New Under the Sun:
Volume 4, Issue 8
As we move into August, we enter the back-to-school season. This transition from vacation to study is prime time to read something that will expand our knowledge, whether or not we are of school age. A good choice is reviewed in this month’s newsletter. For other options, check out previous book reviews in the archived issues.
Sunny Days Ahead for PMS Sufferers: It is estimated that 8 – 20% of women who menstruate suffer from symptoms serious enough to be classified as premenstrual syndrome or PMS. These symptoms may include headache, cramping, breast tenderness, irritability, and fatigue, among others. A variety of drug treatments have been used, but they come with both monetary and physical costs. Therefore, researchers are continuing to study other possible treatment methods that are both low cost and without major side effects.
The subjects for the research described here were a subset of nurses taking part in the Nurses’ Health Study II. Of the subset, 1057 were identified as having PMS, while 1968 did not and acted as controls. The purpose of this study was to determine if any dietary factors appeared to be associated with reduced probability of suffering from PMS so dietary information was obtained from the subjects at three points over a 10-year period. This study was particularly interested in calcium and vitamin D intake and so included information on supplements taken. The researchers found that increased calcium and vitamin D intakes from food were associated with reduced probability of PMS, while intakes from supplements were not associated with a reduction in risk. The vitamin D intake from food ranged from an average of 91 IU/day to 383 IU/day. Calcium from food ranged from an average of 529 mg/day to 1283 mg/day. Therefore, the least probability of PMS occurred among those women averaging about 1200 mg/day of calcium and 400 IU/day of vitamin D from food sources.
The researchers cite another study of PMS sufferers which measured blood levels of 25 OHD (measurement of vitamin D status), 1, 25 OHD (hormonal form of vitamin D), calcium, and parathyroid hormone across the menstrual phases. They found that women with PMS had low levels of calcium, 25 OHD, and parathyroid hormone, but elevated levels of 1, 25 OHD. This is what one would expect of an imbalanced vitamin D hormonal system. Based on this prior study and their own study, the researchers recommend that physicians encourage their younger patients to increase their intake of calcium and vitamin D. Bertone-Johnson ER, Hankinson SE, Bendich A, Johnson SR, Willett WC, Manson JE. Calcium and vitamin D intake and risk of incident premenstrual syndrome. Arch Intern Med. 2005 Jun 13;165(11):1246-52.
Comment: The researchers of the Nurses’ Study did not measure actual 25 OHD levels at any time so a significant piece of information is missing from their research. In order to determine the true impact of diet and/or supplementation on health, it is necessary to know the baseline vitamin D status of the subjects. Only then can it be determined whether or not supplementation had an impact on PMS risk.
However, much recent research has thrown into question the value of supplementation vs. obtaining a nutrient directly from food. This should not be too surprising since our bodies are adapted to eating food, not supplements. It is probable that it is the combination of micronutrients in a food item that gives the food its beneficial properties, not the separate elements themselves. And it is much more difficult to overdose on a natural food item than it is on supplements and/or processed foods containing supplements since those levels can vary. The same, of course, is true of vitamin D supplementation. The body cannot overdose on vitamin D obtained from UVB radiation exposure, but could on supplementation. Of course, the supplementation would have to be higher than 10,000 IU/day, so overdosing would be rare.
If an individual has optimal vitamin D levels a high intake of calcium is not important. Populations living in equatorial zones ingest about 500 – 700 mg/day and are healthy. It would appear, then, that the more important factor in PMS risk reduction would be to optimize vitamin D levels. While the researchers did not find a benefit with vitamin D supplementation as opposed to eating foods with vitamin D, it is possibly because the amount of supplementation was too low. It is also probable that the body achieves more vitamin D benefit from appropriate sun exposure than from supplements. However one chooses to optimize vitamin D levels, reducing PMS symptoms is yet another reason for physicians to begin routinely determining their patients’ 25 OHD levels.
Abstaining from Abstinence-Only: The United States has double the rate of births to teens between 15 and 19 that the United Kingdom has, a 50% higher rate than is the case in Canada, and a rate almost 8 times higher than in the Netherlands. The number of non-Hispanic white teens giving birth in the United States is higher than in any other developed nation. Despite information on STDS, 37% of teens in the US who have sex did not use a condom the last time they had sex. Among teens in high school in the United States, 45% of girls and 48% of boys had sexual intercourse. Similar or even higher rates of teen sex occur among European teens. Why, then, are European rates of teen pregnancy so low and rates of condom use so high? It appears the primary reason is that European, and presumably Canadian, teens receive much more comprehensive sex education than is the case for teens in the United States.
The American Academy of Pediatrics and the Committee on Adolescence are so concerned about the high rate of teen pregnancy [Over 90% of teen pregnancies are unintended, over half of which end in spontaneous or induced abortion. ] that they have issued a report which strongly urges that teens receive comprehensive sex education including complete information on contraception and the prevention of STDS and pregnancy. According to their report, “Youth who participated in programs that provided information about abstinence, condoms, and/or contraception; who were engaged in one-on-one discussions about their own behavior; who were given clear messages about sex and condom or contraceptive use; and who were provided condoms or contraceptives have been found to increase consistent condom and contraception use without increasing sexual activity.”
Pediatricians are clear that abstinence is obviously the best way to prevent disease and pregnancy. However, they are realistic enough to realize that approximately 50% of teens in high school will have sex anyway and that the more knowledge the teens have, the better off they will be. Abstinence-only education is, in fact, potentially dangerous education since once those teens initiate sexual intercourse, they are much less likely than better-educated teens to use condoms and other forms of contraception. The report concludes that if we wish to lower teen pregnancy rates, we need to encourage abstinence while also providing information on contraception. Jonathan D. Klein, MD, MPH and the Committee on Adolescence. Adolescent Pregnancy: Current Trends and Issues. PEDIATRICS Vol. 116 No. 1 July 2005, pp. 281-286.
Comment: Sexual activity is part of normal human behavior. Prior to around 100 years ago, girls did not begin menstruating until they were about 15 or 16. Because it takes approximately 18 months for periods to regulate, they were unlikely to become pregnant until they were about 17 or 18 even if the girls were having sex. Since marriage also occurred at an early age, they were probably married at that point. The result was that teen sexual behavior was not as serious an issue as it is now when the average age of menarche is about 12 and marriage is delayed into the 20s.
While abstaining from teen sex would definitely eliminate the problem, such advice totally ignores human biology. Sexually mature females (and a girl of 15 or 16 who has been menstruating for 3 or 4 years and has completed her growth is sexually mature) are biologically primed to reproduce, to have intercourse. Pretending that they are still children ignores reality. The best and most appropriate solution is to give preteens (those 10 – 12) and teens the most complete information on human sexuality and contraception possible. This will have the effect (which perhaps seems counterintuitive to the abstinence-only folks) of actually reducing sexual activity somewhat and definitely reducing the teen pregnancy and STDS rates.
Book Review: In a previous issue [June 2005] I discussed the necessity of determining the funding sources for published research since those funding the research can exert pressure to skew how the results are presented. This month we review a book which takes the entire medical field to task for its monetary relationships with business. On the Take: How Medicine’s Complicity with Big Business Can Endanger Your Health by Jerome P. Kassirer, MD is a real eye-opener.
Kassirer has not only been a physician for several decades, he was also the Editor in Chief of the New England Journal of Medicine (NEJM) for over eight years, and is currently a professor of medicine at two of the ivy league medical schools. He has the credentials to enforce his critique. Kassirer became increasingly concerned about physician/industry ties during his tenure as Editor in Chief when he tried to find physicians who had no conflicts of interest to write review articles for NEJM. At times, he had to reject half a dozen candidates before he found an appropriate author. His successor decided that this was too much trouble and so authors at NEJM are now permitted to write about topics with which they have conflicts of interest. What this means is that an article which reviews treatment options for a particular disease and concludes that one type of treatment is preferable may be written by a physician who is a paid consultant for the pharmaceutical company which makes the recommended drug. While the author’s conclusions may well be correct, the conflict of interest has to give one pause.
It is the policy of journals to require authors to list their funding sources and any other conflicts of interest. However, conflicts are becoming so extensive that journals are unwilling to use valuable page space to list them. In one case mentioned by Kassirer, the conflicts of the 29 authors (yes, many scientific studies have large numbers of authors, which is becoming another editorial issue) were published on the journal’s website instead of in the print copy because printed out, the conflicts list came to three single-spaced pages. In addition, the editors rely on the veracity of the authors. If an author chooses not to list a particular funding source, there is nothing to prevent this.
Kassirer believes the problems begin in academic medicine when seminars and conferences are sponsored by the pharmaceutical industry. At the most basic, for a luncheon seminar, the company provides lunch along with pens and pads stamped with information on their latest drug. Most everyone would agree that these “gifts” are minimal and inconsequential. However, Kassirer sees them as the beginning of the slippery slope. While it is hard to believe that a cheap plastic pen or a notepad could lead to a conflict of interest, they provide wedges that pharmaceutical companies are extremely effective at using to their advantage. First it’s pens, then it’s paid continuing education courses, then it’s consulting fees where little consulting is done, and so on down the slope. The end result, according to Kassirer, is that big business now funds more research than does the NIH. And when the FDA needs independent experts to decide on drug approvals, it has an extremely difficult time finding anyone who is without conflicts of interest.
According to Kassirer, “…pharmaceutical companies spend more than 21 billion dollars a year on promoting and marketing their products, of which about 88 percent is directed at physicians…this amounts to more than $30,000 spent on each physician.” [p. 77] Something more than pens and pads are being passed out to the medical community. What does this mean for patients?
It is quite probable that your personal physician is not a company consultant, does not have ownership in a medical supply or services company, and does not do any business-funded research. However, it is also probable that your physician does keep track of the latest treatment and best practices guidelines. This is commendable. The question then becomes, who funds and who writes these guidelines? It turns out that industry has its fingerprints all over them. There is also the issue of how the physician is reimbursed for medical care. Treatment options can affect the physician’s bottom line. Do they get paid for pumping through as many patients as possible each day? Do they get paid for keeping costs down? Do they get paid for optimizing customer satisfaction? What should a patient do?
Kassirer’s opinion is that the patient should not have to worry about these items. “In the final analysis, it is not a patient’s responsibility to protect himself against the medical profession, it is the profession’s responsibility to protect the patient. Doctors have a responsibility to help patients understand their recommendations… Ultimately, the physician must bear the responsibility to act in his patient’s best interests.” [p. 153]
But one person’s conflicts of interest are another person’s resume builder. The longer a researcher’s curriculum vitae, the greater the career potential, and nothing builds a CV like consultancies. And nothing builds one’s income like the fees these consultancies bring. Not to mention the income potential from patenting and selling a medical device or partnering in a radiology or dialysis facility. Sadly, there are some medical students and practicing physicians for whom income potential is more important than patient care. I was rather stunned by the comment one medical student made in a class I taught. She said something to the effect that there was no point in going through the grind of medical school if she didn’t get to live in a gated community at the end of it. Based on other student comments, I think her view was a minority opinion, but it would be something worth knowing before choosing her as your physician.
Although Kassirer details a litany of concerns, he does feel that the situation can be improved. First and foremost, physicians must refuse any type of gift, no matter how small because acceptance of gifts can lead to both the appearance of and the actuality of bias towards the giver. Second, the patient comes first, no matter what. Third, scientific research should not be funded by industry interests. Fourth, it is the duty of the profession to ensure that the medical industry does not make care unaffordable for patients. And fifth, until financial conflicts are eliminated, there must be methods to enforce full and complete disclosure of such conflicts not only to others in the field, but to patients as well. This is asking a lot of the medical community. Will they be willing to do it? Probably not without pressure. Kassirer spends several pages dissecting his own list of principles, balancing problems with benefits of implementing them. One of the major roadblocks to implementation is that the professional organizations are on the take themselves and, therefore, have little incentive to enforce stringent conflict of interest policies. Kassirer compares this to the policies of other professions and concludes, “[T]hat physicians are not held to the standards of journalists, attorneys, and other professionals is one of the great scandals of our time. In contrast to the rules and guidelines that govern other professionals, those that govern medicine are missing…” [p.200]
This is an important and thought-provoking book. I strongly urge everyone to read it. Broad public awareness of the conflict of interest problem among medical professionals is the first step towards its elimination. Physicians need to refocus, perhaps with public encouragement, on the meaning of the word “profession.” Kassirer quotes Supreme Court Justice Louis Brandeis’ definition: “…it is an occupation which is pursued largely for others and not merely for one’s self;…it is an occupation in which the amount of financial return is not the accepted measure of success.” [p. 171]
AnthroHealth Tip of the Month: Stretch your body and mind to maintain flexibility. When you are flexible, you will be able to roll and bounce back, rather than break. Although you can stretch at any time during the day, doing it when you first wake up is a good way to begin the day. Flexibility exercises are an especially good way to get out the kinks you may have from sleeping on a less-than-perfect bed. They also get the blood pumping to the brain, making you feel more alert. You can keep your mind flexible by doing a crossword puzzle, learning a new hobby, or studying a foreign language. Stay flexible, feel younger.
© 2001-2009 Kathleen E. Fuller, PhD. All rights reserved.