Monthly Archives: February 2009

One could be forgiven for thinking, after reading certain recent media reports, that vitamin D can perform miracles. This humble supplement, it was claimed, had the power to prevent no less an evil than multiple sclerosis, prompting reports of a rush on health food shops and pharmacies.

MS is a chronic illness that affects the nervous system. An afflicted person can have a variety of symptoms, some minor, others with serious consequences for mobility and health. There are few treatments, and there is little agreement about cause.

One theory is that MS is an autoimmune disease, in which the body reacts aggressively to its own cells. Others think it’s a genetic disorder, since the relatives of MS sufferers are at increased risk. Another possibility is that there is an infectious agent responsible, perhaps a viral trigger. One compelling explanation relates to geography: the further one goes from the equator, the greater the number of MS cases, suggesting that a lack of exposure to sunlight could be an influencing factor.

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More from the Prince’s Foundation for Integrated Health: we should look forward to May, when publication of guidelines with an “integrated approach… bringing together mainstream medical science with the best of other traditions… movement including exercise, yoga, tai chi/qi gong…” will apparently be published.

The PFIH is working with Mind and the Royal College of Psychiatrists, among others, to achieve this aim. I am horrified – the RCP has had (at least, up till now) a strong ethos for evidence-based treatments. I can’t imagine these reputable organisations working directly on guidelines with the pharmaceutical industry, for example, on how to use their products in hospitals. So why turn to the PFIH for “inspiration, understanding and practical tools” on “integrated health”?

Good facilities should be expected in psychiatric hospitals but are nothing to do with “integrated health”. Instead, they are everything to do with treating people well and with dignity. Integrated health is also nothing to do with the occupation which patients may benefit from - woodwork, gardening, crafts – but don’t often get the chance to thanks to the decimation of the numbers of occupational therapists in hospitals and the community.

Autism is not the only developmental disability that a child can be born with. It does, however, garner a lot of attention. Part of the reason is that we still don’t understand the condition as well as we would like. And we still have no way of testing for it through prenatal screening.

Recent research has, however, raised the possibility of such a test. A study published in the British Journal of Psychology showed an association between higher levels of testosterone in amniotic fluid samples and autistic traits in the older child. In light of this information, Simon Baron Cohen, professor of developmental psychopathology at the University of Cambridge, has called for a debate on the ethics of prenatal screening. He is against the practice, as he made clear in an online article in Community Care magazine.

If there is one absolute about screening tests – where testing is done in the absence of symptoms – it is that one has to be extraordinarily careful. The prenatal tests currently available – for Down’s syndrome and spina bifida – are meant to be performed only after appropriate discussion of the potential problems. Yet these tests are still limited in the information they can give us. They do not tell us how disabled the child will be, or what his or her life would be like.

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This follows on from a post a couple of weeks ago about this paper in the BMJ and the duty of doctors to explain both pros and cons of breast screening to patients. Here is a letter and article on this subject today in the Times.

Antibiotics don’t work on most colds, flu or sore throats. This is old news, but the Department of Health is re-launching their Antibiotic Awareness Campaign to remind us. Indeed, the more antibiotics are used, the bigger the problem resistance becomes. So I’d like to know what the sense is in making antibiotics prescribable by more healthcare workers, in reducing the amount of pharmacology taught in the medical undergraduate curriculum, and in plans to make certain antibiotics available over the counter.

I’ve been reading a brave book that I wanted to like but I don’t. It is called Drug Truths: Dispelling the Myths about Pharma R&D. The author is John L LaMattina, who is the retired president of Pfizer Global Research and Development.

The pharmaceutical industry has had a bad press over the past couple of years, and nothing would have given me greater joy to report that all was now good; that there was no more overselling of drugs and no more inappropriate advertising. But instead, I am seriously worried by this book. It seems to imply that there was no such overselling in the first place and that industry has always behaved well.

For example, let me quote a piece about disease mongering. “The view that the pharmaceutical industry sits around dreaming up new diseases and then convinces people that their minor ailment urgently needs drug treatment is absurd. First of all, a company cannot simply declare a new disease and market a drug to treat it. A disease must be recognised by global regulatory agencies who set up criteria that a drug must meet in order to have even the most remote chance to be approved. Second, payers must believe that the condition is serious enough to warrant reimbursement of the cost of the drug to treat it. Third, physicians must believe the disease is serious enough to be willing to prescribe a drug to their patients to treat it. And finally, patients must be concerned enough about their pain or discomfort to be willing to seek treatment in the first place.”

From a perspective of unfiltered primary care, I think I’m in a reasonable position to comment. Why do patients go to their doctor? All kinds of reasons. The ecology of what goes on in the consulting room is dependent on numerous external influences; advertising – or let us call it “disease awareness”, where people are encouraged via “educational campaigns” to see their doctor if they have symptoms of various diseases or disorders, is one. Expectation of medication is introduced with ease. One example is the “awareness campaign” a couple of years ago encouraging men to attend their doctors if they had erectile dysfunction. On the value of seeing one’s doctor, I could not disagree. However, ED can have a variety of causes, from the psychological to vascular disease. Medication can be useful, however it may not be appropriate, and further tests may be needed. But by creating expectation of medication, the process of proper medical care is short circuited. LaMattina has not considered that some physicians will simply give in to the expectation and pressure to prescribe. Similarly, LaMattina describes irritable bowel syndrome (IBS) as another disorder where the pharmaceutical industry cannot be accused of disease mongering: “This is clearly not a disease invented by a pharmaceutical sales executive.” What he fails to do is to appreciate the spectrum in the disorder. Like depression, anxiety, and pain, there will be some people who are entirely or heavily disabled by their symptoms. And then there will be others who have minor symptoms, who are only occasionally bothered by them, who may find that taking medication is more hassle than not, or who have other non-pharmacological ways of dealing with their symptoms. But ”disease awareness” advertising threatens to make these people “patients” with all the problems that this delivers.

Similarly, with cholesterol, LaMattina says, of a particular senario, “…should you take a statin? Given that statin use lowers your risk of a heart attack by as much as 35 per cent, the answer should be a resounding ‘yes’! This type of treatment is not disease mongering – it is preventative medicine.” But actually, it’s not just disease mongering but also scaremongering. It is almost impossible to make a realistic decision about risk based on relative risk alone. What you need to know is your absolute risk – there is no point knowing what per cent you can reduce your risk by until you know what your risk was to start with.

Now, if the pharmaceutical industry were able to say: actually, we won’t get involved with “awareness campaigns” anymore because the best health information is independent health information,  I would be happier. If there was an acknowledgement that funding patient groups was fraught with difficulty, I might be sympathetic. The recent report from the Royal College of Physicians on Physicans and the Pharmaceutical Industry . makes it clear that the pharmaceutical industry wants to rehabilitate itself. There are some things all are agreed on  – industry shouldn’t be offering “gifts” to doctors, and doctors shouldn’t be accepting them. But the RCP report argues for “co-operation” between doctors and pharmaceutical firms especially with regard to research. I think this is premature and potentially dangerous. Pharmaceutical companies simply do have a different agenda to doctors. Any relationship has to be under constant and open scrutiny; and I am not sure that there has been a proper appreciation of the past problems such that they have disappeared and will cause us no problems in the future.

Duchy Originals was established by the Prince of Wales in 1990 to raise the profile of organic food and farming. Lines from the company, which gives its profits to the Prince’s own charities, include Rose and Mandarin Shampoo, oaten biscuits, sherbet lemons and handmade Sandringham Strawberry Preserve.

With regal glee, the Duchy website recently announced a new product range. “Suffering from the sniffles? Try a Duchy Herbal Remedy!” Andrew Baker, Duchy’s chief executive officer, said: “Our decision to launch these products reflects The Prince of Wales’s passion for integrated healthcare.” Well, my own pleb’s passion is for evidence-based healthcare that doesn’t cost more than it needs to. So, let’s look at the evidence.

First, the “Detox Artichoke and Dandelion Tincture”. It allegedly can “help support the body’s natural elimination and detoxification processes”. There is no scientific evidence to support the need for “detox”. Detox is a concept which is designed to make us feel that there is a quick fix to long-term excess. There isn’t. The product costs £10. I think this represents particularly bad value.

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The number of computer programs that promise to sharpen, train and preserve brain function seem to be proliferating. There has been a lot of press coverage about a paper in the journal Alzheimer’s and Dementia . The authors reviewed all the evidence available on interventions aimed at preserving cognitive function in healthy elderly people. Just as I say in point number five of the 10 steps to health in ’09, the authors point out that there is no decent evidence that these kinds of programs work. Furthermore, they may even come with potential harms.

As Professor Peter Snyder, one of the co-authors, wrote in an e-mail to me yesterday: ”There are several lifestyle-related things that older persons can do that have much better clinical data supporting their effectiveness, for possibly delaying onset of dementia.  First, there is truly excellent physiological, neurological and clinical outcomes data supporting the role of regular exercise – even three times per week for 20 minutes per session of exercise (e.g., fast walking).  Second, we know that obesity, diabetes and heart-disease are all risk factors for Alzheimer’s disease.  Finally, I suspect that remaining cognitively active does indeed offer some protective benefit… the point of my paper is that there are no credible data to support the increased benefit of these marketed products and brief interventions, over maintaining a socially active lifestyle, remaining engaged and active with family and friends, learning new hobbies, music or a foreign language, playing Suduku or crossword puzzles, cooking, and reading good books on a regular basis.”

Personally, I find this advice very life-affirming.

In the UK, smoking in workplaces is banned. But we can do what we want in our own homes and in our own time (as long at it’s legal).

Glancing through job adverts (reading them is a recurrent hobby, not a search) I note that the World Health Organisation wants to recruit only people who are non smokers – that’s not just people who are non-smokers at work, but non-smokers at home as well. This raises an interesting ethical question: should employers have any right to know what their employees are up to (in a non-lawbreaking sense) when they are off duty? Surely employees are entitled to privacy? Of course, good employers will want to ensure that they are not curtailing employees ability to be healthy – but this is a step beyond.

Now, there may be an argument that smokers are less healthy and require more sick leave than non-smokers. But this seems to be rather discriminatory. Most smokers want to stop, and more smokers belong to lower socio-economic groups. I can’t find any research indicating that people would be helped to stop smoking by this policy (if I am wrong, let me know) but there is plenty of evidence associating unemployment with worse health. All in all, this seems to me to be an invasion of privacy and really rather unfair.

Invitations have been pouring through letterboxes all over the UK to take part in the Biobank.

If you haven’t received one already, let me explain what this particular bank wants from you (thankfully, it doesn’t involve money). The Biobank is a research project, and its aim is no less than to improve the “health of future generations”.

Funded by the Medical Research Council, the Wellcome Trust and the Department of Health, among other bodies, it is recruiting half a million people between 40 and 69 to be surveyed about their health. They will be followed for several decades, in some cases until death. People will be asked about health, lifestyle, work, family history, and have blood and urine samples taken for storage. They will also have tests for blood pressure, bone density and lung function. The researchers may ask for permission to access medical notes, and they may in future examine blood for genetic factors.

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Margaret McCartney’s Blog

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A forum on healthcare policy and professional issues, by Glasgow-based GP and FT Weekend columnist Margaret McCartney.

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