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Personalized Medicine Bait and Switch

Mark Hyman, a proponent of so-called “functional medicine” promoting himself over at the Huffington Post (an online news source that essentially allows dubious medical infomercials to pass as news) has posted a particularly egregious article on personalized medicine for dementia. In the article Hyman distorts the modern practice of medicine, the current state of genetic science, and the very notion of “disease.” It is, as usual, a fine piece of medical propaganda sure to confuse many a reader.

Hyman starts with some standard epidemiology of dementia – it is a common and growing disorder – but then descends quickly into distortion and pseudoscience.

Conventional Medicine Strawman.

Hyman creates what readers are likely to recognize by now as the standard straw man of conventional or science-based medicine, and then uses that caricature to create a false dichotomy with his “functional” medicine. He writes:

But first I want to explain why just naming a disease — whether it is dementia or anything else — is becoming increasingly unhelpful (unless you just want to match the drug to the disease which is the only thing doctors are trained to do).

and

In fact, disease and diagnosis as we know it will soon be an obsolete concept, an artifact of medical history, like bloodletting or phrenology (the art of diagnosis based on the shape of your skull, popular in the 19th century). The reason is simply this: Naming a disease does nothing to help us identify and treat the underlying causes of the disease. We must address these causes if we have any hope of helping individuals heal.

As a neurologist who treats dementia, his straw man is more than a bit offensive. Hyman does not seem qualified, if his writings and videos are any indication, to offer an opinion on medical training. Hyman would have you believe that the science-based approach is going the way of bloodletting. But what he is really indicating is that he does not understand the label of dementia, the concept of disease, or the complex relationship between science and medical practice.

What is a disease?

Hyman uses the term “dementia” quite loosely in his article, so let me explain what we actually mean by this term. Dementia is a clinical syndrome (not a disease) – it is the term applied to a condition of chronic cognitive impairment, regardless of cause.

On the other hand, Alzheimer’s disease is a specific disease – a pathophysiological entity with specific changes to the brain on biopsy and markers in the blood and spinal fluid (although at present only biopsy is useful for diagnosis).

When a patient presents with dementia (actually they present with cognitive symptoms and are diagnosed with dementia based upon history and exam, distinguishing it from other entities, like delirium, psychosis, or specific disorders like language dysfunction) the first order of business is to rule out treatable or reversible forms. This may include depression, medication side effects, nutritional deficiencies, anatomical lesions, strokes, inflammatory diseases, toxicities, and other causes. This is done by history, physical, MRI scan of the brain, EEG, and blood tests.

If an underlying treatable cause is found, it is treated. Patients may then stabilize, improve, and even be entirely cured, depending on the cause and if any permanent damage has already occurred.

If the workup for reversible causes is negative then the patient is not given the diagnosis of Alzheimer’s disease – rather they are diagnosed with an Alzheimer’s-like dementia, or a related but still irreversible cause of dementia.

It is true that simply attaching a label to a syndrome does not necessarily lead to effective treatment or even better understanding, as I have pointed out myself previously. In fact, some syndrome labels are over-used. But the same is not true of a genuine disease label – a diagnosis that carries with it a host of information about epidemiology, risk factors, underlying causes, genetic predispositions, and treatment outcomes.

Hyman hopelessly confuses these two situations, demonstrating a profound lack of understanding of how medical thinking has progressed over the last couple of centuries. Hyman demonstrates his confusion by using the term “dementia” as if it were interchangeable with “Alzheimer’s disease.” He writes:

“There is no effective known treatment for dementia.”

This statement is flawed on many levels. Some dementias are treatable, even curable, if the cause is reversible. It is true there is no cure for Alzheimer’s disease, and no disease-modifying treatment, but there are treatments. Currently available treatments for Alzheimer’s disease, however, are symptomatic only – they improve function but do not alter the course of the disease. Hyman’s sloppy language reflects his sloppy thinking, the likely result is that his readers will end up as confused as he appears to be.

Hyman’s Anecdotes

Hyman’s article goes from bad to worse – after distorting the current state of neuroscience and medical practice regarding dementia, his infomercial for his own idiosyncratic methods begins. He offers, of course, just anecdotes – two patients whom he treated and who we are told improved.

Of course, we are given no information to confirm a diagnosis. Since Hyman appears not to know the difference between dementia and Alzheimer’s disease, it is quite possible that either or both of these patients had a reversible cause of dementia, and their improvement may or may not have had anything to do with his ministrations. But they are useless as evidence for any superiority of Hyman’s approach to the science-based approach.

For example – despite the fact that Hyman would have you believe my training was restricted to pharmacotherapy,  I routinely will check patients who present with dementia for folate and vitamin B12 deficiency (this is standard practice). In addition I check homocysteine and methylmalonic acid levels, because these markers may be elevated even with low normal levels of folate and B12. If this blood work indicates a functional deficiency of either vitamin, then I supplement and monitor the blood work to see how they respond.

This is the evidence-based approach. Scientific doctors are good at asking meaningful questions and then doing research to answer them. Is the B12 and folate level enough? Turns out, the other metabolic markers may be a more sensitive indicator of a relative deficiency. Should we treat every dementia patient with folate and or B12? Turns out, there is no clinical response to routine treatment – so treatment should be targeted at those with a documented deficiency.

Gurus like Hyman, however, are not evidence-based. Rather, in my opinion, they seem to search for any tenuous evidence to support their philosophy or marketing strategy and then make huge hand-waving extrapolations from the evidence to their practice. Hyman, for example, writes:

George had another gene called MTHFR(viii) that made him require very high doses of folate to lower his blood levels of homocysteine, which is a substance very toxic to the brain.

This is part of his genetic “personalized medicine” marketing. But what I described above is true personalized medicine – using markers that have been shown to be useful in individualizing treatment – who needs folic acid and who doesn’t.

But looking at genes sounds more cutting edge – better for marketing. Hyman seems to be cherry picking the evidence. At present there is inconclusive evidence linking the MTHFR gene to an increased risk of dementia in the elderly, and a recent large study showed:

MTHFR genotypes or alleles also did not show any correlation (with dementia).

But worse, Hyman confuses the role of risk factors, markers for diagnosis, and markers for treatment. Some genotypes correlate with an increased risk of developing a disease, but are not helpful in diagnosis. Other genes are useful in diagnosis, but only some of these genes are useful in predicting outcome to specific treatments.

Now, it is true that we hope one day to usher in a phase of medicine where we use genetic testing to tailor our treatments. This is theoretically possible, and we are making progress, but we are not there yet. Just as we hope one day to cure many diseases with stem cells, but I would not pay to go overseas to a stem cell clinic today.

Hyman is misusing current research to determine treatment – but this is simply not evidence-based. It is not “functional” medicine, it is bad medicine. Science-based doctors want to know what markers actually mean – and for treatments that means they need to be tied to treatment outcomes. None of the studies Hyman references actually support the genetics-based treatment decisions he is advocating.

I would also point out that he mixes in some advice that is based on evidence, but that is already part of standard evidence-based practice (or is being incorporated in response to published evidence). For example, here is a study which concludes:

CONCLUSION: Vegetables, unsaturated fats, and a high MeDi score may be beneficial to cognitive function.

MeDi is short for a Mediterranean diet. The evidences shows decreased risk and better long term outcomes for patients who eat plenty of vegetables, have low saturated fats, and generally eat a Mediterranean diet (which has lots of vegetables and low saturated fats). This is a generally healthful diet in many ways – and we don’t need to test your genes to recommend it.

Hyman also recommends exercise – and there is evidence that exercise reduces risk and improves outcome in vascular dementia and other dementias. So that is also part of conventional treatment. I wonder who Hyman thinks is doing all these studies on diet and exercise, since he believes physician training only includes matching drugs to diseases.

Conclusion

Science-based medicine includes many modalities of intervention, including diet, targeted supplementation, exercise, risk modification, symptomatic treatment, and where possible disease modification. The research on any particular medical topic, like dementia, is very deep and nuanced and requires understanding of the complex relationship between syndrome, disorders and diseases, the relationship between biomarkers and pathophysiology, the differences among markers for risk, diagnosis, and treatment outcomes, and the types of evidence that are useful in determining which treatments work and are appropriate for specific patients.

Mark Hyman, in advocating for his “functional” medicine, appears to understand none of this. Instead he whitewashes over all this complexity and would have his readers believe that science-based practitioners take a simplistic knee-jerk pharmacological approach to all patients. The evidence clearly puts the lie to this caricature.

Meanwhile he himself takes what appears to be an overly simplistic approach – extrapolating tenuously and inappropriately from various different kinds of evidence to ultimate treatment decisions. Specifically in this essay he abuses preliminary evidence on the relationship between various genetic markers and disease risk factors to give the illusion of personalized medicine – prematurely declaring the death of the indispensable notion of “disease.”

He seems to have failed to notice that the very evidence he is citing is often closely tied to, or even dependent upon, the concept of a pathophysiological disease.

He further borrows from legitimate science in order to argue for the inadequacy of the scientific tradition that created the evidence in the first place. We know about the legitimate benefits of exercise and a healthful diet because of science-based medicine – not the slick marketing of self-promoting gurus.

Posted in: Science and Medicine

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26 thoughts on “Personalized Medicine Bait and Switch

  1. Anarres says:

    “We know about the legitimate benefits of exercise and a healthful diet because of science-based medicine”

    I like very much this one, alt-woo-guys forget it all the time.

    Thanks Steven.

  2. egstra says:

    You write, “As a neurologist who treats dementia, his straw man is more than a bit offensive.” I think you mean that “to a neurologist who…”. Unless, of course, there is a strawman who treats dementia.

    Other than that, I liked the article.

  3. David Gorski says:

    What really irritates my about Hyman’s article is how he abuses genomics by using rampantly speculative interpretations of genomic data to provide treatments to his patients that have not been validated. He confuses biomarkers with molecular targets for therapy, mixes speculative interpretations of these biomarkers’ importance along with science-based recommendations (diet, excercise, etc.), and then uses the big gamish on patients. Worse, most of the articles he cites do not conclude what Hyman thinks they conclude, nor do they support his treatments.

  4. superdave says:

    In some ways this was the worst Huffpo piece on health I have ever read. A man with a medical lisence dispensing dubious, misleading information that will surely give false hope to some is in a different league altogether from the usual deepak chopra or dana ullman crap.

    I have a question though, how frequently do these reversible forms of dementia get diagnosed?

  5. Happy Camper says:

    @superdave

    Worse than anything DUllman, Chopra, Robert Lanza and the rest of the cranks who populate the pages of HuffPO? That’s a pretty tall order.

    Perhaps you haven’t seen this.

    http://www.huffingtonpost.com/2010/06/30/black-cumin-may-treat-pan_n_629602.html

  6. superdave says:

    @Happy camper,
    I see your point but I am taking into account believability and credentials here. Mark Hyman should know better, and also had loads of links to books he is selling. Funny how few articles on science based medicine end in links selling books even though I know at least one of the bloggers here has in fact authored a book.

  7. mikerattlesnake says:

    “but this is simply not evidence-based. It is not “functional” medicine, it is bad medicine.”

    Dr. Hymen, Bon Jovi has a message for you….

    http://www.youtube.com/watch?v=eOUtsybozjg

  8. MKandefer says:

    It amazes me the distinction between the MDs on this blog, and those on Huffington Post. What do you suspect led you to develop a skeptical mindset, and more appreciation for scientific investigation, than MDs like Mark Hyman?

  9. trrll says:

    Although MDs receive a lot of training in biology, it tends to focus on conclusions rather than process, and they do not necessarily receive much training in actually doing science. Some MDs (such as Dr. Gorski) do actual research, while others chose to pursue their own education in science-based evidence.

    Medicine as a discipline is becoming increasingly science-based, but there is a great deal of inertia. A lot of traditional medical practice is based more upon physiological plausibility (scientific “just-so” stories) than upon actual evidence, and this sort of thinking, combinined with weak knowledge of how to evaluate evidence, can make physicians vulnerable to pseudoscience.

  10. Happy Camper says:

    @MKandefer

    I’m sure there are many reasons why the cranks post there. I have heard that one celebrated doctor who had a promising career jumped the shark and went over to woo after his sister died, others I’m not so sure of. What I can say is that many who call themselves “doctor” at HuffPo are not medical doctors or even have any training in the medical fields. For instance Dr Patricia Fitzgerald who is the “wellness” editor is a doctor of homeopathy (whatever that is).

    Your comment also raises a question that I have wondered about for some time and that is what type of people are attracted to quack/new age medicine? There are obviously relatively intelligent people who are attracted to the “holistic quackery”(for lack of a better term) posted there. Is there a type of people who are attracted the sort of weirdness like homeopathy(my personal favorite), herbal medicine, reiki, acupuncture, chiropractic and other pseudoscientific modalities of so called healing? I get the impression that much of it comes from the new age back to the earth counterculture that was an outgrowth of the hippie movement of the late sixties but for trained medical doctors I don’t have an answer.

    I think it would be an interesting study of just what is the makeup of the movers and believers of the Alt med crowd.

    Any anthropologists out there?

  11. weing says:

    With a name like that he should have been a gynecologist. Maybe it’s greed and seeing they can make more money selling woo with less risk than the practice of real medicine. If he sells what people think they want, he is just exploiting the market. He sounds pretty incompetent to me, so he may have been a legacy admission and never got weeded out. Then again, half the doctors graduate in the bottom of their class.

  12. Anarres says:

    and “Denying aids”

    http://denyingaids.blogspot.com/

  13. Maz says:

    Anyone else having trouble posting comments on this article? The HuffPo moderators seems to think that my comments are unacceptable.

    I guess if being truthful is considered “abusive” language….

    I simply wanted to point out that Hyman would have the reader believe that doctors are pill-dispensing automatons who don’t care what’s REALLY wrong with their patient. He then immediately goes on to recommend drugs and other biologically active substances to the whole of the internet, based on his sloppy diagnostic criteria.

  14. egstra says:

    A general comment – I’ve been reading this blog for some time, and have often wondered who it is that believes the woo crap. Then today, on the bus, I got to talking to an equally old woman… who informed me that Dr. Oz says that stretching for some number of minutes every day can increase your lifespan by 7 years.

    I tried to explain to her that, while stretching is good, and may help keep us more flexible longer, there is no evidence that it increases lifespan. She couldn’t get beyond her own experience (stretching makes her feel better) and, “But Dr. Oz said so.”

  15. Lawrence C. says:

    Isn’t it obvious that this Dr. Hyman, who apparently has a -lot- of things to sell, is simply a shill for Big Functional Medicine, or Big Funk for short?

    I especially loathe this part of his article: “Naming a disease does nothing to help us identify and treat the underlying causes of the disease.”

    Really? How do you identify something without using language to communicate not only to yourself but to, say, the patient or even other doctors? He seems to think that removing parts of language will actually help in the diagnostic arts, leaving us with, one supposes, some kind of Pure Functionalism that needs no specific language to be communicated but will simply be so obvious that everyone will smile and agree on what to do.

    “Hyman’s sloppy language reflects his sloppy thinking….”

    Indeed! These Big Funk people seem to thrive on confusion and jingoism to promote their own interests without any real basis in science. As an old man I get a lot of very silly mail telling me, usually in language reminiscent of Hyman’s, about all sorts of miraculous cures, treatments, medicines and the like. But so far not one of these mailings has suggested that we need to remove basic terms and methods of communication in order to clear things up! Hyman has, indeed, either skirted complexity in the quest for sales or is simply writing ad copy masquerading as a “news” article. Whatever it is, it ain’t medicine.

  16. Happy Camper says:

    @Anarres

    Thanks for the list of books and I have been planning on reading Michael Shermers book.

    What I am interested in: is there a particular makeup of people who fall for the Alt.Med. crud hook line and sinker more than others? From my personal experience I recall (as flawed as it is) many who go for the herbalism, “natural” products, anti – establishment, aromatherapy, crystal sucking, ALt. med people to be either the hippie type or the snake oil salesmen. Yes, I also meet people who I consider the every day working stiffs who use it and swear by it but what I am talking about is the ones who make it a lifestyle. What I am interested in is from an anthropological point of view.

    @Maz

    Don’t worry about it. The censors….er…. I mean “moderators” over at HuffPo are not interested in anything that would be in conflict with their world view. I have tried to comment just how some of the statements made are in violation of the laws of nature never to get them posted. I also wonder if the “moderators” even know the difference between challenging a statement and an Ad Hominem attack.

    At HuffPo, they never let the facts get in the way of a good story!

    @egstra

    Ahhhh…The argumentum ad verecundiam.

  17. Ken Hamer says:

    “Gurus like Hyman, however, are not evidence-based. ”

    Indeed!

    In fact, it would appear that essentially all of them are money-based.

  18. pmoran says:

    Hyman: “In fact, disease and diagnosis as we know it will soon be an obsolete concept, an artifact of medical history, —”

    What an extraordinary statement. Many or most of the advances in medicine have depended upon the ability to break illness up into various categories, having different causes and differing pathological processes.

    So successful has this been that on its better days the whole of “alternative” medicine uses the very same classification system, or otherwise a make-believe one that closely mimics it. Moreover, I don’t think even the most committed “alternative” supporters fail to consult a doctor druing any enduring illness to find our what is really wrong with them.

  19. JMB says:

    It would seem to me that in the US the state boards of healing arts should pay attention to what licensed healthcare practitioners are stating in public media. When statements are made that indicate the practitioner is incorrectly diagnosing or treating patients, then that is grounds for restricting the healthcare provider’s practice.

  20. # Happy Camper

    “From my personal experience I recall (as flawed as it is) many who go for the herbalism, “natural” products, anti – establishment, aromatherapy, crystal sucking, ALt. med people to be either the hippie type or the snake oil salesmen. Yes, I also meet people who I consider the every day working stiffs who use it and swear by it but what I am talking about is the ones who make it a lifestyle. What I am interested in is from an anthropological point of view.”

    Is the title of your anthropology dissertation going to be. “The effect of social conformation on the crystal sucking habits of the hippie types?” :)

    The term crystal sucking seems to lack cultural relativism, perhaps? From an anthropological point of view, that is.

    My pet theory is that there is a large sub-set of the alternative medicine community that is basically DIY based. That the incredible complexity and inaccessibility of medical knowledge is frustrating, so they look for a simpler approach that offers DIY solutions.

    To me this would suggest that the more the medical community can put user friendly information and choices in the hands of the patient and clearly tailor health care decisions based on the patient’s input, the more appealing that will be to the DIY set. That is to say the more they are a guide rather than an authority…

    Oh, and everybody should redecorate. There is probably a certain set in the alternative community who just can not stand to see another teal or mauve formica counter top.

  21. Happy Camper says:

    @micheleinmichigan

    LOL Thanks for the comment.

    My close friends use the term “crystal suckers” as a derogatory remark for those who buy into the new agey, crystal healing, aromatheropy and magical thinking energy medicine tripe. To say that I am contemptuous of that type of thinking (and lifestyle) would be an understatement even though many who I have meet seem to be friendly and well meaning people. First and foremost I am a skeptic with a tinge of cynicism and when someone makes an extraordinary statement the first thing that comes to mind is “prove it”.

    As for your “pet theory” I think you are correct. I have accused a few Alt.Med. practitioners of being doctor wannabes who didn’t have the grades or the resources to go to med school and become a proper doctor. That said, there also appears to be a large subset who suspend all belief in reality (and their education) and plunge headfirst into the steaming cesspool of total woo.

    FYI: I am not an anthropologist but think that the Alt.med. people would make an interesting study. Besides, what’s the matter with mauve?

    I’m just saying

  22. weing says:

    “To me this would suggest that the more the medical community can put user friendly information and choices in the hands of the patient and clearly tailor health care decisions based on the patient’s input, the more appealing that will be to the DIY set. ”

    I thought we do that already. To the extent that the patient can be expected to, of course. My pet theory is that we are teaching patients and guiding them to make decisions about their health. If a patient wants, I can impart all my knowledge gained from my education, training and years of practice. It may take a few years however and not one or two visits. After all, I took me a few years to learn it. I can change the oil and filter, windshield wiper fluid, and check and adjust the tire pressure in my car, but balancing tires, aligning, diagnostics, and electrical work, etc, I leave to the experts.

  23. weing – ah ha! Then I can only assume it’s your teal and/or mauve formica.

    Actually, it’s not surprising that you are already doing this, since I based my pet theory, in part, on observations of some positive interactions with doctor’s or other health care professionals who’s guidance helped me feel that I could take care of myself or my kids better.

    There have been other interactions that are not so helpful, but I did not mean my comment to be a broad criticism or pointing out a failure of the health care system. I only mean to say, if one sees an opportunity to support this DIY tendency in a positive way, even if one saw the potential in some new technology (what, I don’t know) I think it may be a worthwhile endeavor.

    But maybe, to doctors, this idea is old hat and cliche, in which case I apologize for expounding on an idea that you’ve heard ten zillion times.

    As to cars, my father and husband were/are engineers. Engineers give mechanics head-aches, I hear, because they “fix” everything in “new and innovative” ways. I still remember the time my dad “fixed” my brake line leak. Mostly I remember in the middle of the night in a cold sweat. Maybe that’s why I have suppressed many of my alternative medicine tendencies. :)

  24. LMAO says:

    Excellent article. Of course, all the articles at SBM are excellent, so…

    On the subject of what makes people go to the alt side, I personally know many people who live various parts of the country who embrace some aspects of CAM to one degree or another. In my experience (anecdotal as it may be), they tend to fall into one of two camps:

    In the minority are those who are often the “old-timers” or “country folk”. They tend to be simple salt-of-earth types, usually with only the most basic education, who are deeply suspicious of mainstream medicine. They may remember a time when hospitals were the option of last resort (i.e., a place you went to die). Doctors were for rich townfolk. Treatment was more likely to come from grannies who used the remedies learned from their own grannies, which were often learned from native Americans. They survived the Great Depression by continuing the lifestyle of their pioneer ancestors, eating bushels of “free” fruits and vegetables and nuts they grew themselves, along with a little extra lean protein from the squirrels and birds and fish they could catch or kill. They got more exercise than most of us would ever be willing to get, playing hard, and working even harder. They seldom encountered illnesses that their good genes, good health and good sense couldn’t overcome. They also remember the New Deal, and because they benefited directly, still believe that it was a Great Deal. These folks today watch their friends get sick, go to the doctor, get chemo or the latest Rx, and promptly die. To them, it’s the doctors and the newfangled drugs that cause all the pain and suffering. They either kill people outright, or just ensure that an already inevitable death will be more painful, more drawn out and more expensive than necessary.

    Then there’s the majority camp. They tend to also do yoga and/or pilates, shop at Whole Foods, and drive a hybrid Prius. None of those things is bad in and of themselves, of course, but they tend to be disproportionately attached to either hippy-dippy crystal-suckers [absolutely LOVE that!] whose “other car” is a pair of Birkenstocks, or the latest bandwagon-jumping followers of the trendy train whose other cars are an Escalade and a Hummer with at least one carseat in the back (as is the case in my affluent Left Coast area). Interestingly, these are almost without exception, people whose politics are based on “belief” in something vaguely laid out as “hope and change” which will be delivered by an inexperienced, underqualified guy who purports to know more than all those evil mainstream people with the real-world experience. And, not coincidentally, a lot of these people “believe” in this guy in spite of the glaring absence of hard facts and a solid plan to support their beliefs. They continue to believe despite all the obvious indications that they are probably engaging in wishful, magical thinking.

    Sorry for the long post. Keep up the good work, SBM… your country needs you! ;-)

  25. E says:

    Well, okay, so speaking of incompetent doctors who must resort to behaving in a deceitful manner and say misleading things in order to continue to bring in an income; here’s at least some good news:

    http://online.wsj.com/article/SB10001424052748704911704575327112758222570.html

    \o/ HURRAH! \o/

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