Monday, October 26, 2009

Do your homework before using alternative treatments (Marin IJ)

A FRIEND asked me this year for medical advice about an affliction that was puzzling and disturbing him.

Why, he wondered, had his sense of smell deserted him. The condition began with a bout of the sniffles, but weeks later and snot-free, it persisted. He could faintly pick up some scents, but only with great effort - such as if he leaned over a bowl of onions or buried his face in a lilac bush.

I was perplexed, but not overly concerned. I told him that it was probably the lingering, but temporary, effects of a cold.

A month went by and my friend's problem persisted. At best, he could smell 15 to 20 percent of normal and if he got the least bit congested, that sent him back to zero.

Now concerned, I considered the day-to-day ramifications of his condition; savory meals unappreciated, spring days muted, underarm ripeness untreated and backyard canine bombs unnoticed. And, I contemplated the notion that while modern civilization has diminished the survival importance of a keen sense of smell, there are situations where smell can warn of imminent danger; as with the decayed cabbage of a propane leak, the garlic odor of toxic organophosphate chemicals or the bitter almond of cyanide gas on the loose.

This past June, as I was just beginning to appreciate the extent of my friend's loss, I saw a news headline that offered a clue to its cause: "FDA says Zicam Nasal Spray can cause loss of smell."

The Food and Drug Administration, based on 130 different complaints,
was advising consumers to stop using Zicam's nasal gel and swab products.

I asked my friend about Zicam and yes, he had used their nasal swab many months before. And he recalled it quite clearly because the product had caused an immediate and intense burning sensation. Thus, he was not surprised to learn of the FDA's notice - he had long suspected that his loss of smell was due to Zicam. But, he was frustrated; Zicam was a homeopathic brand - natural and presumably safe. And, sadly, that is where he and many others had been led astray.

As a recent onslaught of news reports have emphasized, alternative treatments (such as homeopathic preparations) are not guaranteed to be either effective or safe. In fact, in some cases they are far riskier than conventional treatments. This I know from my own practice.

As an emergency physician, I treat many patients who use alternative therapies. This is not surprising; a CDC survey study of 32,000 Americans found that 38 percent of adults and 12 percent of children had used some sort of alternative medical therapy in the previous year.

Rarely do I encounter people who clearly benefit from alternative therapies (although I know there are many who do). Rather, I see those people for whom they have gone awry; such as the woman with a devastating vertebral artery dissection after a chiropractic adjustment or the young man with gastrointestinal bleeding caused by a Chinese herbal medicine.

And I am also aware that most alternative treatments are of no proven benefit.

There are exceptions, such as fish oil and melatonin, but these are rare. In fact, recent studies have rebuffed the therapeutic clams of St. John's Wort, Vitamin E, and Gingko Biloba. This evidence, coupled with the often-disingenuous marketing of alternative products has made me inclined to view anything labeled "natural," or "homeopathic" with suspicion.

For example, during a recent foray to my local, premium-priced natural food store, I encountered one homeopathic medicine of dubious value after another: Bronchial Wellness Herbal Syrup ($19.98 for a plantain-laced elixir), Male Sexual Vitality Tonic ($16.79 based on Ginseng's supposed and unfounded libido stimulation properties) and ChlorOxygen ($17.98 for a "cleansing" product primarily designed to cleanse the wallet). Ironically, some of the folks who purchase these aggressively priced products are the same ones who consider childhood vaccines a moneymaking scam.

Traditional medicine is far from perfect, and I have, in sum, seen far more complications from conventional treatments than from alternative therapies. Pharmaceutical companies and medical device makers use disingenuous marketing and some physicians prescribe medications of dubious value. But nonetheless, the basic process by which mainstream medical therapies are evaluated is much more rigorous, evidence-based and safety-conscious than that of alternative ones.

Fortunately, this is starting to change, in large part due to the work of the National Center for Complementary and Alternative Medicine (NCCAM) - the branch of the National Institute of Health that recently released its research into Gingko and St. John's Wort. As NCCAM's work continues, I suspect that the list of discredited alternative therapies will grow and entrepreneurs will have to scramble to develop a new line of "miraculous and all natural" treatments to fill the void and empty the wallet.

So, far be it from me to tell people not to use unproven alternative treatments - for some these therapies help.

What I advise, however, if that before you use a new homeopathic product picked off the shelves of your local vitamin emporium is to exercise due diligence. Take a look at the ingredients, Google the product online to search for pending lawsuits or claims of harm, and look it up on quackwatch ( and the NNCAM site ( If everything checks out, use with caution. Otherwise, you should be prepared to contact your friendly product liability lawyer. Speaking of which, if anyone has a recommendation, I have a friend in need.

Tuesday, October 13, 2009

Priorities (Marin IJ)

September 30th, 2009

During the last several months of health reform debate, there has been a lot of scary talk. We’ve been cautioned about bankruptcy, denial of coverage, and pre-existing conditions. We’ve been subjected to speculation about delayed procedures and death panels with a mandate to pull the plug on grandma.

Surely, there are many inequities in our health system and with proposed change comes angst, but whether you are for, against or indifferent towards reform, please pause and remember how lucky we are. We live in a country that has a medical safety net; highly specialized emergency departments capable of treating anyone, anywhere, anytime. This safety net may be expensive, imperfect and severely strained – but it exists. Many around the world are not so fortunate.

Dr. Vicki Martinez, a colleague of mine in the Emergency Department, travels each year to Guatemala to provide free medical care. She works with an organization called Faith in Practice ( that has been sending volunteer medical teams to Guatemala for the last 16 years. These teams travel to the most remote and poorest parts of the country, setting up makeshift clinics in rural villages and providing very basic treatment; antibiotics for parasitic infections caused by contaminated water, pain relief for debilitating arthritis, dental care, and simple surgical procedures. Extremely ill patients are evacuated to urban hospitals. In her journal, Dr. Martinez writes about the heartrending circumstances she encounters: “Today we treated a gravely-ill one-month-old infant with cleft lip and palate. Before we could transfer him, we found the baby mottled and dead in its mother’s arms, she unaware. Our horrified team did its best to console her and deal with the death. To us, the loss of a baby would be our greatest nightmare. In truth, the loss of this woman’s 10th baby with its severe birth defect was just an expected tragedy in a life of struggle.” And, from elsewhere in her journal: “It broke my heart to see young people that would certainly die because they were born in the wrong country. I was sure one 21-year-old mother of three had lymphoma by the multiple lymph node masses she had. Sadly enough, if you are poor with an expensive, chronic disease in Guatemala, you are out of luck for treatment. Another young man appeared to be dying of cancer. The most we could do was to help prepare the family for reality and give him pain medicine to ease his suffering.” Each year, I see Dr. Martinez return from Guatemala with a renewed sense of what it means to a physician and extreme gratitude for the health resources at her disposal here at home.

Dr. Scott Cohen, a pediatric colleague, was so horrified by the conditions that he saw during a three-month visit to the Guatemalan jungles that he founded a non-profit organization – the Global Pediatric Alliance ( – to address some of the health needs of the indigenous peoples of Latin America. Most pressing among these are clean water, de-hydration treatment, and child-birthing skills. This last need is particularly grave – approximately 85% of women in these jungles deliver their babies in huts without medical assistance. And consider that out of all female deaths between the ages of 16 and 40 in Latin America, one in five is due to complications during pregnancy or labor. In contrast, in the U.S., a total of 569 women died during childbirth in 2006 – less than half the number of young women who died from accidental drowning.

“I feel that as a physician,” Dr. Cohen told me “I have a responsibility to care about patients in other parts of the world whom I may never have a chance to meet.” He has accomplished this by helping to train midwives and give them the skills and equipment to recognize complications of childbirth, such as bleeding, early on, so that an expectant mother can make it to the hospital – rather then bleed to death in her hut.

When I reflect on the medical care available to Guatemalans and others in the third world, it is clear to me how fortunate we are in this country and what we take for granted. This is not an argument for or against change in our system; it’s just the way it is. But, I think that the experiences of my colleagues in Guatemala highlight what our health priorities can and should be; basic preventive care, in particular for societies’ most vulnerable populations. A good place to start would be improving out infant mortality rate – currently ranked 29th in the world – on par with Poland and Slovakia. Now, that is truly scary.

When Smelling Like a Fish is Worth It (Marin IJ)

October 12th, 2009

For the last several months I’ve been taking a remarkable nutritional supplement that does all of the following:

• Lowers my triglyceride levels and helps keep me trim and lean
• Decreases my risk of developing coronary artery disease (heart disease) and dying suddenly due to a heart arrhythmia
• Alleviates my joint pain and helps keep my mood (more or less) mellow
• Prompts my wife to sometimes tell me “You smell like an aquarium”

No, I haven’t been feasting on our family goldfish. Rather, I’ve been enjoying the myriad benefits of fish oil supplements.

For decades, researchers have wondered why heart disease is much less common among the Japanese than Westerners. While some have proposed a genetic explanation, a 2008 study published in the Journal of the American College of Cardiology seems to suggest otherwise. This investigation found significantly less hardening of the arteries (atherosclerosis) in middle-aged Japanese men compared to middle-aged American men – but only in Japanese men living in Japan. In other words, American men of Japanese descent had similar levels of atherosclerosis as Americans of non-Japanese descent.
What then, was the major difference between the Japanese and the Japanese Americans? Diet. In particular, the blood levels of omega-3 fatty acids (omega-3s) from the consumption of fish species such as salmon, tuna and mackerel. These fatty acids, which are known to biochemists as docosahexaenoic acid (DHA) and eicosapentaenoic acid (EPA), are thought to have anti-inflammatory and anti-clotting properties that deliver significant health benefits. Recent scientific evidence has given omega-3s even more kudos, such that they are well on their way to becoming standard therapy for patients with, or at risk for, heart disease. Consider, for instance, a study published in the Mayo Clinic Proceedings, which found that life-style changes combined with the consumption of fish oil, and red yeast rice decreased LDL “bad” cholesterol levels by 42% – a reduction similar to that seen with the prescription cholesterol-reducing medication simvastatin (Zocor). In comparison to the simvastatin group, the fish oil group had a significant reduction in triglyceride levels (29% vs. 9%). Based on this and other supporting evidence, omega-3s have become the first nutritional supplement ever officially endorsed by the American Heart Association (AHA).

So, the available evidence suggests that omega-3s are beneficial. The next question is how one can smartly and safely incorporate them into their dietary routine. Well, to start with, not all omega-3s are equal – fish-derived sources seem to be more beneficial than plant-based sources (such alpha-linolenic acid – ALA – from flax-seed or olive oil). Unfortunately, studies have demonstrated that certain fish, especially those high in the food chain, have potentially dangerous levels of toxins such as mercury, lead, pesticides (like DDT) and polychlorinated biphenyls (PCBs). Thus, the Japanese approach to eating fish (for breakfast, lunch, dinner and midnight snack) might put you at risk for serious toxicity. And how about fish oil supplements, are they safe? We know that over-the-counter supplements can be dangerous – take, for example, a study of 500 Chinese patent medical products that found that ten percent contained undeclared drugs or potentially toxic levels of heavy metals. But, don’t despair – research suggests that U.S. fish oil products are safe from contamination. A group from Massachusetts General Hospital has tested commercially available preparations of fish oil for toxins (by puncturing the capsules and sending them to the lab for analysis). Luckily, they found undetectable, or nearly undetectable levels of heavy metals (including mercury) and PCBs. One of the brands tested was the brand I personally use, Kirkland, found at the local Costco. The online reviews of the product are stellar, and also suggest an additional benefit:

"I supplement my dog's food with this fish oil,” comments one reviewer, “and it works great to keep his coat shiny. The amazing thing is that is also helps with the ‘doggy’ smell. We used to have to bathe the dog every 2 weeks, but now it is around 2 months before he starts smelling like ‘dog’."

Well, that is pretty remarkable and although I am not sure about the proper dosing for canines, I can tell you that human-based dosing recommendations vary and that people with a history of ulcers or bleeding disorders should be careful because omega-3s do increase the risk of bleeding. In most folks, however, a preventive dose of 250 to 500mg of DHA/EPA per day should be safe and sufficient. The AHA recommends that those with known heart disease take one gram a day and those with high triglycerides may need as much as four grams a day. The main side effect seems to be the occasional fishy burp – which can be alleviated with a hearty meal, a dash of mouthwash, or a dollop of mint jelly.

So, after researching the topic, I have decided to continue my supplementation habit and hope that my wife forgives the occasional whiff of an aquarium. Afterall, one’s heart is more important than one’s breath. Isn’t it?