Dueling Headines

You may think of aspirin as a medication with a fairly good reputation.  It’s been around for over a century; it works well for everyday aches; and there’s evidence to suggest that for some people, it can help prevent heart attacks and multiple forms of cancer.

At least, until this past week.  Then you may have seen headlines suddenly suggesting that aspirin could cause heart attacks.

“Salt in everyday painkillers linked to premature death”1
“Aspirin link to heart attacks”2
“Sodium-packed medications raise stroke and heath risks”3

Meanwhile, other headlines continue to tout aspirin’s virtues.

“Aspirin could help cure deadly diseases”4
“An aspirin a day could help stop dementia”5

It’s all enough to give you a headache.

By F Delventhal from Outside Washington, D.C., US (Image on Flickr  Uploaded by UAwiki) [CC-BY-2.0 (http://creativecommons.org/licenses/by/2.0)], via Wikimedia CommonsSo, when you reach for your headache medicine, what does it look like?  If it fizzes, you may want to think twice.  These dispersible or effervescent forms of medications, which use sodium compounds for the fizz, were the ones associated with a 16% higher risk of heart attack or stroke.  Plain tablets meant to be swallowed whole didn’t have this problem.

_____________________________________

1Herald Scotland
2Mirror.co.uk
3Los Angeles Times
4Zee News
5Daily Mail

The “beware of sodium in fizzy medicine” article:“Association between cardiovascular events and sodium-containing effervescent, dispersible, and soluble drugs: nested case-control study” BMJ 2013; 347 doi: http://dx.doi.org/10.1136/bmj.f6954 (Published 26 November 2013) Cite this as: BMJ 2013;347:f6954

And the “aspirin could prevent dementia” article hasn’t been written yet.  Those headlines have to do with the beginning of a new study examining the benefits of aspirin.  When the results come out, sometime in 2019, look here for clarification.

Smoking: now there’s one fewer reason not to quit

"My Last Cigarette" by justj0000lie; Creative Commons some rights reserved

“My Last Cigarette” by justj0000lie; Creative Commons some rights reserved

A lot of folks are concerned about gaining weight after they quit smoking.  Some folks worry about how they’ll look, or if they’ll fit into their “skinny” jeans.  Other folks wonder whether the health effects that can come from extra weight would cancel out any benefit from quitting smoking.

Today, JAMA published the results of a study(1) that examined that very question.  (JAMA used to be called the Journal of the American Medical Association.)  The researchers involved watched what happened over time when real people quit smoking.  Specifically, they tracked about 3200 people who didn’t have any evidence of cardiovascular disease from 1984 through 2011.  Every four years, researchers would check in with this group of people and find out how they were doing.  Doctors would check their weight, heart rate, blood pressure, and so forth; patients would report whether or not they smoked; and they’d discuss how their health had been over the years since the previous exam.

Over that 25 year span, some people quit smoking.  Over that 25 year span, some people had heart attacks, or had strokes, or developed congestive heart failure.

What researchers found when they analysed who had cardiovascular events shouldn’t come as a surprise:

  • folks who quit smoking within the past four years (between one check-up and the next) were only half as likely to have a bad cardiovascular event
  • folks who quit smoking more than four years beforehand had, again, about half the chance of having a bad cardiovascular event
  • folks who never started smoking had only one-third the chance of having a bad cardiovascular event
  • and the benefits of quitting smoking held up even for those who gained weight after quitting.

So, don’t let fear of gaining weight hold you back from doing what might be the single best thing smokers can do for their health: quit.  If you need help, contact your healthcare provider or call 800-QUIT-NOW.

1. Clair C RN. Association of smoking cessation and weight change with cardiovascular disease among adults with and without diabetes. JAMA. 2013;309(10):1014–1021.  Online at http://jama.jamanetwork.com/article.aspx?articleid=1667090

 

 

“Getting Exercise” vs “Getting Up”

(woman sitting outside with laptop)This week I came across an article in PLOS ONE looking at the difference between “getting exercise” and “getting up”: Minimal Intensity Physical Activity (Standing and Walking) of Longer Duration Improves Insulin Action and Plasma Lipids More than Shorter Periods of Moderate to Vigorous Exercise (Cycling) in Sedentary Subjects When Energy Expenditure Is Comparable by Bernard M. F. M. Duvivier et al. Here’s the question: which is better for your health — doing some high-intensity exercise an hour a day, but basically sitting the rest of the time, or skipping high intensity exercise entirely while spending several hours a day up and on your feet?

Researchers randomly assigned participants to one of three exercise regimens:

  • SITTING:  8 hours/day sleeping or otherwise lying down; 1 hour/day walking; 1 hour/day standing; and the rest (14 hours) sitting.
  • INTENSE EXERCISE: 8 hours/day sleeping or otherwise lying down; 1 hour/day walking; 1 hour/day standing; 1 hour/day working hard on a stationary bike; and the rest (13 hours) sitting
  • MINIMAL INTENSITY: 8 hours/day sleeping or otherwise lying down; 5 hours/day walking; 3 hours/day standing; and the rest (8 hours) sitting.

Notice that the “intense exercise” option is close to what many folks hope to be able to do.  It’s spending a full hour at some heavy-duty aerobics, with the rest of the time working at a desk, watching TV, and puttering around.  It’s hard to picture how one could structure one’s life to match the minimal intensity scheme.  This may be why all twenty of the study participants were between 19-23 years old: it seems like something a college student might be able to handle for a few days at a time.

The participants were assigned to these different exercise plans in random order, for four days at a time, with ten days “washout” in between for which they were asked to go back to their usual levels of activity.  Researchers measured their activity by strapping monitors to their legs; they kept track of their calorie intake by keeping food diaries.

After each four-day  segment, participants had their cholesterol and triglycerides measured.  Each participant was also given a glucose tolerance test: after drinking a liquid with 75 grams of glucose, blood sugar and insulin levels were measured over the next two hours.

So which group had the better cholesterol numbers?  Which group needed less insulin to process the same amount of sugar — that is, had less insulin resistance?  You see this coming, don’t you.  The “minimal intensity” regimen was associated with blood test markers for better heart health and lower risk of diabetes.

Of course, this is just a preliminary study.  Studying four days of altered activity won’t tell us what a lifetime of different habits might do for health, and lower blood sugar on a test today doesn’t necessarily mean a lower chance of developing diabetes 5-10 years from now.  I’d love to see a study that had less walking and more standing: I’m a lot more likely to get a standing desk than I am to get a job walking all the dogs in my neighborhood.  Still, it’s one more piece of data suggesting that a few hours a week at the gym can’t correct the damage of a week sitting at a computer and watching TV.

(Image credit: “Bethesda Fountain” by Ed Yourdon, under a Creative Commons attribution & share alike license.)

Alternative? Quackery? Experimental? BoingBoing!


On one of my favorite geek blogs, BoingBoing, Xeni Jardin recently posted about quack cancer cures. Xeni was diagnosed with breast cancer a while ago, and she’s been “talking about cancer, sharing the experience of… treatment” for a while now. She’s been getting lots of advice lately from “well-meaning friends” who have suggested some pretty outrageous so-called cures. I’d love it if you took the time to read her post, and some of the ones on other blogs she linked to, as she pointed out the difference between evidence-based medicine and anecdata. “What doctors like my rad-onc practice is constantly under scrutiny, and has endured the test of peer-reviewed science and empirical logic. It’s the best we have…. If I had fake cancer, I’d totally use fake cancer cures. But I have real cancer.”

Not eight hours later, another post appeared on BoingBoing.  Lindsay Stark wrote about the Ancestral Health Symposium, a place where “MDs and naturopaths” talked about “what has come to be known as the paleo diet.” Lindsay, “once a gangly nerd with weak and painful joints” from ankylosing spondylitis (AS), touted her experience with the “so-called caveman diet”: “I don’t hurt anymore; I’m thriving.”

So what’s the difference? Why is a “weird fad diet” OK to look at for treating AS (Lindsay), when “people who sell fake cancer cures are murderers” (Xeni)?

The two BoingBoing posts can actually fit together quite well; I just think the two authors, writing independently, left out a middle piece. Before I can fill that part in, I need to backtrack for a moment to one of the posts Xeni referenced.  Orac at scienceblogs gives some non-standard definitions:

“Conventional” medicine is based on scientific knowledge whereas alternative medicine is based on clinical or anecdotal evidence.

I’d point out that not nearly as much of “conventional” medicine as we might like is actually based on thorough scientific study, but I’ll agree that much of alternative medicine does not have rigorous scientific data to back it up.  Sometimes, that’s because the “alternative” is simply incorrect: no matter what you may hear from which celebrity, the vaccine for measles is not the cause of the dramatic increase in autism.  We know this because as we learn more about autism, we can now see signs of the condition in children months before the vaccine would be given.  Sometimes, it’s because tests are hard to conduct or difficult to fund.  Before the effect of acupuncture on knee arthritis could be studied, researchers needed to develop a way for patients to receive what they thought was acupuncture, but wasn’t: special not-needles that stayed in place even though they didn’t enter the skin.  And sometimes, what starts out as an unverified claim gathers enough evidence to make the jump from “alternative” to “conventional”.  A good example here would be the use of fish oil to prevent heart disease.

There’s another word used for treatments that haven’t become part of conventional medicine, but may make it there one day: “experimental.” Many people who wouldn’t dream of seeing an alternative healer, or who would be dubious of an MD who practices “integrative medicine” (another quote from Orac: “it’s just alternative medicine ‘integrated’ with real medicine, and you all know what happens when you ‘integrate’ cow pie with apple pie”) might consider enrolling in an experimental drug trial.

“Alternative” treatments often come from a different world-view than that used in conventional medicine. Maybe a particular remedy comes from a system that emphasizes balance among multiple traits (hot-cold, or yin-yang); maybe there’s discussion of life-force (ki, chi, prana…) that science hasn’t identified yet. But I would point to the pragmatic quality of science and suggest that if it repeatedly works, in multiple replicated experiments, it shouldn’t matter who thought of the idea: it still works.

So if you’re considering an unconventional treatment, look at some of the details.

  • Is it something that’s being actively studied, or are you just shown testimonials of patients who say it worked for them? Testimonials may be a place to start, but they’re not enough. It’s always possible to find someone who had improvement while trying a particular treatment. The question is, did the treatment cause the improvement?
  • Are the claims out-of-scale? If someone tells me that a certain kind of tree bark can reduce blood sugar in diabetics who take it every day, and that they have a few small-scale studies documenting this effect, I’ll have a look. (Maybe some day I’ll do a post about cinnamon.) If someone tells me about a rare fruit that can cure all cancers, I’ll walk away quickly.
  • Are there side-effects? Pretty much everything has side effects, especially if you are using multiple products or taking more than the recommended amount. Even water can be dangerous: drinking too much water during physical exertion, for example, can cause dangerous changes to the electrolyte levels in the body. If someone tells you a particular treatment avoids a side effect of a conventional treatment, you might be interested. If they tell you that it has no side effects of its own, be concerned.

The conference that Lindsay Stark went to was not just Paleo-proponents sitting around and talking about how well a particular diet worked for them, or selling cookbooks or memberships in grass-fed beef co-ops. To quote her post again: “Binghamton U biological anthropologist David Sloan Wilson called for the testing of the mismatch hypothesis in rigorous and controlled studies; and… Mat Lalonde laid out heaps of data showing… the foods recommended by the paleo diet win out in terms of nutrient density alone. In other words, evolution provides the hypotheses that we then can test. (emphasis added).

While anything based on diet or nutrition is sometimes called alternative, it’s that willingness to rigorously test the hypotheses, rather than just accumulate personal stories, that makes Lindsay’s post about the paleo diet a story about experimental medicine as well. Orac’s objections notwithstanding, there is an overlap between experimental, alternative, and conventional medicine: and in my definition, that mix is integrative medicine.

(Image: ‘Tug of War ‘  by Josh James; http://www.flickr.com/photos/joshwept/5689555989/sizes/z/in/photostream/)

Don’t just sit there, do something!

Image

BMJ (formerly the British Medical Journal) published a study today emphasizing the perils of a sedentary life.  The key message?  “…Life expectancy in the USA would be 2.00 years higher if adults reduced their time spent sitting to under 3 hours/day…”

The study was based on data from a survey of Americans about their health habits, the National Health and Nutrition Examination Survey (NHANES).  Looking at answers to questions about sitting and watching TV, researchers were then able to use other studies which linked sitting to shortened life expectancy to come up with an estimate of the years of life lost, just by sitting.

You can read the article at http://bmjopen.bmj.com/content/2/4/e000828.full.pdf+html.

Which is as good an introduction as I could hope to find for this blog.  I’m a family physician, practicing in the eastern United States.  While I’m often honored by the faith it seems that many people have in the abilities of “modern medicine” to correct problems and cure illness, it’s far more accurate to say that external help — health care professionals, medications, surgery — can only do so much.  To a large extent, health is the result of the choices we make every day: to be active instead of sedentary, to eat nutritious food rather than empty calories, to spend time with people we care about.

I’m not perfect; none of us are.  It’s my hope that if I can help you know the research and the science, you’ll be able to make choices you’ll feel good about now — and better about in years to come.

(Image: ‘Free Child Walking on White Round Spheres+Balance+Creative+Commonshttp://www.flickr.com/photos/40645538@N00/233228813)