescribed, but their usefulness is not a “myth.”

      1. stanmrak says:

        Here’s a recent study that would dispute your assertion. Researchers at the University of Oxford say eating one apple every day matches the vascular benefits of modern statin drugs without the harmful side effects.

        In a study published in the British Medical Journal, the researchers found that prescribing an apple a day would prevent or delay around 8,500 vascular deaths such as heart attacks and strokes every year in the UK. Those results were very similar to the projected results of prescribing statins to everyone over the age of 50, without the side effects of statins.

        This is just from eating one apple a day… imagine if you made other similar preventive dietary changes.

        http://www.bmj.com/content/347/bmj.f7267

        1. WilliamLawrenceUtridge says:

          Hi Stan,

          For once we agree, an apple a day is good for you and more people would be better off if they followed this basic medical advice from their doctors. Too bad they don’t.

          Of course, that’s an aggregate piece of advice that might not apply to someone with familial high cholesterol, and the benefits of both an apple a day and a statin for those whom dietary improvement isn’t an adequate solution would save even more lives. It doesn’t have to be either-or, ideally it would be both.

        2. Harriet Hall says:

          Some of us know that you can never go by the results of a single study. Systematic analyses of the medical literature clearly show the benefits of statins.

          1. stanmrak says:

            “Systematic analyses of the medical literature clearly show the benefits of statins.”

            We know there’s a lot of bogus studies on statins. In addition, we really don’t know how many negative studies have been buried. The drug industry controls the medical journals and they can control what studies get published and which ones don’t.

            1. Harriet Hall says:

              Bogus studies? Name them and explain how you know they are bogus.
              The drug industry controls what gets published? Prove it!

              1. justsayno says:

                You can find a slight benefit for statins, but it’s only because of their anti-inflammatory effect. It is not because they lower cholesterol.

                There are better and less harmful ways to treat chronic inflammation. It mostly results from the deadly American lifestyle.

              2. Harriet Hall says:

                However statins work, they have been proven to reduce all-cause and cardiovascular mortality. No life style modification has ever been shown to accomplish that as effectively.

              3. justsayno says:

                “The drug industry controls what gets published? Prove it!”

                This post was all about corruption in drug companies. They do whatever they can get away with to increase profits.

            2. MadisonMD says:

              The drug industry controls the medical journals and they can control what studies get published and which ones don’t.

              Which is why it is amazing they allowed BMJ to publish the apple-a-day study! Perhaps big pharma is in bed with big apple. Together they dictate what is published, right Stan?

            3. Dave says:

              I seem to be reading a lot of published articles lately in the journals about medications NOT working. The most recent one I saw was published last week in the NEJM about preoperative clonidine. Here’s some of the abstract:

              “BACKGROUND
              Marked activation of the sympathetic nervous system occurs during and after noncardiac surgery. Low-dose clonidine, which blunts central sympathetic outflow, may prevent perioperative myocardial infarction and death without inducing hemodynamic instability.
              METHODS
              We performed a blinded, randomized trial with a 2-by-2 factorial design to allow separate evaluation of low-dose clonidine versus placebo and low-dose aspirin versus placebo in patients with, or at risk for, atherosclerotic disease who were undergoing noncardiac surgery. A total of 10,010 patients at 135 centers in 23 countries were enrolled. For the comparison of clonidine with placebo, patients were randomly assigned to receive clonidine (0.2 mg per day) or placebo just before surgery, with the study drug continued until 72 hours after surgery. The primary outcome was a composite of death or nonfatal myocardial infarction at 30 days.
              RESULTS
              Clonidine, as compared with placebo, did not reduce the number of primary-outcome events (367 and 339, respectively; hazard ratio with clonidine, 1.08; 95% confidence interval [CI], 0.93 to 1.26; P=0.29). Myocardial infarction occurred in 329 patients (6.6%) assigned to clonidine and in 295 patients (5.9%) assigned to placebo (hazard ratio, 1.11; 95% CI, 0.95 to 1.30; P=0.18). Significantly more patients in the clonidine group than in the placebo group had clinically important hypotension (2385 patients [47.6%] vs. 1854 patients [37.1%]; hazard ratio 1.32; 95% CI, 1.24 to 1.40; P<0.001). Clonidine, as compared with placebo, was associated with an increased rate of nonfatal cardiac arrest (0.3% [16 patients] vs. 0.1% [5 patients]; hazard ratio, 3.20; 95% CI, 1.17 to 8.73; P=0.02).
              CONCLUSIONS
              Administration of low-dose clonidine in patients undergoing noncardiac surgery did not reduce the rate of the composite outcome of death or nonfatal myocardial infarction; it did, however, increase the risk of clinically important hypotension and nonfatal cardiac arrest. (Funded by the Canadian Institutes of Health Research and others; POISE-2 ClinicalTrials.gov number, NCT01082874.)"

              I think it has been the case historically that if a drug company funds a study and the study is adverse to their drug the study is less likely to get published. There is a big movement now to correct this, although given the number of new drugs in development and the paucity of drugs actually making the cut this may produce a lot of useless articles. Anyone who actually spends time reading the journals will see articles which paint certain rugs in a negative light – I just used this example because it was fresh in my mind and took no trouble to cite. To state that drug companies control everything published is not accurate. They will do whatever they can to maximize profits but they don't own the journals.

        3. David Weinberg says:

          @stanmrak

          The apples vs statins study was NOT a clinical trial. It was data modeling using the actual effects of statins derived from randomized trials. The data for apples was modeled from epidemiology studies. Anyway, they were truly comparing apples and…..oranges. I wouldn’t put much weight to the results. I think the authors were having more fun than trying to do high impact science. The design was listed as:

          “Comparative proverb assessment modelling study”

          From the footnotes:

      2. justsayno says:

        That just is not true. Maybe if you have patients exercise 3 minutes a week for one month, you will not see improvement over statins. But lifestyle changes require time and commitment, and you may not see benefits immediately.

        But what you are saying is ridiculous. It is widely recognized even by mainstream medicine now that lifestyle is extremely important for physical and mental health.

        1. weing says:

          “That just is not true. Maybe if you have patients exercise 3 minutes a week for one month, you will not see improvement over statins. But lifestyle changes require time and commitment, and you may not see benefits immediately.”

          Because you say so?

        2. Harriet Hall says:

          What did I say that you think was not true or was ridiculous? What gave you the idea that I don’t recognize that lifestyle is extremely important?

          1. justsayno says:

            “No matter how much you wish it were true, lifestyle changes have not been shown as effective as statins in reducing mortality (both cardiovascular and all-cause). ”

            That is ridiculous. And your statement can’t even be interpreted, because we don’t know what the lifestyle changes were exactly, or for how long a period of time they were studied.

            Doctors usually recommend 30 minutes of aerobic exercise 3 times a week, or something like that. That is not nearly enough to make much difference, especially for someone whose health has already been damaged by decades of poor lifestyle.

    2. Andrey Pavlov says:

      many drugs, in general, control the effects of disease rather than the cause.

      O Rly?

      Antibiotics? Antivirals? Antifungals? Chemotherapy? Digoxin? Monoclonal antibodies? Viral based gene therapies? Anti-pyretics?

      I could go on. Those all very much treat the cause of the disease. Others like beta blockers, antihypertensives, diuretics allow us to regulate physiology for better outcomes in diseases that cannot be treated directly (if your heart muscle dies from a heart attack, there is no direct treatment – though we are working on that – so in the meantime we give beta blockers which improves mortality).

      Sorry mate, but that is a tired old trope that is so wrong it’s laughable.

      (learned today that “laughable” is one of the 1,600 words invented by Shakespeare)

      1. WilliamLawrenceUtridge says:

        Don’t forget about vaccines. Prevention FTW!

        1. Andrey Pavlov says:

          Well, sure, that too. But those were very specifically drugs that targeted the cause of a disease in progress. Let’s not overload our interlocutor’s brain by bringing in the idea of preventing the disease in the first place.

    3. MTDoc says:

      The only myth this doctor has been brainwashed into believing is that if you work hard and stay dedicated to your patient’s welfare, the system will reward you in the end. Maybe that was naivete, but it didn’t apply to primary care docs. As for being influenced by TV ads, you must think we are a sorry lot intellectually.

      1. Calli Arcale says:

        a) Everybody can be influenced to some extent by TV ads, whether they admit it to themselves or not. Doctors are not immune to this effect, though likely better armed against dubious claims.

        b) The real problem isn’t doctors being influenced by ads. It’s *patients* being influenced by TV ads, and that is in fact precisely the intent of such ads.

    4. WilliamLawrenceUtridge says:

      The public has been brainwashed into thinking drugs are good, the more the better.

      More options are certainly good, but I don’t think anybody wants individuals taking more drugs. Polypharmacy is recognized as a problem, and part of current drug development efforts is to reduce side effects so you don’t need to take multiple drugs to counter-act adverse effects.

      The TV news is interrupted about every 15 seconds for another drug ad, and these ads show people dancing ecstatically because they started taking yet another drug.

      Where I live, drug ads are rare – and thankfully so. Direct-to-consumer advertising is indeed a problem, I wonder if it helps anyone but Pfizer.

      One typical example is cholesterol lowering drugs — high cholesterol is very often a result of artery disease, not a cause. The cause is very often chronic inflammation and type 2 diabetes. Statins happen to be anti-inflammatory, so they can have some benefit in decreasing artery diesease. But they also can have serious side effects, and there are much better ways to treat chronic inflammation. Mostly lifestyle improvements.

      It would be great, all doctors would agree, that lifestyle improvements would be hugely helpful to nearly every single person on the planet. It’s too bad that many people don’t undertake such improvements, and that for some their first wake-up call means they either must take a drug to resolve an acute problem, or kills them outright, or renders them unable to undertake such improvements. If patients listened to the preventive advice offered by doctors, the CDC, the FDA, the USDA, the NIH and yo’ mama, their lives would involve far fewer drugs and much greater quality of life. Not that you can blame doctors, the CDC, the FDA, the USDA, the NIH or yo’ mama for patients not exercising or putting down the fork.

      But the public has been brainwashed by the drug industry into thinking cholesterol lowering drugs actually improve health. There is an unfortunate myth, which is believed by most Americans, that we are becoming healthier and living longer because of ever-improving drugs.

      Sounds like you might have been brainwashed by cholesterol skeptics than the opinions of medical researchers. Merely because an opinion is iconoclastic or appeals to the malfeasance of Big Pharma, doesn’t make it right.

      1. justsayno says:

        Most people seem to be unaware of what is required for health. They do not seem to know how damaging processed food and lack of exercise really are. Their MDs give them cholesterol lowering drugs, without ever explaining that high cholesterol very often results from refined carbohydrates and lack of exercise.

        Maybe their MDs are not aware of these simple facts. I recently had a conversation with someone whose parents have artery disease, and she told me it was becasue they eat too much salt. It turns out that her parents have type 2 diabetes. I explained that salt is mostly irrelevant, and that her parents had strokes because they have diabetes, and they have diabetes because they eat refined carbohydrates and never got any exercise.

        I don’t think she believed me, because that is not what the doctor told her.

        And this is one example out of many I have heard over the years.

        1. Harriet Hall says:

          I hope what her doctor told her was more nuanced than your explanation. It would be great if we could avoid diabetes simply by exercising and avoiding refined carbohydrates, but it’s not that simple.

          1. justsayno says:

            Most of the time, type 2 diabetes can be avoided just that simply. The disease is extremely rare in cultures that do not follow the typical American lifestyle of no exercise and plenty of refined carbohydrates.

            And it’s hard to believe you don’t know this.

            1. Harriet Hall says:

              Do they follow the typical American lifestyle in Tokelau? Did you know the prevalence of diabetes in that country is the highest in the world at 37.5% of the population? You might want to do some research before you make assertions that do not match the facts. See http://healthintelligence.drupalgardens.com/content/prevalence-diabetes-world-2013

              1. justsayno says:

                http://www.ncbi.nlm.nih.gov/pubmed/2777000

                Harriet I hope you will educate yourself, for the sake of your patients. This is serious. There are way too many MDs like you, who tell their patients their diabetes 2 is genetic, and lifestyle improvements won’t help. Just take the drugs.

                “The factors most likely contributing to this difference, are changes to a higher calorie, high protein diet, higher alcohol consumption, a greater weight gain and altered levels of physical activity in the migrants. A number of populations in the Pacific have been shown to have a low rate of diabetes in their traditional setting, but may have a genetic predisposition for diabetes which responds to factors in the urban industrialised environment and life-style.”

              2. Harriet Hall says:

                Don’t be silly! I have never said lifestyle improvements won’t help. I merely questioned your blanket statements that do not correspond to the facts. I defy you to find a single MD who has ever told patients their diabetes is only genetic and lifestyle improvements won’t help!

              3. Windriven says:

                “There are way too many MDs like you, ”

                And way too many liars like you.

                Why did you leave this part of the abstract out of your citation:

                may have a genetic predisposition for diabetes which responds to factors in the urban industrialised environment and life-style. ”

                That isn’t just cherry-picking.

              4. justsayno says:

                “Do they follow the typical American lifestyle in Tokelau?”

                Well Harriet, your question implies that you don’t think they have diabetes because of lifestyle. In fact, you are very wrong.

                People who live in traditional cultures have never been found to have diabetes 2. (If you don’t like the word “never,” substitute “almost never” or “very seldom”).

                Diabetes 2 is entirely (or nearly entirely) a result of overly processed food, and an inactive lifestyle.

                THIS IS EXTREMELY WELL KNOWN.

                So your questioning it is bizarre.

                There are always genetic factors. People who have lived in industrial cultures for generations may have adapted somewhat to the unhealthy lifestyle, while newly industrialized cultures may be more vulnerable.

                That is just a theory, I am not proposing it as an established fact.

                But there definitely are established facts on this subject. The effects of the industrial (which I referred to as “American”) lifestyle are very very well known.

                “I defy you to find a single MD who has ever told patients their diabetes is only genetic and lifestyle improvements won’t help!”

                They might not say in explicitly, but it often is implied. Your statement about Tokelau, for example, strongly implied that their high rate of diabetes 2 is genetic. You did not know that their lifestyle has become industrialized.

                And what MDs do NOT say is also important. I know of many examples of patients who were encouraged to take drugs for high blood pressure or cholesterol, but were NOT told that lifestyle is critical.

                And if they were told to exercise, it was only 20 minutes 3 times a week.

                If they were told anything about nutrition, it was to not eat salt, red meat or eggs. They did NOT get diabetes from those things, they got it from white flour and white sugar, but the MDs did not mention those.

              5. Harriet Hall says:

                “People who live in traditional cultures have never been found to have diabetes 2″
                Citations, please. Did you look at the link I provided, showing the incidence of diabetes in different countries? Is that data consistent with your hypothesis?

                You contradict yourself. You say “Diabetes 2 is entirely (or nearly entirely) a result of overly processed food, and an inactive lifestyle.” and then you say there are always genetic factors. What percentage of diabetes cases do you think can be attributed to genetic factors? Have you ever seen a skinny person with an extremely active lifestyle who nevertheless developed type 2 diabetes? I have.

                Diet and exercise are important, but I think you are grossly oversimplifying a complex issue.

              6. Harriet Hall says:

                Another thought about traditional societies. Most people with type 2 diabetes are asymptomatic, so it’s plausible that diabetes was not found in traditional societies simply because no one did blood tests to look for it.

              7. WilliamLawrenceUtridge says:

                Harriet I hope you will educate yourself, for the sake of your patients. This is serious. There are way too many MDs like you, who tell their patients their diabetes 2 is genetic, and lifestyle improvements won’t help. Just take the drugs.

                This makes it sound like doctors never measure patient cholesterol, they just give drugs. I’m pretty sure that’s not how it works. I’m pretty sure you’re setting fire to a straw man.

                Also, traditional lifestyles are often very good at maintaining low cholesterol, because they usually involve a lot of exercise (work) and a lot of unprocessed (often highly uniform) foods. But once the switch is made to first-world-type diets, traditional peoples tend to get very sick, very quickly. It would be great if we could manage to get everyone to stick to a high-exercise, low-processed diet lifestyle, traditional or not. But the reality is, most people don’t. It’s hard work, and modern conveniences take away a lot of the incentives and necessities to expend energy. Humans are naturally lazy, they are naturally going to gravitate towards less exercise and simpler foods. That’s why dieting and exercising is difficult to maintain in a land of surplus and sloth. But just pointing this out doesn’t magically make people eat better and exercise more.

                As all doctors know.

                People from traditional societies really do seem to have strong genetic predispositions to type II diabetes in the presence of affluent lifestyles, but the solution to this problem is not obvious. Are you going to force them to adopt their traditional diets and lifestyles? Have you ever survived when your primary source of food comes from chopping down a coconut tree, hollowing out the pith, running water through it for days, chewing the pith, letting it ferment, then eating it? Sure, it’s great for type II diabetes, but there’s substantial risk of malnutrition, and I for one lack the 60 hours per week it takes to do so in addition to my full-time job (and posting comments here).

        2. Angora Rabbit says:

          Hi, Justsayno. (sorry that feels so weird to type) You’ve got part of the message but not a complete one. Best current data are showing that NIDDM risk is roughly 50/50 environmental/genetic. But the genetic predisposition is very strong and should not be ignored. I tell my students that “genes load the gun, and environment pulls the trigger.” Certainly keeping insulin values lower (by reducing intake of simple sugars) and exercising more (which increases expenditure, but also can increase intake!) can be helpful, but by no means is it the only cause or cure. Our recommendations are for people to consume no more than 10% of calories as refined or discretionary sugar.

          Certainly what you suggest about the sugar and exercise can be helpful. But what to do when people follow that advice (so think they are) and the NIDDM still happens? Then they won’t follow any advice. Rather than being absolutist, we teach people to make a series of changes that, individually, are small but collectively have a real impact.

          I have to add that the salt might be relevant to CVD if they are hypertensive, which increases the pressure in the pipes atop the already increased vascular resistance. And assuming they are salt-sensitive, but in reality most westerner (and easterners!) are consuming more salt than needed. Cooking more rather than eating crap in a box, as you say, is a good way to reduce salt,and at the same time also helps in reducing dispensable sugar. So it really is connected with small steps.

        3. Sawyer says:

          “They do not seem to know how damaging processed food and lack of exercise really are. ”

          Out of the dozen or so writers and hundreds of regular readers on this site, I’m going to offer you a ballpark estimate:

          ZERO people think constantly eating large amounts of fast food high in saturated fats, cholesterol, and sugar is a healthy lifestyle.

          ZERO people think a lack of exercise is a healthy lifestyle.

          Where the heck do all these mythical doctors that give terrible medical advice reside? Narnia? Wonderland? I have yet to see one on this site or in an actual hospital.

        4. WilliamLawrenceUtridge says:

          Justsayno, do you really think that patients are unaware of the fact that they should eat less processed foods, more fruits and vegetables, and get more exercise? Because I’ve been hearing about the obesity epidemic for over a decade now – it might have sunk in.

          Yes, doctors dispense cholesterol-lowering drugs. If patients improve their diets and get more exercise, and that lowers their cholesterol sufficiently, their doctors take them off the drugs. If patients do not do this, their cholesterol stays high and they stay on the drugs.

          Now, in this scenario, who bears responsibility for lowering the patient’s cholesterol?

  3. Liz says:

    I do not understand why drugs are allowed to be advertised on TV. Prime time TV is full of ads for prescription drugs. Clearly this is profitable for the drug companies or it would not be done. We are all living longer better thanks to advances in medical care but problems persist that can be easily corrected. Doctors should be informed by the drug companies about new products. Consumers should learn from the doctors about products available to help them. Direct marketing to consumers is not allowed in many countries and should not be allowed in the US. Spend that money on your sales to doctors and maybe less incentive to pressure not needed sales of a product.

    1. Windriven says:

      Agreed. Prescription drugs should not be advertised in the mass media. The sub-rosa to my ear is: “your physician isn’t likely to prescribe this crap without a push so YOU go an plead for it.”

      I always laugh at the disclaimers though. A drug for some chronic irritation may cause everything from sexual disfunction to cancer of the toenails to sudden inexplicable death – but that’s a small price to pay for freedom from, whatever, rosacea.

      1. stanmrak says:

        Very few people pay attention to the disclaimers because they are being spoken as you’re shown visuals that are designed to distract you. It works. Drug companies can advertise on TV because the media and the drug companies are owned by the same people, the ones that also own Congress.

        1. WilliamLawrenceUtridge says:

          Again we appear to agree – direct to consumer advertising is probably not good for the consumers! Somebody mark the calendar!

          Doesn’t mean drugs don’t work, or there are non-drug alternatives for all things that risk human health, but at least on this bare marketing point, we agree. Hooray!

    2. Frederick says:

      Here in canada Only non-prescription drug can be advertise, like Tylenol, cough syrup ( excellent post on SBM about how many of those do not really work). And of course “natural” supplement and all that woo can also be advertise.
      But you don’t see Prescription for Zolof :-)

      1. CHotel says:

        One of the few things I like about Health Canada.

        We do have some flaws though. Reminder ads (The ones where no indication for the drug are mentioned: “Zoloft, talk to your doctor”) are allowed to run all the time unfortunately, apparently due to some weird policy loophole that I don’t understand. We also get an influx of pharmaceutical ads on American TV channels that we can’t really do anything about.

        1. Frederick says:

          Yeah, I know, since I watch lot of Us show ( big bang theory for the win!) We see a lot. I’m not a lawyer, but i know they are more regulated than in the us BUT still need to be tighten i guess.

  4. S Endecott says:

    Would not an appropriate answer to the question posed by the sales rep be, “show me that the efficacy, safety and value of your particular product is in line with the needs of my patient”? Would that not be a legitimate answer to the not-necessarily-corrupt statement inquiring “what’s it going to take to get you to prescribe more of my product”?

    And, while I abhor many aspects of the pharmaceutical industry — most notably, the scum that is Glaxo (RIP SK&F), sales reps have a job and serve a purpose. They are trained to “close the deal” and, perhaps, the green rep was just, awkwardly, honing his/her approach.

  5. KillCurve says:

    A complex issue indeed. Breaking of big pharma scandal stories make me cringe as they are used to fuel consipiracy theorists, but at the same time they remind me that inevitable corruption is being actively policed. I would really like to see a reasonable estimate of the incidence. There clearly is a need for evolving regulation, but without any idea of the overall public health impact from this type of corruption it seems very tough to know the best course of action.

  6. “Gone are the previously ubiquitous drug lunches, branded gifts, and sponsored trips.”

    Fantastic. I did not know that. Probably a lot of people assume it’s still going on, as I was.

    1. Windriven says:

      Paul,
      I think those things are more gone in large urban centers than in smaller and more rural ones. And I’m not sure the sponsored trips are all that gone anywhere.

      And even Crislip has a branded gift from a medical company :-)

      1. MTDoc says:

        A quick laugh! I use rolls of exam table paper in my workshop to protect my bench surfaces from paint stains. The Clinic can’t use it because along the edge is the word “fosamax”. Shameless.

      2. Mark Crislip says:

        Just to be clear, the Unasyn rep, who did not care for me, sent me a Fleets enema with a Unasyn sticker on it. I keep it proudly on my desk, the only thing I have ever accepted from pharma

        1. Windriven says:

          And every time I imagine the exchange and what you thought and what the drug rep thought, I chuckle out loud. A rare case of ‘a good time was had by all.’

          1. Windriven says:

            “sent me”

            Crap. In my imagination the gift was presented in person. I’m not sure how little you thought of the drug rep. It couldn’t be much less than I think of him now that I know he wussed out and mailed it.

      3. thorhauff says:

        I work in rural healthcare in Oregon and we do get any drug rep subsidies. That is federally regulated.

    2. stanmrak says:

      Whatever steps are taken to prevent corruption, new ones will be designed and implemented. You can be sure of that.

      1. WilliamLawrenceUtridge says:

        Wow, three times in one day! Indeed, people and companies are reactive to new legislation! And this observation applies just as much to quacks and SCAM pushers too – prevented from making specific claims, they use instead structure-function claims and the Quack Miranda Warning.

        Now there’s a loophole that should be sealed – you should only be able to advertise or list conditions for which well-designed RCTs exist, none of this “support eye health” nonsense. Quacks will still push them (and often sell them from their own offices, which doctors are forbidden to do), but at least someone walking into a pharmacy will find less nonsense thrust into their vision.

        1. Windriven says:

          “Wow, three times in one day!”

          The “End Times” must be upon us. I think I’ll convert. What did Southpark say the right religion is?

          1. CHotel says:

            I think it was Mormon, though I could be confusing it because they’ve made fun of oh so many religions.

            1. Windriven says:

              I think you’re right but I’ve not been able to find the episode though I remember the scene vividly.

            2. Frederick says:

              yes it was the Mormons :-) That ones is funny!
              I’m a Atheist, so i guess I’m going to party in HELL!!! lol

              1. Windriven says:

                Well bring along a bottle of your favorite libation. I’m looking forward to having a drink with Christopher Hitchens, Thomas Jefferson, and Bertrand Russell.

                Seriously, who would you rather have a chat with, Isaac Asimov or Benedict XVI? Come to think of it, you might not have to choose!

              2. Frederick says:

                Oh man, Isaac Asimov, and also Carl Sagan. Around a good beer, that Hell would be a Heaven! hehe.

          2. stanmrak says:

            There’s far more truth in South Park than in most of the mainstream news media.

            1. Frederick says:

              especially the episode where they laugh about conspiracy theorist, and make fun of The 9/11 conspiracy. They also do the same about Scientology and Quack like that. Lot of Scam, medium and thing like that go in the grinder.

              1. Jason says:

                They also make fun of the people who think that vaccines cause autism in the episode “assburgers” and “you’re getting old”

          3. WilliamLawrenceUtridge says:

            Well, God was a Buddhist…

    3. Eldric IV says:

      The lunches, gifts, and trips are not entirely gone but they are much less ubiquitous.

      With greater scrutiny of Pharma-physician relations, a lot of attention has shifted to pharmacists. Just the other week, we had a visit from a drug rep who obliviously prattled on about what was and was not reportable with respect to gifts, marketing materials, and other freebies she was offering for our pharmacy section vs our hospitalists. Her tone indicated it was all such a bother.

    4. Xplodyncow says:

      Those freebies are generally not used anymore. Around 2008, I think, several pharmas agreed to stop handing them out. It’s a voluntary agreement, of course, not a mandate.

      However, the so-called Sunshine Act went into effect this year. So if a pharma company wants to give HCPs a gift, it needs to cost less than $10, or their names go on a publicly available list.

  7. dh says:

    1) I would like to see all direct-to-consumer advertising and drug rep interactions with physicians eliminated.

    2) I disagree with the point being made that drug companies provide an important educational service to physicians. Sure maybe to lazy physicians or those who are too busy to read independent journal synopses (like ACP Journal Club or Annals of Internal Medicine year-in-review). But I wouldn’t want to be the patient of a physician who was so busy or lazy that they couldn’t get their education from anything else than a drug rep. Do you think that drug rep is actually going to provide unbiased information on his or her competitor’s products, including generics? Highly unlikely.

    3) The question is what to do about the smorgasboard of conferences supported by drug companies. With more and more information being accessed online and free of charge, actual conference attendance at educational events is bound to decline. I would like to see either totally unrestricted educational grants given by industry or pull industry out entirely (phasing it out over time). May be unrealistic, but most ideals are unrealistic, especially when juxtaposed with the current corrupted reality (the Voting Rights Act was viewed as unrealistic in the early 1960′s). Time to think big.

    I stopped attending industry-sponsored events a long time ago. I don’t take their pizza, pens or bags. I try to get my content directly by reading trials that come out. I understand there is pernicious influence there too but I don’t need some drug rep or bought-off KOL interpreting trial data for me.

    1. WilliamLawrenceUtridge says:

      I disagree with the point being made that drug companies provide an important educational service to physicians. Sure maybe to lazy physicians or those who are too busy to read independent journal synopses (like ACP Journal Club or Annals of Internal Medicine year-in-review).

      You might be wrong in this. There was a study a while back that corroborated this very point – drug reps did increase appropriate prescriptions of novel medications superior to existing drugs. Of course, the “superior to existing drugs” part is really a big problem since there are so many “me too” drugs. But there is evidence. But not regarding generics, the article was specifically about novel drugs.

      Plus, drug reps would know doctors and their specializations, and thus how to target their efforts and pitches. As Dr. Crislip said once, reading the medical literature is like trying to drink from a firehose, and pharma reps can predigest it for them. Like so many things, I question whether it is black and white.

      But still, I would never endorse free-for-all drug reps and gifts. A knotty question.

  8. Ed Whitney says:

    “I don’t say that all these distinguished people couldn’t be squared; but it is right to tell that they wouldn’t be sufficiently degraded in their own estimation unless they were insulted with a very considerable bribe.” –The Mikado

    An insult of a mere £100 would be wholly insufficient to degrade me in my own estimation.

    A much more demeaning insult would be required.

    1. MTDoc says:

      Sort of reminds one of the joke whose punch line is something like, “I know what you are, just trying to determine the price.” Better stop now before I’m “moderated.”

    2. Alia says:

      Remember that in Poland docs, especially the onces who are employed only in state-run hospitals and practices, earn much (and I mean _much_) less than the ones in the US or UK. So yes, GBP100 can be a tempting bribe over here.

  9. Mary Russell says:

    My office stopped hosting drug reps about a year ago. This was a decision that was made by my husband (and family practice co-worker) and I once we had the political clout in the office to push it through. Although some of our coworkers enjoyed the social interaction with the reps, we (natural introverts) resented the presence of reps in the hallway, who took up our time with biased, industry driven charts and sales pitches. We were trained to practice evidence-based medicine, and (I would guess) 90% of our prescriptions can be bought off the $4 list at Walmart. Most of the drugs the reps pushed offered marginal benefit compared to the generics. I once had a rep tell me I should prescribe his version of fish oil because it had fewer side effects. When pressed for details, he admitted that there was no endpoint data proving greater efficacy for prescription fish oil, and that the diminished side effects included 3 fewer burping episodes per day- all for a price of $50/month more than generic OTC fish oil tablets! Good grief.

    1. Rokujolady says:

      Those fish-burps ARE pretty awful, though

  10. PMoran says:

    “The public has been brainwashed into thinking drugs are good, the more the better.”

    Maybe a little. However, the billions of dollars spent upon supplements and various forms of CAM suggests that the drug companies are (also) mainly just tapping into more basic human medical needs and wants, possibly during an era of exceptionally high expectations of medicine.

    Health economists have long accepted that there is virtually no limit to the ability of the public to consume health services. I guess nearly everyone would like to feel better in some way or other, and we can also derive pleasure from taking actions, such as taking vitamins, that we think are good for us (so long as it doesn’t involve a lot of effort – like exercise or dieting).

    This “compulsive” aspect to the consumption of medicines is one reason why public access to harmless placebo-type palliatives, such as those of CAM, can arguably be a good thing — helping to reduce adverse drug reactions, side effects and interactions and other problems when unnecessarily powerful drugs are used for minor complaints. (There are complementary pressures upon doctors to over-prescribe once they become involved).

    The sad paradox is that we have drugs that are so close to providing the public with a blissful (diazepam and other drug types), almost pain-free (opiates), existence, but not without the habituation and other ill effects that so far make that impossible.

    1. Windriven says:

      Well said.

    2. justsayno says:

      “The sad paradox is that we have drugs that are so close to providing the public with a blissful (diazepam and other drug types), almost pain-free (opiates), existence, but not without the habituation and other ill effects that so far make that impossible.”

      What?? There is no substance that can make you blissfully high without a corresponding low. Even if there were, pain and anxiety have important warning functions.

      So I really can’t figure out what you are saying.

      1. WilliamLawrenceUtridge says:

        What?? There is no substance that can make you blissfully high without a corresponding low.

        Indeed, that’s what makes addictive drugs addictive. Most addicts are generally no longer seeking the high, they are seeking to avoid withdrawal.

        Even if there were, pain and anxiety have important warning functions.

        Absolutely, but two points:

        1) Pain and anxiety’s warning functions don’t make them any more pleasant to endure.

        2) The nature of what these feelings portend have changed dramatically since the evolutionary pressure to create them in the first place occurred. To the point that in many cases both pain and anxiety can become island problems independent of any meaningful warning.

  11. Davdoodles says:

    Bbbuutt… talking mean about GSK kind of undercuts the whole notion that we are all Big Pharma Shills.

    Presumably now, the ant-science seagulls will only be able to to caw about us being “Big Pfizer-and-Bayer-and Merck Shills”

    Wait, I forgot. They always conveniently utterly ignore the many posts on SBM about issues with the pharma industry.
    .

  12. Alia says:

    I’m Polish and our officials claim that this case with GSK has been investigated since 2012, with no new developments as of today – that’s for one.

    The second point that I want to make – our healthcare system is quite complicated, with free-of-charge medical care available to everyone who has an insurance (and most people are). However, doctors employed in state-run clinics and practices earn very little. Many are employed by private practices and hospitals (which make a lot of money because state-run system is not efficient and you sometimes have to wait several months to see a specialst or have a non-emergency surgery). But those that are not, will be more susceptible to corruption. And also, our state-run hospitals are so poor that they cannot afford to send their staff to medical conferences, so conferences hosted by pharma companies are often the only conferences that those physicians will attend.

    Of course, nothing of this is in any way an excuse for corruption, I just wanted to shed some light on the situation over here.

    And a COI disclosure – my cousin used to be a rep for Pharmacia Upjohn, back in 1990s, engaged in shameless promotion of Zyrtec (which nowadays is available OTC, so you just need a good TV ad).

  13. justsayno says:

    You contradict yourself. You say “Diabetes 2 is entirely (or nearly entirely) a result of overly processed food, and an inactive lifestyle.” and then you say there are always genetic factors. What percentage of diabetes cases do you think can be attributed to genetic factors? Have you ever seen a skinny person with an extremely active lifestyle who nevertheless developed type 2 diabetes? I have.

    THERE ARE GENETIC TENDENCIES THAT WILL NOT CAUSE DISEASE UNLESS THERE ARE ALSO LIFESTYLE FACTORS. THIS SHOULD NOT NEED TO BE EXPLAINED>

    Diet and exercise are important, but I think you are grossly oversimplifying a complex issue.”

    YOU ARE CONFUSING A COMPLEX ISSUE. INTENTIONALLY, IT SEEMS.

    People who do not have access to processed food, who live in a traditional culture, who are not physically inactive VERY SELDOM get diabetes 2. THIS IS EXTREMELY WELL KNOWN.

    You need to advocate drugs, for some reason.

    Sometimes, a person with a healthy lifestyle might get diabetes 2. Anything at all is possible. But is it probable? No, not at all.

    1. Harriet Hall says:

      “THIS IS EXTREMELY WELL KNOWN.” Maybe so. If it is, it should be a very simple matter for you to provide links to the evidence. Please do that. I agree that there are genetic predispositions that will not cause disease unless there are also lifestyle factors. I’m not sure diabetes is one of them. Show me credible evidence, and I will follow it wherever it leads.

      No, I don’t need to advocate drugs. I only need to advocate what works. I advocate exercise and healthy diet, and I only advocate drugs when the first two don’t control the disease.

      1. justsayno says:

        “The much lower prevalence of type 2 diabetes and obesity in the Pima Indians in Mexico than in the U.S. indicates that even in populations genetically prone to these conditions, their development is determined mostly by environmental circumstances, thereby suggesting that type 2 diabetes is largely preventable. This study provides compelling evidence that changes in lifestyle associated with Westernization play a major role in the global epidemic of type 2 diabetes”

        http://www.ncbi.nlm.nih.gov/pubmed/16873794

        It took me about 5 seconds to find this. If it isn’t enough to convince you, I could spend another 30 seconds and find plenty more.

        1. weing says:

          “This study provides compelling evidence that changes in lifestyle associated with Westernization play a major role in the global epidemic of type 2 diabetes”

          What are the relevant changes in lifestyle associated with Westernization of the Pima?
          What was the means of transportation in the past for them? What is it now? What was the average length of starvation periods in the past? What is it now? What happens when you inherit genes that allow you to survive prolonged periods of starvation and you remove the starvation?

        2. Harriet Hall says:

          “The much lower prevalence of type 2 diabetes and obesity in the Pima Indians in Mexico than in the U.S. indicates that even in populations genetically prone to these conditions, their development is determined mostly by environmental circumstances, thereby suggesting that type 2 diabetes is largely preventable.

          It most certainly is NOT “enough to convince me.” It shows correlation, not causation. Do you understand the difference?

          1. justsayno says:

            Harriet I certainly do understand the difference, but obviously you don’t.

            They compared Pima Indians with traditional lifestyles to Pima Indians with Industrialized lifestyles. Genetics is relatively constant between the groups, and environment is very different.

            I cannot imagine how you can see this as mere correlation.

            It is what we call a “natural experiment,” which strongly suggests causality even though it was not deliberately designed.

            A similar kind of example would be identical twin studies, where the twins happen to have been raised separately in different environments. Conclusions can be drawn about the role of genetics vs environment in various diseases, etc.

            Twin studies are extremely well known and it is not possible that you never heard of any.

            The study I linked is not a twin study, very obviously, but it follows a similar pattern.

            The main difference between the groups is lifestyle. And considering that we already know (or should know) that lifestyle is the major factor in diabetes 2, the conclusion of the study is not at all surprising.

            But you seem to be in deep denial about this, and unable to think rationally on the subject.

            Others skeptics here are saying almost the same thing as I am, but you seem incapable of seeing what hardly any scientific person could possibly deny.

            1. weing says:

              “The main difference between the groups is lifestyle. And considering that we already know (or should know) that lifestyle is the major factor in diabetes 2, the conclusion of the study is not at all surprising.”

              The question is how much does lifestyle need to be changed? Do we just shut-off gas, electricity, and food supply to these people so that they can enjoy the pre-Western lifestyle and its benefits of not having diabetes? I don’t think so. There were similar benefits noted in Europe, with less heart attacks, from the deprivations caused by WWII. Try getting people to deprive themselves of modern, so-called Western, conveniences.

            2. Harriet Hall says:

              As Weing has pointed out, that kind of natural experiment is not sufficient to prove causation because there are too many possible confounders. You yourself speak of “the main” difference; surely an “industrialized” lifestyle involves other differences besides the specific aspects of diet and exercise that you are thinking of. Without further studies to pinpoint specific causal factors, all you have is speculation. The history of science has demonstrated over and over that that kind of speculation, no matter how logical and compelling, often proves to be wrong.

              1. justsayno says:

                What you are saying is complete nonsense.

                The article I linked is good evidence, especially since there are many many others showing the same thing. There are controlled experiments showing the same thing.

                I can only conclude that you are stubbornly determined to deny some obvious facts, just because you like to advocate certain drugs.

              2. MadisonMD says:

                Harriet and Weing are saying that there were many differences between the populations. This study alone cannot determine which variable is responsible for different rates of diabetes in the two populations. It only says that 18-22% or less of the effect appears to be purely genetic.

                I think there are other lines of evidence supporting the idea that obesity, excess caloric intake, and perhaps excess simple sugars play a role in causation, so I would not dispute.

                None of this refutes the need to manage diabetes with drugs, as you seem to be arguing, justsayno. Only it argues that we should also focus on caloric intake and reduce obesity. This is why it is standard of care for MDs to counsel weight loss and refer to dietician for all new diabetics. This is why there is a focus of pediatricians and adult primary care providers on managing childhood and adult obesity in their patients.

                You are creating a false dichotomy.

        3. MadisonMD says:

          I find justsayno’s article fairly compelling evidence. You have a (reasonably) genetically matched population living in two countries, one with higher obesity and a measured* diabetes rate of 34% (male), 41% (female), the other with a rate of 6% (male), 9% (female). That would suggest that the majority (but not all) of the risk in the U.S.-located population is due to environmental factors.

          Some caveats: (i) Not a perfect genetic match–as indicated by Harriet, it is possible that one population differs substantially from the other; (ii) external validity– the magnitude of the environmental-versus-genetic effects could be different in other populations. Yet, I think it is fairly compelling.

          Despite justsayno’s argument, we still need to treat diabetics with medications that reduce the risk of kidney failure, heart failure, blindness, infection. Also, they should be referred to a dietician, advised to loose weight, increase activity, avoid simple sugars.

          Yet, justsayno’s evidence argues for public health measures to improve diet, exercise, reduce obesity. Well, actually we do. Do we invest enough in public health? I don’t know– it depends on the effectiveness of public health measures.**

          I suspect that “Just say no” is not a terribly effective public health policy.

          ————————-
          *It is important to actually measure the rate rather than rely on reported rates because it may be under-reported in one population that has poor access to care.
          **By the way, physicians have strongly promoted changes to reduce obesity and use healthstyle changes diabetes. Guidelines specify referral of all diabetics to dietician. The AMA has CME training modules for physicians on managing obesity. Could more be done? Probably. But few interventions seem to strongly impact lifestyle habits.

  14. Dave says:

    There was an article in the NEJM 1991 325:147 giving the following data.

    For people with a body mass index of less than 24, the rate of diabetes was approximately 7/10,000 patient-years. In this weight range the amount of exercise had no effect on the incidence of diabetes

    For people with body mass index between 24 and 25.9, the rate was 13/10,000 patient years for those exercising more than 2000kcal/week and 18/10,000 pt-years for those exercising more than 2000 kcal/wk

    For people with body mass index greater than 26, the rate is about 50/10,000 pt years for those exercising less than 555 kcal/wk, 40/10,000 pt/years in those exercising 500-1999 kcal/week, and 36 for those exercising more than 2000 kca/week.

    There’s a chart in UpToDate showing this but I couldn’t get it to copy over. I think we can say that if you eat too much and exercise too little you increase the chance you will get diabetes, but you can do everything right and due to genetics, unknown environmental factors or bad luck still get type 2 diabetes.

    1. Dave says:

      the middle paragraph should read “less than 2000 kcal/wk” for the 18/10000 incidence. There’s no edit capability on these posts unfortunately, and I’ve been up all night. Sorry for other misprints here.

  15. Self Skeptic says:

    Steven Novella said:

    Assuming the charges are upheld, such cases are very damaging to public confidence in the system. This is similar to cases of researchers faking their published research — I cringe every time I read about such cases.

    There are some important questions, however: how common are such occurrences? And is this the isolated corruption of these individuals, or is it endemic in the system? The first question is difficult to answer. We can only know about exposed cases. Given the number of physicians and drug reps in the world, however, and the fact that the number of such cases that come to light are relatively few it would seem that such cases are the exception rather than the rule.

    We don’t need to speculate about the prevalence of big corporations (mostly pharmaceutical) improperly influencing medicine. There are many books, by highly respected MDs, that have been written about It. Why not read some, and add this crucial factor to the SBM world view? (I’m assuming that people devoted to SBM and skepticism, will put discerning the truth, ahead of maintaining public confidence in the system. Science is dead, without a primary commitment to reality, over public relations.)

    This latest GSK peccadillo is just one small episode in a big problem that has been developing for decades. The solution, for medical academics and scientists, is difficult, because no one can make a new drug or device available, without the collaboration of a pharmaceutical company, large or small. I’m a scientist, doing work in mammalian biology relevant to medicine, so I’ve thought about these issues. After the first few months, or years of outrage at how big corporations pursue their goals, it becomes clear that simply demonizing the entire industry, isn’t the best option (though specific condemnation of certain corporate practices, seems appropriate.) I think the best alternative, is to get a good detailed understanding of all the ways science and medicine can be, er, improperly influenced, by corporate goals and ethics. We can’t get that, while being too squeamish to look at it without blinking.

    I’m personally more worried about corporate influence on medical academics who dominate their fields, because when they get things wrong, it affects millions of patients. But the little guy who takes 100 pounds, or $100, matters too. I’m also worried about a backlash, already apparent in some fields, that will result in some fields swinging toward underdiagnosis and underprescribing, in the mistaken impression that this is how to fix the problem. That is just another sweeping bias; it won’t result in better medical care, over all. The real fix, is attention to detail, guided by a robust appreciation of all the factors in play.

    The good thing about thoroughly referenced books, is that you don’t have to agree with the author’s views about everything, to appreciate the facts they’ve collected and referenced. For example, if you’re inclined to distrust some individual author’s point of view, you still have recourse to his or her citations.

    The idealistic things we were taught as young people about how medicine works, and how big companies work, should probably be tempered by evidence of how they’re really working, when writing for an adult public. It’s not something you’d want to tell young grandchildren; but I think it’s somewhat questionable to write about the topic in public, without getting thoroughly educated on the facts of the matter. Spreading comfortable illusions is not the job of science, or of skepticism. Even if the comfortable illusion is about how pure and trustworthy our professions (medicine and science) are.

    There is a pretty solid consensus that the relationship between medical science, and big corporations, needs some reform. I think it has to happen within medical culture. Doctors mostly want the best for their patients, so they have an incentive to change. And they mostly have the intelligence required to do it. (The health sector corporations are meeting their goal, making big profits for executives and stockholders, so they have no incentive to change.) Mere laws can’t deal thoroughly with this kind of thing; they are always several steps behind.

    I’m listing so many books, because everybody doesn’t like someone. ;) If you don’t like one of these authors, read one or more of the others. They are all available at my local public library, and of course at online bookstores. Some are available as e-books and audio books.

    All of the following are thoroughly referenced, written by people with good professional credentials, and well-written enough for enjoyable reading.

    There is usually a tone of outrage in these books; but that shouldn’t bother SBMers. ;) It’s because the authors haven’t lost their sense that we can, and should, do better than this, as a profession (medical and/or scientific), and as a wider culture. In other words, they aren’t shruggies about these issues.

    Bad Pharma: How Drug Companies Mislead Doctors and Harm Patients (2013) by Ben Goldacre, MD (Skeptic in good standing, due to his book Bad Science, so I recommend this one first for SBMers. I like his concept of “fake fixes;” there is a lot of that going around.

    Deadly Medicines and Organised Crime: How Big Pharma Has Corrupted Healthcare (2013)
    by Peter C. Gotzsche, MD, Cochrane Collaboration
    Forwards by Richard Smith, MD (former editor, BMJ) and
    Drummond Rennie, MD (former editor, JAMA)

    How We Do Harm: A Doctor Breaks Ranks About Being Sick in America (2012)
    Otis Webb Brawley, MD (Emery U, former chief medical officer of the American Cancer Society), Paul Goldberg

    Overdiagnosed: Making People Sick in the Pursuit of Health
    by H. Gilbert Welch, MD , Lisa Schwartz, MD, Steve Woloshin, MD

    White Coat, Black Hat (2010)
    Carl Elliott, MD (U. of Minnesota, ethicist). I like this one because he raises the issue, that physicians get seduced by big pharma flattery, into becoming “KOLs” (key opinion leaders, who get snared into giving talks that push certain drugs). It’s not all about money.

    Here are some older ones, which I’m citing because I think it’s important that some editors of the prestigious medical journals felt that they had to speak out about what they were seeing. In an authority-based system like medicine, only recognized leaders can start the ball rolling on reform.

    The Trouble with Medical Journals (2006)
    by Richard Smith, MD (former BMJ chief editor)

    On the Take: How Medicine’s Complicity with Big Business Can Endanger Your Health (2005) Jerome Kassirer, MD (former NEJM chief editor)

    The Truth About the Drug Companies: How They Deceive Us and What to Do About It (2004)
    by Marcia Angell, MD (former NEJM chief editor)

    Severed Trust: Why American Medicine Hasn’t Been Fixed (2000)
    by George Lundberg (former JAMA chief editor)

    1. MadisonMD says:

      Agreed. This website mostly critiques companies and practitioners purveying unproven– and unlikely– therapies by exploiting DSHEA, by enlisting government licensing, or by otherwise evading the regulatory process required to prove drug effectiveness/safety. This allows them to push sales as look as patients can be duped.

      But pharma companies, even when they plays by the rules (and sometimes companies don’t), can find plenty of loopholes to increase sales… and its also a whack-a-mole to close these loopholes:
      -promoting off-label therapy
      -direct to consumer advertising of prescription medications
      -providing incentives to physicians prescribe (somewhat reduced in recent years)
      -hiding data that dis-confirms safety/efficacy of the drug (also somewhat improved)

      I think you are arguing for a strong regulatory process, and skepticism applied to pharma. Agreed. In fact, I think most here would be in favor of closing these loopholes–GSK, other pharma, gero-vita, Herbalife, Dr. Weill, Boiron, etc. etc. etc. On top of this, there need to be stiff penalties to breaking the rules– as GSK did here. But the rules should be the same for all, without the DSHEA loophole, without licensing practitioners of unlikely and unproven therapies.

  16. justsayno says:

    “None of this refutes the need to manage diabetes with drugs, as you seem to be arguing, justsayno. Only it argues that we should also focus on caloric intake and reduce obesity. This is why it is standard of care for MDs to counsel weight loss and refer to dietician for all new diabetics.”

    Maybe advanced diabetes can’t be completely cured by lifestyle improvements. But it definitely can be prevented, or reversed before it becomes severe.

    Focusing on caloric intake is a very bad idea, in my opinion. People in traditional cultures don’t count calories. They just don’t have access to cars, TVs, and junk food.

    1. MadisonMD says:

      Maybe advanced diabetes can’t be completely cured by lifestyle improvements. But it definitely can be prevented, or reversed before it becomes severe.

      Not always. Sometimes it can be prevented. But if it is not prevented, if it occurs in the absence of obesity, or if the patient fails to change diet and habits enough to reverse it, treatment is necessary. Otherwise you damn your patients to blindness, kidney failure, heart disease. That’s not a good idea.

      Focusing on caloric intake is a very bad idea, in my opinion. People in traditional cultures don’t count calories. They just don’t have access to cars, TVs, and junk food.

      People in poor areas don’t heave ready access to calories so no counting needed. Your public health messages seems to be “let’s just be poor-.” Why would a Pima Indian want to move to the US anyway when the prevalence of diabetes is so high. How many can you convince to just move back to take advantage of the lower rate of diabetes?

      1. justsayno says:

        We don’t have to advocate poverty to advocate some of the benefits of living in a traditional culture.

        When you own a car, it becomes second nature to drive everywhere, even when it’s close enough to walk. When you own a TV, you sit and stare at it for hours, wasting your precious time on earth. This is all natural enough.

        If we look at the health benefits of NOT driving everywhere, of NOT using up all your free time staring like a moron at a screen — if we can overcome our natural lazy nature and take control over these things, we could be MUCH healthier. And maybe our society wouldn’t go completely broke from health expenses.

        A simple low-tech lifestyle is probably much healthier (as long as you have access to antibiotics and surgery if needed). But we don’t have to give up our high tech luxury to be healthier. Just use a little common sense and don’t drive if you are only going two blocks. Don’t eat stuff that doesn’t even remotely resemble food.

        1. Dave says:

          Actually, every doctor posting here fully agrees with you that people would be a lot healthier if they did what you are suggesting. You should not get the impression we don’t.

          However, some people do everything right and still get disease. A physician wrote an editorial in JAMA a few years ago about this. He was young, ate well, had a normal cholesterol, normal blood pressure, was an athlete and didn’t smoke. He also developed an MI. He said that in the ER he was given a bunch of questions, which he took as trying to blame him for his condition. His response to the question about whether he got adequate exercise was “Probably not. I only run 50 miles a week”. Point is, not everyone does something to get their disease, even though the “blame game” is rampant.
          Also doctors live in the real world, where many patients will not or can not adhere to the best lifestyle. Exercise may be difficult if you have no safe place to exercise. Some people just won’t do it. Try following a healthy diabetic diet if you’re a long distance trucker or night shift worker. Go ahead and castigate the doctors for giving meds to control diabetes if lifestyle doesn’t work or patients won’t follow diet, exercise etc, if it makes you feel better. I’ve personally seen the results of microvascular complications of diabetes – renal failure, blindness, painful neuropathies, amputations. It’s not a theoretical issue to me, it’s horrid reality. Anything to prevent or delay it is worthwhile.

      2. justsayno says:

        ” Otherwise you damn your patients to blindness, kidney failure, heart disease. ”

        Diabetes drugs won’t prevent that, maybe just postpone it. Lifestyle changes, on the other hand, might prevent the awful results of long term diabetes.

        1. weing says:

          “Diabetes drugs won’t prevent that, maybe just postpone it. Lifestyle changes, on the other hand, might prevent the awful results of long term diabetes.”

          Control of diabetes will prevent these. For all intents and purposes, you already have heart disease if you are diagnosed with diabetes.

        2. MadisonMD says:

          Diabetes drugs won’t prevent that, maybe just postpone it.

          So, you don’t think there is benefit in postponing kidney failure, blindness and amputation? If you postpone it long enough you die of something else before these things happen. Then it is effectively prevented.

          Lifestyle changes, on the other hand, might prevent the awful results of long term diabetes.

          It might *delay* it as well. It might not if it is not done or if for any reason it is inadequate to control the diabetes. And often it won’t be adequate once diabetes develops.

          Blindness, kidney failure, heart disease, amputation are bad. They can be prevented or at least delayed for many years. Not, cool, dude.

        3. WilliamLawrenceUtridge says:

          It sounds like you’re saying diet, lifestyle and drugs can all be useful in the management of type II diabetes (because, may I point out – if you’re a patient with type II diabetes, postponing kidney failure, blindness and heart disease is a very good thing, though one could read your comment as saying the opposite). I don’t think anyone here would disagree that all three have a place. But you seem to be more interested in condemning the fat and lazy who have type II diabetes than you are in curing them. I hope you’re not a doctor. It’s very hard to inherit our stone aged body and thrive in our space age present. Further, your solutions really do seem to be pretty draconian – starve the fat fuckers, take away their cars and their electricity, force them to live without the modern conveniences that my life and lifestyle allows me to ignore with patrician disdain. Make them eat nothing but beans and corn, just like their ancestors did, because being unhealthy is all their faults, and if only they weren’t such lazy, unlikeable assholes, they wouldn’t be sick.

          Maybe I’m misreading your tone, but please allow me to at least flag it for your attention.

          Anyway, good for you for having great genetics and sufficient income to allow you the leisure time to cook your own meals, buy unprocessed, often expensive foods, and post about how lazy other people are on the internet. Truly, if everyone were just like you the world would be a better place.

    2. n brownlee says:

      “Maybe advanced diabetes can’t be completely cured by lifestyle improvements. But it definitely can be prevented, or reversed before it becomes severe.”

      Very early Type II diabetes can sometimes be controlled- not cured- by very strict diet management and a strict exercise regimen. But by the time it is diagnosed it has usually progressed, and it continues to progress. I controlled my Type II for almost a decade but it has progressed to the point that I need drugs in addition to my diet & exercise routine. In case you’re wondering about my obesity problem, I don’t have one. I have a neuroendocrine tumor disease called Carcinoid, controlled by a drug called octreotide. The drug causes Type II- if the Carcinoid disease doesn’t cause it first. Octreotide suppresses my tumor growth and keeps me alive, and in addition to Carcinoid it’s prescribed for acromegaly, thyrotropinoma, and vasoactive intestinal peptide-secreting tumors (VIPomas). It’s prescribed for millions of people. They are all at risk of Type II diabetes, whether they eat white bread or brown..

      So you see, it’s not so much that what you know is wrong. It’s that what you know is a tiny grain of sand on a wide, wide beach.

  17. justsayno says:

    “At any stage of type II diabetes, from an obese child to a person dependent for 20 years on insulin injections, exercise could have a dramatic effect on improving insulin sensitivity.”

    http://www.sciencedaily.com/releases/2007/02/070207171215.htm

    1. weing says:

      “At any stage of type II diabetes, from an obese child to a person dependent for 20 years on insulin injections, exercise could have a dramatic effect on improving insulin sensitivity.”

      Yes, it could. So can bariatric surgery.

      1. justsayno says:

        So, weing, you would rather your patients have SURGERY than do something natural and healthy??

        1. weing says:

          “So, weing, you would rather your patients have SURGERY than do something natural and healthy??”

          That’s a loaded question. Do you mean like the patient on 80 units of Lantus besides metformin, with a BMI of 45? He had the surgery and is no longer on Metformin or Lantus. I have many like that. I have a few that were early into the disease and were able to lose the weight with diet and exercise and no longer use Metformin. Hope it will last.

          To lose weight, you need to do both. Running an hour a day will burn 500 calories and you’ll lose a pound after a week, if you don’t, non-consciously, increase your caloric intake.

          1. justsayno says:

            The purpose of exercise is NOT to burn calories. We naturally eat more to make up for whatever was burned.

            The reason for exercise is to reverse some of the damage done by decades of inactivity. The metabolism cannot function normally without some physical exercise.

            And dieting by restricing calories only further slows the metabolism.

            So your typical type 2 diabetes patient may be overweight in spite of not eating very much. Knowing that restricting calories is useless, why would doctors still recommend it?

            1. weing says:

              “Knowing that restricting calories is useless, why would doctors still recommend it?”
              You wonder why? Maybe because it’s not useless.

            2. Harriet Hall says:

              Restricting calories is not useless.

              1. justsayno says:

                Restricting calories without repairing the metabolism with exercise most certainly is useless. Dieting by restricting calories, without exercise, is probably the major cause of obesity, along with refined carbohydrate addiction.

                So many patients get this dangerous advice from doctors like weing and Harriet: Exercise won’t help much because it doesn’t burn enough calories, and you just eat more. And the most important thing is to restrict calories.

                And metabolic syndrome is not a useful concept — maybe not to someone who does not understand it.

                No wonder type 2 diabetes is an epidemic. Very tragic, because it is so easy to prevent and can often be reversed or greatly improved.

              2. Harriet Hall says:

                “Dieting by restricting calories, without exercise, is probably the major cause of obesity”

                Ha! Thanks for the laugh. Now I’ve heard everything!

              3. justsayno says:

                Restricting calories slows the metabolism. This is well known. Too bad you don’t know it, and you are supposedly and expert on health.

              4. Windriven says:

                “Exercise won’t help much because it doesn’t burn enough calories, and you just eat more. And the most important thing is to restrict calories.”

                What bullcrap! No one here has said not to exercise! And while it is true that calorie restriction tends to slow metabolism it doesn’t stop it.

                One most certainly can lose weight by dieting. But to be effective the diet must be a permanent change of dietary habit – something most people can’t or won’t do. So they embark on a cycle of yo-yo dieting.

                Every physician that I know recommends a program of diet and exercise compatible with the overall health of the patient. It is an egregious straw man to suggest otherwise.

            3. weing says:

              “Dieting by restricting calories, without exercise, is probably the major cause of obesity, along with refined carbohydrate addiction.”
              Do you always argue against your misrepresentations of what someone says? You obviously don’t know any physiology. But I suppose you think that you do, making it impossible for you to learn. That’s how you end up with nonsense like obesity being caused by restricting calories.

              1. Dave says:

                Heck! Here I thought overeating and not doing exercise was the major cause of obesity. How could I be so ignorant?

              2. Chris says:

                Which is kind of at the crux of why I ask for his “natural methods” to deal with obstructive hypertrophic cardiomyopathy. That is one genetic heart anomaly that can cause death through exercise.

                I have a feeling he does not have an answer for me. It may be out of his myopic view of reality, even though it can occur in about one in a thousand (and sometimes just five hundred) persons.

              3. justsayno says:

                Dieting is known to cause obesity. Unbelievable that you never heard of this.

              4. Dave says:

                Justsayno, everyone undertands what you’re saying, but you have deliberately misrepresented so much of what Dr Hall has said that it’s hard not to misrepresent what you are saying. It’s true that most people who go on a restrictive diet will not be able sustain it, their body may readjust its caloric needs, then when they inevitably go back to their former eating patterns they gain their weight back and more. This is why most diets fail. Weight gain is still related to overall consumption of calories in excess of expenditure. There were no fat people in concentration camps to use the most extreme example.

                The standard medical advice for weight loss, which you will undoubtedly disagree with, twist around and misrepresent, is to permanently change eating habits (“diet” can have several meanings, but many take it to mean a short-term reduction to lose weight and then a return to former eating patterns, which is how I think you are using the term), reduce portion sizes, eat a lot of vegetables and fruits and limit high-calorie/low nutritional value foods, and do this PERMANENTLY. This is in addition to increasing activity. The people I know who are leanest are not the ones who spend a half hour a day at a gym but those who have a hobby which they really enjoy which involves activity – trail runners, road runners, cross-country skiers, rock climbers, mountain bikers, etc. “Exercise” is in their lifestyle, not something worked in each day but something played at each day. Having said that, I also know people who have lost weight from doing gym-related exercise or something like crossfit. The problem is that repetitive gym exercising is often boring and hard to sustain.

                You actually entered this forum by saying that lifestyle changes can help diabetics. Everyone here has agreed with that, merely pointed out that those measures alone are often not possible (either the patient can’t do it or won’t do it) or not sufficient. I’ve then asked you what YOU would do if you had patients where lifestyle changes weren’t followed or weren’t sufficient. Would you use medication to limit harm or not? If so, what’s your beef? Still haven’t heard a response.

              5. weing says:

                “Restricting calories slows the metabolism. This is well known. Too bad you don’t know it, and you are supposedly and expert on health.”

                Oh it’s well known. But only non-experts know that it causes obesity. I can imagine the inmates in concentration camps not eating to get fat.

        2. Chris says:

          Can you tell me an alternative to septal myectomy for obstructive hypertrophic cardiomyopathy? What is the natural and healthy way to remove the excess heart muscle growth that partially blocks the aortic valve? The same growth that causes a drop of blood pressure during any kind of exercise because that action prevents the blood from going though the aortic valve.

          I am truly curious. Just as curious as I was when after my son’s surgery the health insurance nurses called to consult on “preventative measures.” They really did not know who to prevent a genetic heart condition.

        3. WilliamLawrenceUtridge says:

          So, weing, you would rather your patients have SURGERY than do something natural and healthy??

          I would much rather my patients, if I had any, had surgery rather than dying from a naturally infected appendix that bursts and kills them.

          But yeah, a 400 pound 18-year-old would be much better off getting enough exercise, and restricting their calorie intake sufficient to obviate the need for diabetes-treating drugs. You know, they probably just didn’t know they needed to eat better and exercise, we just need to tell them (or perhaps induce them with a cattle prod?) and they’ll get off their 400-pound asses, and shed the 900,000 extra calories they’re packing.

          What I’m getting at is that it’s a little more complicated than simply pointing out being fat and sedentary is bad for you. I actually undertake the recommendations for diet and exercise, and let me tell you – despite having a good, well-paid job with lots of leisure time, it’s not easy. I wish it were as simple as simply not wanting to be hungry, or not finding sugar delicious.

          But hey, perhaps your name calling and obviousness is a reasonable solution.

    2. MadisonMD says:

      exercise could have a dramatic effect on improving insulin sensitivity

      Sure it could. But it might not. Or the patient might not do enough exercise. So you would just damn them to kidney failure, blindness, and amputation, then? Not cool.

    3. Dave says:

      There was a study several years ago (I don’t have the citation off the top of my head) looking at preventing diabetes in people with impaired glucose tolerance, using either metformin or diet/exercise/lifestyle changes. Over the study period, which was about three years, lifestyle changes were effective about twice as often as metformin in preventing progression to diabetes.

      No one is denying that exercise is important to a healthy lifestyle, especially in diabetics already prone to coronary disease, Justsayno. However, I think you overestimate the willingness of patients to change their lifestyles. Every physician has witnessed the following despite talking to patients to the point of frustration about their behavior. Note that it’s not just exercise, it’s all sorts of unhealthy behavior:

      Chronic lung patients who have been on a ventilator for respiratory failure who insist on continuing to smoke.
      Patients s/p surgery, radiation or chemotherapy for lung or head and neck cancer who continue to smoke.
      Patients with recurrent pancreatitis who continue to drink alcohol.
      Patients with alcoholic cirrhosis with multiple admissions for gastrointestinal bleeding and hepatic encephalopathy who insist on continuing to drink. (I have gone so far as to try to get one such patient committed to get him to stay off alcohol because I felt his encephalopathy was such that he was not capable of making rational decisions and he was literally killing himself with alcohol. The courts disagreed. Of course he then drank himself to death a short while later.)
      Patients with congestive heart failure or getting dialysis for renal failure who continually ignore salt and fluid restriction advice, resulting in untimely need for urgent unscheduled dialysis or repeated admissions for fluid overload.
      The aforementioned diabetics who refuse to adhere to a diet. and have miserable diabetic control.
      Patients who have had heart attacks or who have peripheral vascular disease who insist on continuing to smoke.

      A look at the number of obese people in our society is an indication of the difficulty many people have with keeping their calories down and getting adequate exercise, as is the proliferation of “miracle weight-loss” fads that litter the tabloids and TV shows such as Dr Oz’s. You can say “just say no” but lots of people cannot do it.

      As the saying goes, “you can lead a horse to water but you can’t make him drink”.

    4. Dave says:

      There was a study several years ago (I don’t have the citation off the top of my head) looking at preventing diabetes in people with impaired glucose tolerance, using either metformin or diet/exercise/lifestyle changes. Over the study period, which was about three years, lifestyle changes were effective about twice as often as metformin in preventing progression to diabetes.

      No one is denying that exercise is important to a healthy lifestyle, especially in diabetics already prone to coronary disease, Justsayno. However, I think you overestimate the willingness of patients to change their lifestyles. Every physician has witnessed the following despite talking to patients to the point of frustration about their behavior. Note that it’s not just exercise, it’s all sorts of unhealthy behavior:

      Chronic lung patients who have been on a ventilator for respiratory failure who insist on continuing to smoke.
      Patients s/p surgery, radiation or chemotherapy for lung or head and neck cancer who continue to smoke.
      Patients with recurrent pancreatitis who continue to drink alcohol.
      Patients with alcoholic cirrhosis with multiple admissions for gastrointestinal bleeding and hepatic encephalopathy who insist on continuing to drink. (I have gone so far as to try to get one such patient committed to get him to stay off alcohol because I felt his encephalopathy was such that he was not capable of making rational decisions and he was literally killing himself with alcohol. The courts disagreed. Of course he then drank himself to death a short while later.)
      Patients with congestive heart failure or getting dialysis for renal failure who continually ignore salt and fluid restriction advice, resulting in untimely need for urgent unscheduled dialysis or repeated admissions for fluid overload.
      The aforementioned diabetics who refuse to adhere to a diet. and have miserable diabetic control.
      Patients who have had heart attacks or who have peripheral vascular disease who insist on continuing to smoke.

      A look at the number of obese people in our society is an indication of the difficulty many people have with keeping their calories down and getting adequate exercise, as is the proliferation of “miracle weight-loss” fads that litter the tabloids and TV shows such as Dr Oz’s. You can say “just say no” but lots of people cannot do it.

      As the saying goes, “you can lead a horse to water but you can’t make him drink”.

      1. justsayno says:

        Harriet’s claim was that improving lifestyle is LESS effective than drugs, for diabetes 2.

        You are saying that you think improving lifestyle is MORE effective than drugs, but patients won’t follow their doctors’ advice.

        We both disagree with Harriet, it seems, and any reasonable person would probably agree with us and disagree with her. Her opinions on this subject are on the fanatical pro-drug fringe, not at all grounded in scientific evidence or logical thinking.

        As for your claim that doctors are being sensible and advising lifestyle improvement, I really don’t know.

        For example, I recently had a conversation with a middle-aged woman who is 50 pounds overweight, and admits to being addicted to refined sugar. She also does not exercise at all.

        Her doctor put her on cholesterol-lowering drugs, and never said anything about the importance of lifestyle.

        That is just one example, I realize, but I have heard so many others.

        And patients are constantly exposed to pro-drug TV ads. When do you ever see a TV ad that says exercise will stabilize your blood sugar and cholesterol?

        You don’t, because no one makes money by giving that advice. The drug companies probably hope your doctor won’t educate you about lifestyle.

        Harriet Hall is a good example of a doctor who must convey a pro-drug message to her patients by telling them diabetes 2 is mostly genetic and a healthy lifestyle won’t prevent or cure it. She might say “Oh by the way, improving your lifestyle might help a little, but the drugs are the most important factor.”

        How many people will do the hard work of giving up junk food and getting off their butt for a while, if taking a pill supposedly works better?

        I suspect that many doctors either don’t mention lifestyle to their patients, or mention it in a half-hearted unenthusiastic way.

        But I agree that most people are lazy, that is our nature, and it takes a lot to motivate us to change. Maybe if doctors framed the message better patients might listen? I don’t know.

        Another problem is that many doctors probably don’t follow their own advice, since they may not have time to worry about diet and exercise. So how can they enthusiastically promote things they don’t bother doing themselves?

        1. weing says:

          “lifestyle is MORE effective than drugs, but patients won’t follow their doctors’ advice.”

          More effective at prevention not treatment. The only drug that was more effective at preventing diabetes than lifestyle changes is no longer on the market. That was troglitazone.

          “And patients are constantly exposed to pro-drug TV ads. When do you ever see a TV ad that says exercise will stabilize your blood sugar and cholesterol?”
          What about the ads for candy, ice-cream, soft-drinks, pizza, etc?

          “Harriet Hall is a good example of a doctor who must convey a pro-drug message to her patients by telling them diabetes 2 is mostly genetic and a healthy lifestyle won’t prevent or cure it. She might say “Oh by the way, improving your lifestyle might help a little, but the drugs are the most important factor.””

          I seriously doubt she would speak to a patient as definitively as a non-medical person. You are setting up a straw man.

        2. Harriet Hall says:

          @justsayno,

          You have distorted my position out of all recognition. I do not think diabetes is “mostly” genetic; I think it is probably about half genetic and half environment/lifestyle. I recommend diet and exercise for prevention, not drugs. For patients who are already diabetic, I usually recommend lifestyle changes first, before drugs; but they are usually not enough by themselves even if patients comply, which few of them are willing or able to do. And if the blood sugar is very high, it is in the patient’s best interests to use medication WHILE they are changing their lifestyle (they can always stop the meds if they lose weight and get the blood sugar under control). Blood sugar control tends to deteriorate over time, and most patients will need to have drugs added eventually to control the disease and prevent complications. The NEJM study (Weing posted the link) showed that lifestyle was more effective than drugs for prevention, but it also showed that to prevent one case of diabetes, 6.9 people had to follow the lifestyle program. Some people develop diabetes despite having a normal weight, exercising, and eating a healthy diet. My opinions on this subject are NOT on the fanatical pro-drug fringe, they are well grounded in scientific evidence and logical thinking. You owe me an apology.

          1. justsayno says:

            “However statins work, they have been proven to reduce all-cause and cardiovascular mortality. No life style modification has ever been shown to accomplish that as effectively.”

            I sure don’t owe you any apology. You owe your patients an apology. If this is the message they get from you, that is very unfortunate.

            As for your patients not usually following your lifestyle advice — why would they, if you tell them statins work better than lifestyle changes?

            And I would like to know exactly what lifestyle changes you recommend. I wonder if you have actually kept up with what really works. Low fat diets are usually a bad idea, for example.

            1. Harriet Hall says:

              I was talking about people who already have heart disease or are at high risk. I meant that there is no good evidence that lifestyle modification alone will reduce mortality as effectively as statins for those people, especially since patients are so resistant to drastic lifestyle modifications. Even in some of the most promising studies on lifestyle modifications, statins were given to those who were at greatest risk.

              What do I recommend? For everyone, exercise, weight control, and a varied diet that emphasizes plant food but does not prohibit meat or any other specific food category. I don’t recommend low fat, but I ask people to keep in mind that fat is over twice as high in calories as protein and carbs.

              Next time you want to criticize another person’s approach, you might FIRST want to ask what their approach is, rather than asking after you have attacked them.

              1. justsayno says:

                So you don’t warn your patients about refijned carbohydrates. I didn’t think you would.

              2. Harriet Hall says:

                Again, you attack me before finding out all the facts. I advise limiting the amount of refined carbohydrates and sugar (because it is high in calories without other nutrients) in favor of complex carbohydrates which are more nutritious and help reduce calorie intake by producing more satiety. I recommend whole grains and foods high in fiber. But I don’t “warn” them that refined carbohydrates are evil; I think they can be included in a healthy diet.

              3. Chris says:

                justsayno: “So you don’t warn your patients about refijned carbohydrates. I didn’t think you would.”

                And you know this because…?

                By the way, I am really curious what the “natural methods” you would recommend prevent the blockage of blood through the aortic valve from obstructive hypertrophic cardiomyopathy. This is a case where “exercise” can be lethal.

              4. justsayno says:

                “Again, you attack me before finding out all the facts. I advise limiting the amount of refined carbohydrates and sugar (because it is high in calories without other nutrients) ”

                OF COURSE I found out the facts. This is what you said:

                “What do I recommend? For everyone, exercise, weight control, and a varied diet that emphasizes plant food but does not prohibit meat or any other specific food category. I don’t recommend low fat, but I ask people to keep in mind that fat is over twice as high in calories as protein and carbs.”

                You did NOT mentioned refined carbohydrates.

                And in your next comment, you showed that you know NOTHING about addiction to refined carbohydrates.

                White sugar is especially bad, since it causes a temporary high followed by low energy, which results in cravings for more sugar.

                The continual barrage of refined sugar during the day eventually results in insulin spikes, and can eventually lead to insulin resistance.

                And, of course, insulin resistance can lead to type 2 diabetes.

                People who drink soda thoughout the day, or coffee sweetened with sugar, may wind up with a dangerous sugar addiction.

                White flour is also bad, for similar reasons, and is one of the most common ingredients in the typical American diet.

                But you don’t tell your patients any of this? How do I know? I know because your comments specify your advice, and they say nothing about the dangers of refined carbohydrate addiction.

                You probably never even heard of metabolic syndrome, the syndrome that commonly leads to type 2 diabetes.

              5. Harriet Hall says:

                There you go again! When I said what I recommend, why did you assume I was obligated to explain every single detail of everything I ever say to patients?

                I think “addiction” to refined carbs is a misnomer, and I think “addiction to sugar” is an over-hyped myth based on a grain of truth: that some people develop a habit of eating sugary foods and the sugar is quickly metabolized so the satisfaction doesn’t last and they develop cravings. I maintain that sugary treats in moderation can be part of a healthy diet as long as they don’t lead to weight gain and as long as the rest of the diet contains adequate nutrients.

                If you didn’t know whether I had ever heard of metabolic syndrome, you could easily have found out by googling my name and “metabolic syndrome” and you would have found an article I wrote about it.

            2. Dave says:

              Justsayno, are you trying to be provocative? Current medical recommendations are to limit sugars to less than 10% of calories and to eat whole grain products rather than refined products. She does not deny the importance of diet. It is you who do not understand that these ARE part of standard medical recommendations, and that lifestyle -diet modifications are the FIRST recommendation in any guideline for diabetes. If a doctor doesn’t recommend this they are not practicing the standard of care. The trouble is, that’s often not enough. Why don’t you access the guidelines and read them? While you’re at it answer my previous questions to you.

      2. Dave says:

        Note the study I referred to was designed to see if diabetes could be prevented in patients without diabetes but with impaired glucose tolerance.

        If a patient already has diabetes, it’s not “either” lifestyle changes “or” medications. You use whatever tools you have to use to accomplish the task of controlling the diabetes. I have seen “cures” ( meaning attaining normal A1C levels without neding medication) in patients who have lost large amounts of weight, on their own or with bariatric surgery. Most patients with diabetes have slow progression of beta cell loss.

        1. Dave says:

          A few points:
          What a doctor tells a patient and what the patient remembers being told are different things. That one reason doctors document what they do. This has been studied and I think the retention rate is about 50% but I’ve got better things to do with my time than look up the studies.

          It’s not just doctors. Try talking to a diabetic nurse educator or dietician about patient compliance with their advice. Ditto alcohol or drug treatment counsellors.

          The reason your friend was put on statins is that having diabetes confers the same risk of having a future heart attack as if she had already had one heart attack.
          If she’s not been received dietary/lifestyle advice she should be. It’s in all the guidelines and would be considered standard of care.

        2. weing says:

          “If a patient already has diabetes, it’s not “either” lifestyle changes “or” medications.”

          I would add that it is impossible to control diabetes without at least some lifestyle changes. If the patient refuses to follow the diet and to exercise, then I end up having to add on meds, insulin, and eventually huge doses of insulin and still without adequate control of their diabetes. I have a few patients like that too. They are the most frustrating ones to deal with.

          1. WilliamLawrenceUtridge says:

            Justsayno’s advice, which I have been mocking, seems to lead to the conclusion of “patients who do not comply with diet and exercise recommendations should not be given medication and should just die instead”. If that’s not his/her intention, then s/he should reconsider his/her messaging.

            Patients bear a considerable amount of responsibility for not adhering to guidelines for a healthy lifestyle. Doctors can talk until they are blue in the face, it won’t do any good if the patient wasn’t already thinking about changing how they eat and live. In the meantime, should patients be prevented from accessing medicines until they undertake an exercise and dietary regimen sufficient to satisfy Justsayno and his/her ilk? That’s quite the Darwinian experiment.

            Perhaps doctors could do better if given more time with individual patients. But what determines the average length of appointment? Where I live, the duration is based on the presenting complaint. In the US, my understanding is that in many hospitals it is “managed care”, which is to say “keep all appointments short” unless you are paying out of pocket.

            A good reason to have a real health care system rather than the current version.

  18. weing says:

    @Dave,
    I think you are referring to this study.

    http://www.nejm.org/doi/full/10.1056/NEJMoa012512

    1. Dave says:

      That is the study I was referring to. Thank you.

  19. Dave says:

    “As for your claim that doctors are being sensible and advising lifestyle improvement, I really don’t know.”

    Correct, you do not know. I’m sure there are some who don’t but most doctors I know, far more than you know, talk about this a lot. I’m a hospitalist. EVERYONE admitted to my facility with diabetes gets a diabetic nurse educator to see them. EVERY alcoholic gets seen by an alcohol treatment counsellor. Our system requires that outpatient doctors advise patients about smoking at least three times a year. This is monitored and their pay decreases if they do not do this as it’s a performance measure. Every patient with hypertension is required to have exercise counselling – also a performance measure. I cant speak for other systems but I know what the guidelines say.

    We have a residential alcohol treatment program lasting several weeks. Success rate is about 20% The spirit is willing but the flesh is weak.

    1. justsayno says:

      Tobacco, alcohol and refined sugar are all addictions. You can’t change an addict by giving them a lecture. There might be strategies that work — maybe different ones for different patients. But you really have to understand these are addictions. Simply telling people to change does not work.

      1. Dave says:

        Do you even know what a “residential alcohol treatment program” is? It’s far more than lectures. You have a problem with using medications plus a smoking cessation program to get people off cigarettes? That’s a pretty common approach (offering these is part of the smoking cessation advice required by my health care system, by the way, not just telling patients to quit. And this advice has to be documented )

        What the heck is your point? It seems to be the following so maybe you’d better clarify it:

        1)If people followed a good diet and got lots of exercise they would never need medications. (Unfortunately, not always true. Diet and exercise are important but not always sufficient)
        2) If patients don’t follow diet and exercise they still shouldn’t be put on medications. (I actually know a few doctors who sort of follow this – surgeons who refuse to operate on people with peripheral vascular disease unless they quit smoking. Most however have the opinion that they may not get the patient to quit the behavior but meds or surgery might limit the harm from it)
        3) Doctors don’t know the importance of lifestyle practices (Given that a large portion of a doctor’s life is spent dealing with the fallout from poor lifestyle choices, it’s hard to imagine anyone having this idea unless they’ve been listening to alt-med diatribes too often).

        A few questions: What would YOU do if you were caring for a patient who had diabetes but wouldn’t follow lifestyle advice?
        What would YOU do if the patient had uncontrolled diabetes despite lifestyle advice?
        What would YOU recommend to the patient mentioned earlier who was 100 lbs overweight and had poor control of diabetes despite tons of insulin and metformin.

        I’m not posing these questions rhetorically. I’d like to see your response.

        One humorous story – A local hospital offered a smoke-ender’s clinic and asked a cardiologist to give one of the lectures. He started off by saying that he wished he could physically show how cigarettes had affected his life but he couldn’t get his porsch and house through the auditorium doors. In case anyone out there is too dense to get the drift of this, he was pointing out that he would have a lot less business were it not for cigarettes.

  20. Self Skeptic says:

    Wow, this is a really long digression. You all wouldn’t, by any chance, be avoiding a discussion of the main topic, would you? ;)

    Maybe one of the SBM bloggers should write a post about diabetes, summarizing the current beliefs in mainstream medicine, and giving us the most popular references (with emphasis on free full text, for those not in academia) so this could be discussed with some knowledge, and hopefully critical thinking, regarding current medical science and beliefs on this subject. Also, a post presenting the current research and beliefs, on how people can successfully change habits that are rewarding short-term, but bad for health long-term, would be relevant.

    Meanwhile, could we have some input on doctor’s attitudes about the influence of big pharma’s need and pursuit of big profits, on medical practice, and worse, the medical literature upon which current standards of care are based? I’m sensing some large-scale denial in most (not all) of the SBM bloggers, and most of the followers, despite the overwhelming evidence, and I’m wondering exactly what the rationales are for that.

    I’d be especially interested in how you’re handling this, Dr. Hall, within your own belief system. And Dr. Novella of course, since you wrote the original post, in which you expressed the possibility and hope that this is a small, and not a systemic, problem. That possibility is implausible, once one looks unflinchingly at the evidence.

  21. justsayno says:

    “Dieting by restricting calories, without exercise, is probably the major cause of obesity”

    Ha! Thanks for the laugh. Now I’ve heard everything!

    Harriet was entertained by my comment, but it really is sad, not funny, that so many doctors are unaware of the damage caused by repeated dieting.

    http://jn.nutrition.org/content/108/11/1724.long

    http://www.nytimes.com/2012/07/01/opinion/sunday/what-really-makes-us-fat.html?_r=0

    1. weing says:

      “Harriet was entertained by my comment, but it really is sad, not funny, that so many doctors are unaware of the damage caused by repeated dieting.”

      It’s not the dieting. It’s the not sticking to the diet. That’s also called yo-yo dieting.

    2. Dave says:

      I think pretty much everyone, doctors and lay public, know something about yo-yo diets. Doctors spend a lot of time taking care of health problems caused by obesity and are not entirely clueless about it or its health effects. How much of your life is spent dealing with these problems? Do you have any data regarding the beliefs of doctors about these issues, or are you just drumming up your statements out of the air and because obesity is such a problem? Additionally, how is the advice YOU would give to someone to lose weight different than standard medical advice? Please answer, we would really like to know. Do you have some miracle weight loss plan? They’re not hard to come by, you can read or hear about a new one every week, but I don’t know any that actually work longterm.

      This is similar to your previous comment about people not being aware of the effects of unhealthy eating. I don’t know a single patient who thinks the high calorie stuff sold at fast food outlets is good for you. That’s like saying patients and doctors are unaware of the effects of cigarettes.

      1. justsayno says:

        Dieting by restricting calories, without exercise, is unlikely to work. For one thing, it may cause hunger, which is one of the most powerful drives. If a person is hungry day after day, their will power eventually has to fail.

        But as the articles I linked explain, any weight lost is gained back quickly, and more, as soon as the calorie restriction ends.

        So many Americans get caught in this dangerous cycle, and eventually wind up obese.

        When doctors emphasize the importance of calorie restriction, and minimize the role of exercise, they help create the obesity epidemic.

        I would explain all this carefully to diabetes 2 patients. They need an hour or more of moderate pleasant exercise every day, like walking or swimming or bicycling. And they cannot eat any refined carbohydrates.

        Salt and fat don’t matter, but nothing excessive is good. Natural non-junk food is best, obviously. Trans-fats are poison. Butter and eggs are fine.

        If A patient refused to take my advise, I would let them go see another doctor for bariatric surgery and pills.

        1. n brownlee says:

          Are you, seriously, under the impression that Dr. Hall doesn’t know the effects of diet and exercise on Type II diabetics? Have you been reading her comments in some kind of fugue state? Do you imagine that your self-justified and massively self-important “prescription” for Type II diabetics is somehow not just equivalent but superior to Dr. Hall’s education and decades of clinical experience?

          Are you completely unaware of how self-righteous, rude, and massively ignorant your comments have been? Go back to the beginning of your comments and READ your own, and those of everyone else who commented. Slowly, so they sink in.

          1. justsayno says:

            Dr. Hall got a big laugh out of the idea that restricted calorie dieting can cause obesity. She never even heard of the idea.

            She also claims that statins work better than lifestyle improvement.

            She also denies that refined carbohydrates can be addictive.

            She also denies that metabolic syndrome is a useful concept.

            She is generally ignorant about one the most dangerous epidemics in our society.

            1. Windriven says:

              You know, you’re really boring. For a while it was amusing reading your stupidities. But now it is just repetitive and numbing. Congratulations, you’re as interesting as Novocaine. You’re reached your pinnacle.

        2. Sawyer says:

          You purposely pidgeon-holed Dr. Hall by focusing on a single statement rather than the overall scope of her recommendations. Go back and read other posts by her and other SBM writers. The idea that anyone here is against exercise in general is ludicrous. Not to mention the fact that this entire yelling match has ZERO relevance to the main topic of GSK bribing doctors.

          You will not have a productive conversation with anyone here if you keep mischaracterizing their positions. People have cynically employed this approach for years on this site. But it has never worked. Ever.

          1. justsayno says:

            One of the main themes of the comments here has been that patients won’t follow their doctors’ lifestyle advice.

            But the advice — according to comments on this post — is restricted calorie dieting. And they might mention exercise, but hardly anyone specified what kind or how much. I know that doctors often recommend 20 minutes 3 times a week, which is not enough.

            Advising restricted calorie dieting is not very helpful, since it is a major cause of obesity. It is also next to impossible to suffer hunger pains day after day. Before you tell patients to do that, try it yourself.

            And not understanding that refined carbohydrates can be addictive is also not helpful to patients.

            Some of the posters and commenters here really need an education on the subject of metabolic syndrome, diabetes 2 and lifestyle.

            1. Sawyer says:

              “Some of the posters and commenters here really need an education on the subject of metabolic syndrome, diabetes 2 and lifestyle.”

              Perhaps. But you’ve essentially guaranteed that such a conversation will never happen. You started this discussion by making up nonsense about statins, and then by misinterpreting pretty much every single statement by every subsequent poster. Has this strategy ever worked, anywhere? If education is your mission, you’ve already set yourself up with a Herculean task.

              Every person I have ever encountered on this site advocates *slight* calorie reduction (ie NOT starving yourself) in combination with exercise to combat weight gain, heart disease, diabetes, etc. If you go back and read other posts rather than just a handful of comments, I think it’s downright impossible to not to draw these conclusions. If Dr. Hall hasn’t specifically made them other SBM writers have, literally hundreds of times.

              1. Dave says:

                I don’t think JSN reads the comments. I’ve posted the standard exercise advice copied directly from the American Heart Association website, we’ve talked about permanent alterations of eating patterns rather than putting people on restrictive diets, etc. It doesn’t sink in.

                Dr Hall spent over thirty years in intimate contact with diabetics and people with the metabolic syndrome. I’d say she knows quite a bit about it. Tell us, JSN, how much time have you spent fighting these disorders? Do you have any personal experience in taking care of diabetics? Or did you just read about it in a book or some website? And please tell us why you would not give medications to someone whose diabetes could not be controlled with diet and exercise?

        3. Dave says:

          Believe it or not your recommendations do not differ in any substantial way from mainstream recommendations. From the AHA website:

          “The amount of physical activity any individual person needs for weight loss can vary, but you will need to get both regular physical activity and a healthy eating plan to lose weight and keep it off. A good plan may include 30 to 60 minutes of moderate intensity aerobic physical activity, like brisk walking, done nearly every day. Find something you can do and find ways to enjoy it. Take a brisk walk or a jog with a friend or your dog. Enjoy a video that gets you moving.

          Additionally, you need on 2 or more days a week muscle-strengthening activities that work all major muscle groups (legs, hips, back, abdomen, chest shoulders, and arms). Besides helping you lose weight, it also helps reduce your abdominal fat and preserve muscle during weight loss.”

          Refusing to care for patients who don’t follow your advice to the letter is a cop out. If doctors only took care of lean people who exercised an hour a day a lot of sick people would be left in the lurch, as would those who have physical or social problems preventing them from living as healthy a life as you would demand. Once again, what would you do if a patient does everything you ask and still has uncontrolled diabetes?

          There’s a medical joke – “Being a doctor would be a piece of cake if it weren’t for sick people.”

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