Practicing Family Medicine

Why Today’s Medicine Will Never Cure a Chronic Illness?

2011-04-17T17:55:00.001+03:00

As I dive deeper into nutritional medicine, I never stop asking why we in main stream medicine are different when the starting points are the same and honest smart people are present in both schools. I think, I finally came to a plausible explanation. I cannot state that this explanation is fully addressed by either schools of medicine. The coming three paragraphs will take you through my new understanding. I beg you to halt passing judgments before finishing the three paragraphs. Once you’re done, pass what every judgment you want. However, please do that after giving yourself few minutes of imagining the picture that I am trying to draw.

Before I start with my first of the three paragraphs this is the wards that started it:

The main error of the biomedical approach (today’s medicine approach) is the confusion between disease process and disease origins. Instead of asking why an illness occurs, and try to remove the conditions that lead to it, medical researchers try to understand the biological mechanisms through which the disease operates, so that they can then interfere with them.

Fritjof Capra (1982)

For example in the case of diabetes, we study in details what happen to diabetics at the macroscopic, microscopic, chemical and physiological levels. Then, we use this knowledge to develop treatment methods to change this disease state. We have been doing this for decades if not more. What happens to patients using these treatments? Diabetes slows down. The general deterioration in a diabetic health slows and complications do not occur or occur at a later age. But, we never cure diabetes. You can draw another parallel with other chronic diseases as Multiple Sclerosis (MS). Now, stop here; imagine of what I just said trying to suspend judgments. When you are ready move to the second paragraph:

In chronic diseases as diabetes and MS there is less number of cells to do a vital function. In the case of diabetes it is the pancreatic beta-cells (beta-cells for short) in MS it is the central nervous system Glial cells. Let say that a healthy individual has 1000 beta-cells, a newly diagnosed diabetic (type II) will have 500 of these cells. And over seven to ten years the number will drop to zero. This is weather being on treatment or not. Beta-cells like almost all living cells are in a dynamic state of regeneration. The 500 cells that we were left with die and new ones will regenerate just like in healthy individual who has 1000 cells. Could the reason that lead for the number of beta-cells to drop to 500 still exist, and unless removed the constant states of cell regeneration will never lead to having 1000 beta-cells?

The final paragraph:

Let assume that the cause of diabetes is not having enough beta cells, and the produced disease state is because of this drop in number of beta-cells. Then, if we ignore the cause of the drop of the number of beta cells from 1000 to 500 (that are in a dynamic state of regeneration) and just focus on the state existing with 500 cells we will never cure diabetes.

I finished drawing the picture. When you are ready, please write your thoughts.

In conclusion, I hope you can see with me that two of the main reasons why today’s medicine can only slow the progression of chronic illnesses and never cure them is the fault of ignoring the two facts presented:

assuming that understanding the disease status will lead to understanding the underlying cause of chronic illnesses
de-emphasizing the reality that the human body is in a constant state of regeneration thus the disease process being studied by today's medicine is not merely a single event as those that break down a machine, disease process is being constantly regenerated. My humble proposal for a way out is to address this process of regeneration and improve it. The solution may turn out to be extremely simple as proposed by nutritional medicine and as done by any farmer: to grow healthy cells (and plants) you simply need:

Nutrients (including water and oxygen)
Expulsion of waste
be in the proper environment

Capra, F., 1982. The turning point: science, society, and the rising culture. A Batman Book/ Simon and Schuster, New York, USA.

What is a ‘Disease’

2010-09-17T08:07:00.001+03:00

In a book I am reading by Martin L. Budd: Low Blood Sugar (Hypoglycemia) the 20th Century Epidemic?; he defines a disease entity as a condition producing symptoms. (page 23)

The book argues that hypoglycemia is a disease entity that exist in non-diabetics and that this disease has many detrimental effects on health. The main cause of this disease according to him, is a combination of a genetic make up and the diet we eat.

I do not agree with the definition he has for ‘disease.’ I think that ‘disease’ should be defined based on the cause and not the manifestations of a condition. Having said that, defining a disease by the collection of symptoms produced is an excellent starting point. It is the definition I have been searching for to describe the symptoms produced by having excess amount of stool in the large bowel that is relived by passing it, when the symptoms do not fit with any agreed on description of constipation or IBS.

The Best Explanation for the Trivial Effect of Hereditary Factors on Disease

2010-09-08T10:30:00.003+03:00

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I just read the best explanation for the fruitlessness of the excessive focus on hereditary and genetic factors in disease. The book is the saccharine disease by T.L. Cleave (1975). You can download a copy of the book from here. The explanation I am pointing to is on pages 9 and 10 in this downloaded copy and pages 3 and 4 in the printed book.

Consider the infantry assault against enemy entrenchments in the First World War of 1914-1918. In that war it was found, as would be expected, that during these assaults tall men were shot down by machine gunners considerably more often than sort men were.

Being taller is a hereditary factor that has many advantages but not with infiltrating solders in First World War. More, we would not care if this tall solder's father died in a similar situation. We need to focus on the true causes of disease, the factors that interact with our make-up and results in disease. Focusing or hereditary factors distract us.

We Must Consider all Perspectives to Propel Medical Science: Another Shot at Practiced Evidence Based Medicine

2010-08-31T16:57:00.001+03:00

I am reading a book by Richard D. Moore, M.D., Ph.D. called the high blood pressure solution: a scientifically proven program for preventing strokes and heart disease.
The theme of the book (which I will not discuss in detail here) is that the main cause of essential hypertension is an imbalance in the Potassium Sodium ratio in our cells that is caused by the disproportionately high sodium to potassium ratio in our western diets.
In the chapter titled ‘Why Haven’t You Heard of These Developments?’ he reveals his explanation for the current prevailing medical practice philosophy. The main philosophical position he addresses is the under-play of the effect of diet and the overuse of drugs. He sees one of the main reasons for this erroneous philosophical position as being what he calls the 'golden triangle'; an unholy alliance between medical schools, drug companies, and politicians. He describes the history of the development of this alliance, as he has firsthand experience with the detrimental effects of this alliance.

He also has written a section titled: ‘The Confusion of Empiricism with Science’. Here is a long quote:

Part of the problem is that many in academic medicine confuse empiricism-just collecting and analyzing facts- with science. But although empiricism is part of science, this alone isn't science. It is just taking measurements and doing statistical analysis of the results. Some think that is all there is to science. But as quantum physicist Roland Omnes says:
Statistical methods are a valuable tool to accelerate the discovery of empirical rules, but it would be a mistake to assume that they are sufficient to attain the consistency afforded by the full scientific methods.

The approach Dr. Moore used to come with a cure for hypertension is what is deficient in the medicine we are applying: the use of the largest possible perspectives and taking in all possible points of view and then testing them against nature. Yes, this would include empirical/evidence based testing. Dr. Moore used the following six points of view to come up with this treatment: anthropology, vegetarianism, animal studies, clinical studies, drug studies, and biophysical research. The second step is to ignore all authorities other than Mother Nature. He particularly warns against experts/authorities in minutiae that lack the perspective to see the big picture.
Needless to say that this is what is needed to propel medical practice. The only science is the one that considers all possible perspectives weather or not are hard to assess empirically.

Leonardo's Call for Holistic Reasoning

2010-06-17T04:25:00.000+03:00

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Leonardo used the term "abreviators" to describe the reductionists of his time:

The abbreviators of works do injury to knowledge and love ... of what value is he who, in order to abbreviate the parts of those things of which he professes to give complete knowledge, leaves out the greater part of things of which the whole is composed? .. oh human stupidity!... You don't see that you are falling into the same error as one who strips a tree of its adornment of branches full of leaves, intermingled with fragrant flowers or fruit, in order to demonstrate that the tree is good for making planks.

I read this quote in Fritjof Capra’s latest book: The Science of Leonardo.These are Capra's own comments:

Reducing the beauty of life to mechanical parts and valuing trees only for their lumbar is an eerily accurate characterization of the mind-set that dominates our world today.

As illustrated in my previous post, Leonardo relied on detailed observations of nature and of his many experiments. Yet, he kept the whole in his mind. In this era of medicine this is what we need. We need not learn more and more about less and less. Instead, we need to step back, and have a deeper look into how things are inter connected. Omeprazole effects on the incidence of pneumonia and Clostridium difficile collitis is a call to step back and connect things.

FORA.tv - Fritjof Capra: The Science of Leonardo

EBM wrongly Instated Epidemiological and Statistical Laws as Clinical Laws

2010-06-15T13:42:00.001+03:00

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Having thought deeper about how I have been practicing, I realised that there is an overarching law in practice Medicine. This contradicts what I alluded to in my previous post. The overarching laws in today’s practice are the laws of evidence based medicine (EBM). These are laws of statics and epidemiology. For example, I believe I have been practicing under these two Laws:

randomised controlled trials are to be meticulously applied.
our clinical decisions should be based on randomised controlled trials whenever possible.

As the title of this post suggests, I don't believe that evidence based medicine should be or is capable of having the status of a law. Yes, EBM offers the best available tools for us to discover nature’s laws. The laws of nature, if true are 100% correct. Unlike statistics, laws have no confidence intervals. We should be 100% confident in laws.

We Need Laws and Not Just Rules

2010-06-15T00:12:00.003+03:00

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This post is another step in my efforts to state my opinion on how should medicine evolve.
Recently, I started learning about medical nutrition from a naturopathic perspective. Before falling into preconceptions, you must realise that naturopathy as a philosophy started with
Hippocrates, as he states:

It is only nature that heals and wherever and whenever possible nature should be given the opportunity to do so.

A modest way to address the naturopathic philosophy is to trust our body's innate capability to heal itself and only intervene when it is deemed necessary.
Having said this, my intention in this post is not to advocate for or defend the naturopathic medicine philosophy. But, there is an intriguing point of view that naturopathy offers that we should seriously consider:
Naturopathy has a law called the Law of Cure that collects dispersed facts into one simple law that once well understood can be applied in treating most if not all conditions. This law is stated by Lindlahr (1913) as

‘Every acute disease is the result of a cleansing and healing effort of nature. ‘

You may not agree with this law. However, the endeavor of deciphering nature’s laws is to be respected. In the medicine we practice we do not have a superseding law, all what we have are dispersed rules. Rules such as - appendicitis is treated by surgery and those with suspected MI need to chew an aspirin pill. Having rules and not laws is a sign of immaturity in the science of medicine. All mature sciences, such as astronomy, physics and chemistry have laws. We should not come up with laws just for the sake of it, however, we should think critically about what laws ought to influence our work. I think one of the main hindrances to the advancement of medicine is that we do not seek the discovery of laws.

For the advancement of medicine I am proposing to:
1. Focus research on finding nature’s laws, the laws that govern health and disease.
2. Train physicians in the proper application of these laws to real life situations.

Evidence Based Medicine: Why I Became Weary of Those Who use This Term?

2010-06-10T08:03:00.004+03:00

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In short, in an effort to make Evidence Based Medicine (EBM) an arching philosophy of practice, EBM had to include evidence that is considered poor by EBM’s very own criteria. The scope of EBM must be narrowed to only be a research paper analysis tool. Unless we do this, we will continue to undermine the quality work produced by the McMaster group and many others.
After limiting the scope of EBM, we should come up with new and practical tools that allow us to be conscientious, explicit and judicious when making decisions about the care of individual patients. Along this journey, we will probably employ new fancy names to describe this philosophy of practice. These names will not include EBM.

Evidence Based Medicine (EBM) has transformed medicine in a good way. Yet unfortunately, EBM is becoming a buzz word and is often use inappropriately. I am in the process of writing my view of how the evidence in medicine should evolve; in detail. But, this is taking more effort than I anticipated. So, for the time being, I thought of writing this short post summarizing some of my thoughts on the matter.

To start, I think the main fault for the inappropriate use of EBM principles falls on those who actually proposed EBM. McMaster researchers that coined the term EBM, described EBM as a method to systematically analyze published research, and to combine this analysis with patient evidence to make clinical decisions (Oxman et al. 1993). Patient evidence includes patient's clinical history, examination, and investigations.

They, then, published a series of articles that outline how to analyse published research. (Oxman et al. 1993)
To fend off criticism, Sackett et al. (1996) published an editorial titled: Evidence Based Medicine: What it is and what it Isn't, that clarified their stance. They defined EBM as:

the conscientious, explicit and judicious use of current best evidence in making decisions about the care of individual patients.

In this editorial, authors stated that EBM is practiced by integrating individual clinical expertise with the best available external evidence.

One of the main criticism of EBM ,as initially proposed in 1992 and 1993, was its undermining of clinical expertise. To clarify (or may be slightly modify) their stance - they now ask to combine the analysis of research papers with “clinical expertise” which is more encompassing than “patient evidence".

Therefore, a flood of so called evidence based guidelines started to appear. These guidelines would propose recommendations that are based on best evidence as per EBM criteria. But, as this is often lacking, the “clinical expertise” of experts is often used. So, the clinical expertise of these experts would be combined with clinician’s own clinical expertise to reach clinical decisions. However, external clinical expertise is considered poor evidence as per the criteria laid out by EBM proponents. (which just does not sound right! especially, for younger physicians like me who's expertise is developing by using these same guidelines.

I believe that Sackett et al. should have backed off by limiting EBM to being a tool to analyse research papers. As I will detail in my upcoming post, EBM does not offer the appropriate tools to apply evidence to individual patients’ cases.That is, EBM does not offer the tools to combine individual patients’ evidence with external evidence. EBM proponents just assume that clinicians would combine these two sources of evidence in a proper manner. But, this doesn’t always happen. Many are using their poor understanding of what EBM as an excuse for bad clinical decisions.

You may or may not agree with me. But, I had to write this post; as sadly, I am becoming more weary of those that use the term EBM than those who don't. Arguably, those who don't shout about EBM to support their opinion must think more deeply and be more explicit in supporting their decisions.

Oxman, A.D., Sackett, D.L. & Guyatt, G.H., 1993. Users' guides to the medical literature. I. How to get started. The Evidence-Based Medicine Working Group. JAMA: The Journal of the American Medical Association, 270(17), 2093-2095.

Sackett DL, Rosenberg WM, Gray JA, Haynes RB, Richardson WS., 1996. Evidence based medicine: what it is and what it isn't. BMJ (Clinical Research Ed.), 312(7023), 71-72.

Vitamin B12 level Drops Progressively as Diabetics Take Metformin

2010-05-21T15:47:00.003+03:00

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This study is uncomforting. We all agree that the true reason for treating diabetes is to reduce or eliminate its complications. And here, evidence shows that the treatment we give to reduce these complications can actually cause them!

In this study 19% of 196 diabetics on Metformin 850mg TID had a progressive drop in their vitamin B12 levels. This study also assessed folic acid levels. With folic acid there was a non-significant trend for lower levels.

Long term treatment with metformin in patients with type 2 diabetes and risk of vitamin B-12 deficiency: randomised placebo controlled trial -- de Jager et al. 340: c2181 -- BMJ

Organophosphate Linked to ADHD in A Pediatrics Article: so Naturopaths Were Right All Along

2010-05-19T10:00:00.002+03:00

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This study compared the level of organophosphate pesticides’ metabolites urinary levels with ADHD symptoms. As these metabolites increased, the prevalence of ADHD increased.

Naturopaths advocate for avoiding all toxins. They proclaim that low levels of toxicity that may not cause acute illness causes chronic ailments due to the chemical reactions of these toxins with our proteins. Homotoxicology practitioners claim to be able to remove these toxins through conjugation reactions that bind these toxins to administered drugs rendering these toxins harmless, or at least less harmful.

Attention-Deficit/Hyperactivity Disorder and Urinary Metabolites of Organophosphate Pesticides -- Bouchard et al., 10.1542/peds.2009-3058 -- Pediatrics

Coenzyme Q10 and Vitamin D Lower Blood Pressure, But What Does This Mean?

2010-05-16T22:33:00.001+03:00

Coenzyme Q10 lowered BP 16.6/8.2 in three studies and 13.5/10.3 in others.

Ca 1200 plus 800 vitamin D lowed systolic BP by 13.1 mmHg.

You may know that the maximum dose of most antihypertensive doesn't lower BP beyond 15-20 mmHg of systolic blood pressure. And even more important is that just lower BP is not enough, Atenolol lowers blood pressure but does not reduce mortality: which is our true goal for treating hypertension.

Another controversial issue is - do we consider asymptomatic high blood pressure a disease or a risk factor? My approach as (that of many others) is to consider asymptomatic high blood pressure a risk factor for diseases, such as strokes and heart attacks and then try to manage the overall risk.This means that simply providing supplements, such as Co-enzyme Q10 and vitamin D to lower blood pressure does not go far enough in my view. Having said that there are two points that may change how I manage hypertension:

1. This article suggests that replacing people with low normal vitamin D lowers their blood pressure. Could low vitamin D be a cause for high blood pressure? Recall that we do not know the cause of over 90% of hypertensive people.

2. Statins that are commonly used in hypertensive people lowers Coenzyme Q10, which when given as a supplement reduces blood pressure. This shows that the way we look at cardiovascular risk reduction needs revision.

Complementary and alternative medicine approaches to blood pressure reduction: An evidence-based review -- Nahas 54 (11): 1529 -- Canadian Family Physician

We Do Need our Stomach's Acidity

2010-05-11T20:18:00.000+03:00

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I have discussed the issue of acid suppression and nutritional deficiency in previous posts. The link between PPI use and pneumonia was previously outlined. This new study outlines the association between acid suppression and nosocomial Clostridium difficile infection.

The push to use NSAIDs for knees OA and just give gastric protection instead of using non-gastric toxic drugs should be questioned.

Arch Intern Med -- Abstract: Iatrogenic Gastric Acid Suppression and the Risk of Nosocomial Clostridium difficile Infection, May 10, 2010, Howell et al. 170 (9): 784

Vitamin B12 as a Medicine to Treat Recurrent Aphthous Ulcers

2010-05-10T11:27:00.003+03:00

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I ran by this study published in January 2009 in The Journal of the American Board of Family Medicine. It shows the usefulness of the use of vitamins as drugs. This was proposed in the 1960s by Linus Pauling and encouraged the start of an alternative approach to heath named orthomolecular medicine. (see my previous post)

Regarding the study, 58 participants were randomized to either receive vitamin B12 1000ug sub-lingual a day or a placebo. A significant number in the treatment group reached 'no aphthous ulcer status' (74.1% vs. 32%; P<0.01)

Effectiveness of Vitamin B12 in Treating Recurrent Aphthous Stomatitis: A Randomized, Double-Blind, Placebo-Controlled Trial -- Volkov et al. 22 (1): 9 -- The Journal of the American Board of Family Medicine

Time to Rethink our Scientific methodology: Long-acting Beta-Agonists With and Without Inhaled Corticosteroids and Catastrophic Asthma Events

2010-05-01T08:44:00.003+03:00

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Many saw this coming … long-acting beta-2-agonists causing an increased mortality only when not combined with cortisones did not make sense. Myself and others voice this oxymoron. We really need to rethink how we think.

This meta-analysis induced 12 studies. The conclusion is as follows:

pooled data show that the use of long-acting β-agonists, with and without concomitant inhaled corticosteroids, was associated with a significant increase in the risk of asthma-related intubations and deaths. The magnitude of risk was, in fact, higher for trials with controlled concomitant corticosteroid use (OR 8.2) than for trials with no corticosteroid use at all (OR 2.2)

You can find the full text at:
Long-acting Beta-Agonists with and without Inhaled Corticosteroids and Catastrophic Asthma Events

Are We Seeing The World in Reverse?

2010-04-04T09:21:00.000+03:00

I am browsing Hoffer and Prousky’s (2006) book: Naturopathic Nutrition: a Guide to Nutrient-Rich Food & Nutritional Supplements for Optimum Health. Here is the world in reverse:

Gastritis -> damage to stomach lining -> reduced acid production -> poor digestion -> nutritional deficiencies.

We need gastric acids to digest meat. It is expected to be hard to release vitamin B12 from undigested meat. Further, vitamin B12 needs healthy stomach parital cells to release its intrinsic factor.

So by chronically giving acid reducing pills, we are exacerbating the problem!

The sequence is convincing, isn’t it?

There are tests that can check for the presence of reduced acid production and other tests that assess the quality of meat digestion.

I will be writing more on reduced gastric acidity. I just need to finish my health informatics dissertation.

Orthomolecular Medicine: My Search for a New Paradigm

2010-03-23T23:06:00.004+03:00

Dr. Linus Pauling (1901-1994) Photo by Dick Willoughby

The future is here. It's just not evenly distributed yet.

William Gibson

Family medicine as a discipline is young. It was an outcry to the practice of medicine in the third quarter of the last century. One of the main chores we took upon ourselves is to focus on prevention. I think we must admit that we lost our way.
Being satisfied by the primary or secondary prevention of statins is a proof of this. Statins at their best provide less than 5% absolute risk reduction for important outcomes.
I am becoming more skeptical. A less skeptical person may see a half full cup; half full and not half empty. But, to see a 5% full cup; 5% full instead of 95% empty is beyond logic.
Using William Gibson’s quote and what Roger Martin (see my post) call for, and most of all luck, I was lead to explore orthomolecular medicine.
Orthomolecular medicine has a very simple philosophy: our body has the innate capacity to cure itself. For this to happen, our cells need to do their jobs. For our cells to do what is expected from them, we need to provide them with needed nutrients.
That's it. Simple yet powerful.

Linus Pauling, the American chemist and molecular biologist who won two Nobel prizes is the person who coined the term “orthomolecular”. Orthomolecular medicine has been practiced since mid last century. But, it is a surprise that most of us have not heard of it. The way orthomolecular medicine provides nutrients to our body’s cells is through the use of an orthomolecular diet and nutrients, principally vitamins.
Orthomolecular physicians/practitioners might surprise you with their use of mega-doses of vitamins. They realize that our cells need different amounts of nutrients during health and illness. They also correctly realize that our current diets just don’t provide all of what our cells needs.
Orthomolecular medicine should not be considered a type of alternative medicine, as it uses the same scientific methodologies used in mainstream medicine. The only problem is that orthomolecular medicine is alienated. Pubmed does not index the orthomolecular medicine journal!
Orthomolecular medicine practitioners use nutrients, mainly vitamins, to maintain health and to cure (yes cure) illnesses.
I hope I have triggered your curiosity. If so you really need to read Hoffer and Saul’s book “Orthomolecular Medicine For Everyone: Megavitamin Therapeutics for Families and Physicians”. Dr. Hoffer is a Canadian psychiatrist who passed away last year at the age of 92. It seems that orthomolecular medicine physicians/practitioners live longer because they practice what they preach.

Gases, Prebiotics, Probiotics and Irritable Bowel Syndrome

2010-01-20T02:57:00.006+03:00

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This is an un-sanitary topic. Yet, for those who have an illness such as irritable bowel syndrome (IBS) is a life quality issue. For the same level of colonic distension, pain and discomfort is worse for people suffering from IBS.

Lately, I started reading about prebiotics and probiotics. This led me to read on our gut microbiota. Some consider our gut micorbiota an organ. Yes, an organ that we did not learn about while in medical school(Gibson 2004).
Above picture is of the 1908 Noble prize in medicine winner Ilya Ilych Mechnikov who poineered interest in gut microbiotia and its connection to health.
Gut microbiota is the bacteria and other micro-organisms living in our gut. Number of their cells is 10 times our cells. They are not all parasitic or pathogenic, rather most are symbiotic. They offer many health benefits. They even feed us. They produce short chain fatty acids that our enterocytes feed on. (Bixquert Jiménez 2009) This is an area of active research and most of the benefits are shown on animal models. For a handful of reasons (big corporations being one) I don’t see this science advancing fast enough. Having said this, there are studies on humans showing some benefits in certain disease entities.
Let’s go back to gases:

I think we all agree that gases are mainly produced by these bacteria fermenting the food we eat. And, you probably noticed that some foods produce gasses more than others. But, this is not all of it. Lumping all our gut’s bacteria together (as with IBS bacterial overgrowth theory) is as lumping all mammals together. You agree with me that elephants and tigers are quite different. There are 400-500 known species in our gut. (Jimenez 2009) These have an undefined number of strains or subspecies.
Lactobacillus and bifidobacterium are two genera that tend not to produce gas when fermenting carbohydrates. (Spiller 2008) And, the more we have of these the less we should have of the gas producing ones, such as clostridia. Therefore, if we can increase non-gas producing bacteria we could reduce gas. There are different methods we can alter our gut bacteria, two have been shown to increase bifidobacterium: prebiotics, and probiotics.
The easiest to explain is probiotics: just ingest live bifidobactirum; some of its strains can bypass the harsh environment produced by gastric acid and bile salts. Live bifidobactirum are found in probiotics capsules and are added to dairy products such as Danon’s Activia yogurt. A study sponsored by Danon, showed if those with constipation predominant IBS eat two servings of Activia yogurt, they would have less gas. (Guyonnet et al. 2007) Something worth noting, we should narrow down to the strain specific level when describing probiotics. For example the tested Danon strain was:

Genus: Bifidobacterium
Species: animalis
Strain: DN-173 010

The other method to increase good bacteria is to feed them. Some types of complex carbohydrates that are not digested by humans reach our colon and are fermented by bacteria. It is found that eating certain types of complex carbohydrates preferentially promotes the growth of Bifidobacteria. Inulin and transgalacto-oligosaccharides are two prebiotics. (Gibson 2004) Lactulse, although not food exerts a prebiotic effect. There are no properly conducted studies that show any clinical benefits of prebiotics for treating bloating in IBS. The opposite is true, there are studies that showed a worsening in bloating with lactulose. (Spiller 2008) Therefore, prebiotics and foods that alter gut microbiota in a positive way need further investigation which will probably be hampered by reduced funding. Big corporations (surprisingly!) can patent probiotics strains clinical use which probably encourages funding into probiotics and not prebiotics research.

Bixquert Jiménez, M., 2009. Treatment of irritable bowel syndrome with probiotics. An etiopathogenic approach at last? Revista Española De Enfermedades Digestivas: Organo Oficial De La Sociedad Española De Patología Digestiva, 101(8), 553-564.

Gibson, G.R. et al., 2004. Dietary modulation of the human colonic microbiota: updating the concept of prebiotics. Nutrition Research Reviews, 17(2), 259-275.

Guyonnet, D. et al., 2007. Effect of a fermented milk containing Bifidobacterium animalis DN-173 010 on the health-related quality of life and symptoms in irritable bowel syndrome in adults in primary care: a multicentre, randomized, double-blind, controlled trial. Alimentary Pharmacology & Therapeutics, 26(3), 475-486.

Spiller, R., 2008. Review article: probiotics and prebiotics in irritable bowel syndrome. Alimentary Pharmacology & Therapeutics, 28(4), 385-396.

Integrative Thinking for Preventive Medicine

2010-01-16T12:53:00.002+03:00

It is time for a new paradigm in preventive therapy. RCTs and meta-analyses are not suited for complex interventions as primary prevention. For primary prevention we need to eat well, exercise regularly, and sleep well. I do not believe that family physicians are trained enough in these areas. More, I do not believe that the science in these areas has reached where it is supposed to be.

It is a shame that over 70 years after the death of Dr. Alexis Carrel his observation holds true till today:

Medicine is far from having decreased human sufferings as much as it endeavors to make us believe. Indeed, the number of deaths from infectious diseases has greatly diminished. But we still must die in much larger proportion from degenerative diseases.

Roger Martin the dean of Toronto’s Rotman School of Business has a suggestion that I think is worth trying in medicine. You can find his suggestion in his book ‘The Opposable Mind: How Successful Leaders Win Through Integrative Thinking’

1. Have a good stance. A stance is how we think of the word, and what we value. Thinking high of RCTs can be thought of as a stance. Refusing to accept any reductionist science to guide preventive medicine is another stance. Always being open to different ideas is another stance.

2. Use abductive reasoning along with adductive and inductive reasoning. You may need to read the book to understand abductive reasoning. My understanding is to use our current knowledge to come with new and imaginative solutions. Abductive reasoning is imagining the possible.

Therapeutics Education Collaboration: a Must Listen to Podcast for Any Family Physician

2010-01-16T09:52:00.002+03:00

If you are family physicians you must listen to the therapeutics education collaboration podcast. This podcast in excellent to perfect on all dimensions:
The presented information, the show notes, the style and the audio qualtiy. Superingly, many podcast don't even come close to this quality.

The two primary hosts are a pharmacist Prof. James McCormack and family physicians Dr. Michael Allan.
I will leave you with this you-tube video for Prof. James McCormack

Blind Men and an Elephant: are Drug Preventive Strategies Missing the Elephant?

2009-09-08T00:22:00.001+03:00

You probably know the blind men and an elephant fable. If not this is a Jain version of it:

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Six blind men were asked to determine what an elephant looked like by feeling different parts of the elephant's body. The blind man who felt its leg says the elephant is like a pillar; the one who feels the tail says the elephant is like a rope; the one who feels the trunk says the elephant is like a tree branch; the one who feels the ear says the elephant is like a hand fan; the one who feels the belly says the elephant is like a wall; and the one who feels the tusk says the elephant is like a solid pipe.

Wikipedia

Each of these six men are correct. Yet, their conclusions are useless to say the least.

The question I would like to raise: are preventive treatments using drugs, such as aspirin, statins, warfarin, and ACE inhibitors missing the elephant?

These blind men are one tool of perception: vision. Scientists use different tools to perceive reality. These tools evolve. Nowadays, we have electron microscopes and PCR. Before using these tools scientists were blind to existing facts. This fable shows that being 100% correct does not assure understanding reality. The outcome of randomized controlled trials can be 100% correct and still derail us from reality.

If you have read some of my previous posts, you probably know where I am going with this. This is another criticism to using reductionist science in preventive science.

Researchers such as Weston A. Price and Daphne Miller noticed the dramatic preventive effect of particular diets. Price went further in connecting the quality of the soil to the quality of fruit, vegetables, milk, and meat. To understand reality we must always consider the possibility of the presence of a striking reality that our perception is not to seeing. This strategy should prevent overplaying findings, as overplaying the effect of saturated fat on heart disease.

Miller, D., 2008. The Jungle Effect: A Doctor Discovers the Healthiest Diets from Around the World--Why They Work and How to Bring Them Home, William Morrow.

Price, W.A., 2008. Nutrition and Physical Degeneration 8th ed., Price Pottenger Nutrition.

Scientific Writing Style Should not be Hypnotizing

2009-09-07T19:14:00.001+03:00

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Scientific articles writing style attempts to emphasize the presented data and not the presenter of the data. This requires a peculiar writing style known to those who read scientific articles. One rule is to never use the first person.

This style is supposed to aid in the impartiality of presented data. However, this writing style is exploited. Drug companies study how to present data to clinicians in ways that would support drug companies’ interests. Moreover, everyone, including scientific writers arebiased. In complying with scientific writing, this bias is purposely hidden.

Readers need to judge the accuracy and usefulness of what they reads. So why not ease up the rules of scientific writings and allow for a more enjoyable read?

Agriculture, Nutrition and Medicine sciences as One

2009-09-02T14:03:00.003+03:00

As physicians we do emphasize diet in our practice. But, do we really go all the way? Is a referral to a nutritionist alone enough?

Having finished reading W. Price’s book on nutrition and degeneration, his observation make common sense. Bad soil leads to bad plants. Those eating these plants whether humans or animals will not reap the expected benefits.

In today’s environment this cycle is handled by three different areas of science: agriculture, nutrition and medicine. Probably the reason we have not learnt from Price is that there are different people in each of these three interrelated specialties.

An Old Known Fact: Degenerative Diseases are Increasing

2009-08-28T16:06:00.001+03:00

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Medicine is far from having decreased human sufferings as much as it endeavors to make us believe. Indeed, the number of deaths form infectious diseases has greatly diminished. But we still must die in much larger proportion from degenerative diseases.

Alexis Carrel, 1873-1944

I started reading the 1939 published book: Nutrition and Physical Degeneration by Weston Price. Price is a Canadian born American dentist, who closed his practice and travelled the world in search for the reasons of rocketing dental degenerative diseases. His book details the findings of his research.

Alexis Carrel is the 1912 Nobel prize winner in physiology or medicine.

A Welldell Berry Quote Against Reductionism

2009-08-26T12:28:00.005+03:00

Here is the quote without any comments:

Reductionism (ultimately, the empirical explanability of everything and a cornerstone of science), has uses that are appropriate, and it also can be used inappropriately. It is appropriately used as a way (one way) of understanding what is empirically known or empirically knowable. When it becomes merely an intellectual "position" confronting what is not empirically known or knowable, then it becomes very quickly absurd, and also grossly desensitizing and false.

Aiming for blood pressure targets lower than 140/90 mmHg is Not Beneficial

2009-08-25T01:04:00.002+03:00

Image by Amarand Agasi via Flickr

This is the conclusion of a newly published Cochrane review. Data that supports aiming for lower targets with drugs just does not exist. As expected from a Cochrane review, they looked at patients’ relevant outcomes, such as total mortality, myocardial infarction, stroke, congestive heart failure, major cardiovascular events and end-stage renal disease.

You can read the physicians’ comments on EvidenceUpdates.

This review makes me ponder the question whether ‘experts’ that come with guidelines are ‘why not’ people or ‘do no harm’ people?

I end with author’s conclusions:

Treating patients to lower than standard BP targets, ≤140-160/90-100 mmHg, does not reduce mortality or morbidity. Because guidelines are recommending even lower targets for diabetes mellitus and chronic renal disease, we are currently conducting systematic reviews in those groups of patients.