Where Do We Live?

By Jacob Schor, ND, FABNO

Photo by Liralen Li via Flickr, used under the Creative Commons License.

There’s a Hebrew expression that roughly translates as "Where do you live?" It’s not meant to ask the location of a person’s residence. Instead it expresses shock, dismay, or disbelief in the ideas held by the person being addressed. By implication, "Do you live on Mars?"

During the winter, I go skiing with my friend Jim every Wednesday. We have done this for almost two decades, from opening day in November to closing day in May. Given the many shared months of our lives spent shivering together, I guess it was fitting that when Jim came back from a business trip to Dublin last winter, he brought me a gift: a handmade wool sweater.

This beautiful sweater came with a brochure affixed to it with one of those plastic fasteners, which needs to be snipped off lest you leave a hole in the garment. The brochure informed me that because the sweater was made of Merino wool, it would be comfortable year round, winter, spring, summer and fall. It is a beautiful sweater and nice to wear outdoors with my vest when the temperature is in the twenties. It’s even wearable indoors when I’m writing, the heat is off and the temperature is below sixty. I’ve tried unsuccessfully to wear it a few times this spring. I joke about wearing it in the summer. We live in Colorado. It’s too hot here to even touch wool during the spring and summer. Though it makes for a good joke, "Oh, the temperature has dropped to 85. Shall I wear my sweater?"

I mention this sweater because I use it as an analogy. That information on that sweater tag teaches us two things. The first is obvious: you can’t believe everything you read. That certainly applies to a good many ‘miracle cancer cures’ my patients read about on the Internet and then expect me to believe in. I tell them about the sweater.

The second sweater lesson is less obvious. The statement that the sweater is wearable year round isn’t false. It’s probably true if you live in Ireland. The truth is relative. In the case of my sweater, to where you live.

My ruminations on the relativity of truth are triggered by Nathan Seppa’s article in last week’s Science News titled "The Sunshine Vitamin."ⁱ

Nathan Seppa and before him Janet Raloff have in their earlier Science News articles closely followed and reported on the growing vitamin D research over the last ten years. This article on the surface purports to cover both sides of the debate triggered by last year’s Institute of Medicine’s report on vitamin D.

Last November, an Institute of Medicine (IoM) panel of scientists announced new vitamin D recommendations. They recommended daily intakes of 200 to 600 IUs per day. For most of us who follow the growing data on vitamin D, and routinely prescribe doses ten times this high, these suggestions seemed absurd.

Seppa points out the argument on which most vitamin D proponents fall back: that "… these amounts still fall short of prehistoric people’s intakes by a Stone Age mile." Living outdoors with little clothing, these people manufactured thousands of international units, or IU, every day, perhaps getting three to five times as much as most people get now.

Seppa then goes on and writes a comprehensive review of the benefits associated with vitamin D. He reviews the many research studies that form the basis of our thinking that vitamin D can produce anti-viral, anti-cancer, anti-allergy (including asthma, allergies etc), anti-autoimmune (including DM, and especially MS), anti-neurodegnerative (Parkinson’s disease, Alzheimer’s disease), anti-hypertensive and anti-cardiovascular disease effects.

Seppa contrasts the IoM’s recommendations with those published this month by the Endocrine Society in the Journal of Clinical Endocrinology & Metabolism.ⁱⁱ "The society, the world’s oldest and largest group devoted to hormone research, called for vitamin D intake levels two to three times higher than the IOM’s recommendations."

The question in my mind isn’t which of these opinions to follow. For naturopathic physicians, this is a no brainer. The majority of us will follow the guidelines and thinking of the Endocrine Society over those of the IoM. The question is why varying groups of intelligent and well-meaning scholars see the world so differently.

I think our views are tainted by the day-to-day needs of clinical practice and the demands it places on us to make pragmatic decisions based on often incomplete data, while those of the IoM panel are made in the academic luxury of being able to stall until more data is available.

Seppa quotes Patsy Brannon, a molecular nutritionist at Cornell University and a member of the IoM panel, who expressed the need for more randomized to settle the question:

"We looked extensively at those areas," Brannon says. In non-bone research, she says, "We found very limited randomized controlled trials, and evidence for cause and effect was not present."

At this point, there is slim if any indication that vitamin D supplementation will be hurtful and ample suggestion that it will provide vast benefits. But that’s our point of view.

This brings to mind another recent article, this one in last Sunday’s New York Times by Siddartha Mukherjee, the author of 2010 book The Emperor of All Maladies: A Biography of Cancer, which won the Pulitzer Prize for General Nonfiction. In his Times article, he reviews the evidence behind the current fear that cell phones will cause brain cancer and compares it with the evidence that links formaldehyde exposure to leukemia and smoking with lung cancer.

Mukherjee points out that the link between formaldehyde and cancer was known in the 1970s. It wasn’t until recently that the National Toxicology Program actually announced the connection. He blames industry lobbyists, particularly plywood manufacturers, for delaying this official stance.

Mukherjee reminds us that "The human trials that established that tobacco smoke is a carcinogen were initially performed in the mid-1950s (some even earlier). The tobacco industry mounted an aggressive campaign to discredit the data, and continued marketing tobacco to the public. The landmark Surgeon General’s Report on smoking and cancer was released in 1964. And it took yet another decade of innovative strategies, including powerful anti-tobacco advertisements and tort cases against tobacco companies, to alter the trajectory of smoking behavior in America."ⁱⁱⁱ

It can take a long time for knowledge to move from research publications to changes in public awareness and behavior. Let’s not even attempt to explain the recent trend toward increased smoking in young people in certain parts of the country.

Seppa sums up the arguments against the IoM’s desire for better evidence of vitamin D effect, and their desire for more randomized controlled trials by quoting Cedric Garland of the University of California, San Diego:

Besides, randomized controlled trials have never been the sole arbiter of medical thinking or policy, Garland says: "If they were, we would all still be smoking cigarettes and no one would be wearing seat belts."

We may never have randomized controlled trials on smoking because at this point it would be unethical to assign people to a ‘smoking arm’ of a trial. The weight of the evidence in support of vitamin D may soon bring us to a similar situation. How can we ethically tell people in a control group to not take vitamin D?

When it comes to wearing Merino wool sweaters in the summer, I don’t live in Ireland. What’s true in Ireland is not true in Denver.

We have to accept that the members of the IoM committee do not live in the same world we do. When it comes to encouraging higher intake of vitamin D, I want to think that we live in the real world, where our desire to improve patient health comes first in our list of priorities.

---

ⁱNathan Seppa. The power of D: Sunshine vitamin’s potential health benefits stir up, split scientists. Science News / July 16th, 2011; Vol.180 #2 http://www.sciencenews.org/view/feature/id/332009/title/The_power_of_D_


ⁱⁱHolick MF, Binkley NC, Bischoff-Ferrari HA, Gordon CM, Hanley DA, Heaney RP, Murad MH, Weaver CM. Evaluation, treatment, and prevention of vitamin d deficiency: an endocrine society clinical practice guideline. J Clin Endocrinol Metab. 2011 Jul;96(7):1911-30. PMID: 21646368


ⁱⁱⁱMukherjee S. Times Patrolling Cancer’s Borderlines. New York Times. July 12, 2011. http://www.nytimes.com/2011/07/17/opinion/sunday/17Mukherjee.html

2010 Year in Review

By Carl Hangee-Bauer, ND, LAc
AANP President

The AANP turns the page on another year. Image by andy.brandon50 via Flickr, used under the Creative Commons License.

As we approach the final days of 2010, I find myself in a reflective frame of mind, looking back at the past year as well as ahead to 2011 with hope and anticipation. Personally this represents my halfway point as AANP President. It’s been an active, exciting and challenging journey so far, and my suspicions have been confirmed that being in this position in the AANP is an opportunity for growth. I think all of my fellow officers and Board members past and present would agree.

The Board and Staff have just completed the work and budget planning for the next two-year cycle and it has made me think about the present state of the AANP and naturopathic medicine.

The AANP is in a very good place. Unlike many associations struggling in these economic times and tapping into their reserves to continue to function, the AANP ended the year with a balanced budget. We are living within our means, in no small part due to the vigilance and management of our executive director, Karen Howard. The AANP is fully staffed as we close out the year, having hired a new marketing and membership associate (Mandisa Jones) and state government relations director (Eugene McGill). In the coming year you will see more resources dedicated to state licensing, inclusion in the federal healthcare system, and benefits to support our membership, among other things.

The AANP Board continues to grow and evolve. This month we say “au revoir” to our departing board members Lise Alschuler, Michelle Clark, Bill Benda, Tabatha Parker and Sara Thyr. We thank you for your service and dedication to the naturopathic profession and wish you much success and happiness as you move on to other opportunities and challenges. On January 1, 2011, we are welcoming Holly Lucille, Joe Pizzorno, Carrie Runde, Keri Marshall and Cindy Breed to the Board as they begin their two-year terms. We are very excited to welcome these new members who bring a wealth of experience and willingness to serve the association and profession. Michael Cronin begins his term as President-Elect in 2011 and is taking on a greater leadership role within the Board as he prepares for his presidency.

As a profession, I believe that naturopathic medicine is in a better position to “take off” and serve more people than perhaps it has ever been. More states are on the cusp of licensure and, with the help of Gene McGill, I hope to see new licensed states soon. We are making inroads on Capitol Hill as Congress and regulatory agencies begin to implement healthcare reform, and I look forward to seeing ND inclusion in federal programs including loan repayment opportunities. Our DC FLI event in May is growing every year and we are now known in D.C.

As I write this it appears that CNME will be re-accredited by the US Department of Education for the next 5 years, the longest time allowed under the rules. Enrollment in the naturopathic medical schools is growing with plans for new schools in the next few years, and more NDs are graduating and bringing naturopathic medicine into their communities. Science and research opportunities are increasing with new NIH grants awarded to ND researchers, and the founding of Naturopathic Physicians Research Institute (NPRI), led by Carlo Calabrese, which will focus on developing studies to examine whole-practice naturopathic care. The Naturopathic Post-Graduate Association (NPGA) is up and running, coordinating residency opportunities amongst the colleges to increase the number of residencies offered and matching residency sites with candidates to improve the residency experience.

Our state naturopathic associations are becoming more sophisticated and active, developing marketing as well as continuing education programs to serve their membership. Better communication and coordination between AANP and state associations is occurring. Rick Marinelli, ND, was recently appointed to the Institute of Medicine (IOM) committee on advancing pain research, care and education, the first ND on any IOM committee.

So 2010 has been a good year for naturopathic medicine and the future looks bright. We have much to be thankful for as we take stock of 2010 and look forward to 2011 and beyond. As always, it comes down to the people who make things happen and the relationships we form—with each other, our patients, other like-minded groups and organizations, our local, state and federal representatives, and so forth.

YOU are the AANP; YOU are the profession. Everything the AANP does is filtered through the question: How does this serve our membership? As 2010 comes to a close, I want to thank everyone reading this for all you do, great and small, as every step moves us that much closer to realizing our dreams and goals for our profession and for the health and vitality of the communities in which we serve.

Have a joyous holiday season and a healthy and prosperous 2011.

The Circle Game

By Bill Benda, MD, FACEP, FAAEM
2011 Naturopathic Champion Award Winner

Photo by Helen White via Flickr, used under the Creative Commons License.

So. It’s time to find a topic for the next edition of the Physicians Who Listen blog. I know because a week or so ago I received the gracefully worded request from Matthew Santoro, the Communications and Media Associate of the AANP, gently reminding me that Friday is the deadline.

And Friday came and went, bringing to my consciousness the fact that my Integrative Medicine: A Clinician's Journal editorial was also overdue by two weeks, and the Journal of the ACM deadline is only a week or so away, and that my mind is and has been a total blank. It’s not writer’s block—I could blather on for hours about various idiocies inherent to the conventional health-care system or how the emerging theory of basing physician pay on patient satisfaction would be the clinical kiss of death in the Emergency Room.

Nope. I’ve come to the sad conclusion that I really have nothing left to say about the field of integrative/holistic/naturopathic medicine that I haven’t said before, and others’ oft-employed editorial option of describing how the purity of our natural therapies reminds me of the first breath of Spring just isn’t my style. And of course I still do not have the courage to remark on Karen Howard’s leaving or how totally predictable our major conferences have become, as it may hurt some people I still like and admire (but stay tuned).

So I am stuck with nothing to say, and therefore have no choice but to talk about why there is nothing to say. Primarily because this grand experiment of ours is no longer grand or an experiment, at least to me, but simply another chapter in the Big Book of Health-care Tales. Not to sound a discouraging note—this conclusion is simply evidence of an inevitable step in the evolution of all great ideas. First the excitement and purity of discovery (this is so cool and makes so much sense), followed by the heady rise against all odds (from ridicule and ostracization (no, its not a word) to the emergence of Weil, Ornish, NCCAM, IOM reports, and countless billions spent out of pocket), all highly seasoned with the seductive flavor of danger (what if we can’t ever make a living doing this? What if we can’t even find a job?).

But then, with every “victory” comes the inevitable price.

“We can’t prove all of this because the reigning research paradigm was created for reductionistic trials” has become “we must make research a priority because it’s the only way the reigning paradigm will accept us.”

“Should we even consider accepting insurance reimbursement?” has transmogrified into “naturopaths are now on the federal CPT committee!”

Our pioneers are now not only writing even more books but also selling their household products online and hosting daily television shows that remind me of a cross between Oprah and Phil Donahue.

And if I get one more “Dear Bill, this is a personal note to you, and I hope you will join me in an exciting seven-day program to cure you patients and increase your income by 25%,” I’ll have to reach for the Nux Vomica.

It ain’t what it used to be, folks, and I guess that can be considered a good thing in today’s social media/newest/greatest culture. It means we’ve arrived. But it makes me want to leave again, to find whatever the next cutting edge is, the one that will challenge the integrative/holistic/naturopathic model I helped create. To feel the resistance rather than the acquiescence, to worry again that I may not really have a clue as to what I am doing.

I want some new paradigm, fresh idea, brilliant concept - one whose purity will remind me of the first breath of Spring . . .