An interesting story in the Kansas City Star on a success of evidence based medicine:
A study published this month in the Journal of the American Medical Association finds that the number of elective angioplasties has fallen by a third in just five years. That mean tens of thousands of people are avoiding a procedure that may have done them little or no good but that costs on average $27,000 and may require years of drug therapy to avoid complications.
Meanwhile, a second new study in the New England Journal of Medicine finds that even after 15 years, patients who chose medication and lifestyle changes over angioplasty were no more likely to die than those who chose the procedure.
There are a couple of interesting angles here. The first is evidence based medicine saves money, and puts people at no greater risk than folk medicine. Secondly, these changes are sticking even as providers are still overwhelmingly paid on a fee for service basis so there is hope for change when the incentives are aligned against positive change. As the US medical payment system moves away from widget fee for service payments to global budgets that allow providers to make more money by keeping people healthier and using only effective services, this change should continue to accelerate.
Finally, from an insurance perspective, cases like this make a strong argument for value based insurance design where highest insurance payments are made for treatments that are shown to be most likely to work for a given set of indicators. The evidence supports angioplasty in emergency circumstances but not as an easy choice for elective procedures.
Redesigning benefit structures to tier payments to effectiveness in a fee for service payment model is a difficult lift. However, it would remove some of the incentives to overtreat with expensive and minimally effective procedures without harming patients. Elective angioplasty, like back surgery for unspecified back pain, could fall into the bucket of services where it is an option. However it would not be a preferred option. It would only be paid at a high level after other, more cost effective options are tried first. It should be a second or third resort, not a first resort when it is not an emergency.
This logic mainly applies to fee for service payment structures as providers should be motivated to do self-tiering in global budget and capitation models.
peach flavored shampoo
This is huge news. Groundbreaking, really. The fact that a newspaper in KS adopts a pro-science, pro-reason/logic stance and isn’t immediately labeled a transgendered, librul activist paper by Ted Cruz is astonishing.
Fair Economist
I’m kind of puzzled that this is presented as new data. I worked for a cardiology company 20 years ago and even then it was clear non-rescue angioplasty only reduced pain and had no survival benefit. Even bypass surgery was only useful for left main and LAD disease, and you only saw long-term benefit if the mammary artery was used. Some of the cardiologists were dragging their feet on admitting it, sure, but 20 years?
cmorenc
Many physicians in high-income surgical specialties may doubtless whine about the intrusion of government regulation into medical decisions over this ongoing development, accompanied by whining about the burden the imposition of electronic medical records is imposing upon their time (which is a genuine issue). But in the end they know their bread is buttered by the insurance companies, and what pays talks and what doesn’t walks, even to high-powered surgeons.
BGinCHI
I’m shocked to learn that all medicine is not “evidence-based medicine.”
Or does that just mean “post-trepanning”?
Sister Rail Gun of Warm Humanitarianism
@BGinCHI: You left off your sarcasm tag.
phein
Can you explain the difference between “elective angioplasty” and “non-elective angioplasty”?
Fifteen years ago, in my early 40’s, an angiogram (in response to persistent and increasing symptoms) quickly became an angioplasty when the screen showed that my right descending aorta was completely blocked, with another branch 95% blocked. Two stents were implanted.
Would that have been described as “elective”, in the sense that, yes, I chose to have it done?
Capri
@phein:
Elective = I have been dealing with chronic angina for a couple months. The doctor thinks that angioplasty might help because there was a “suspicious, sort of fuzzy” area during my last diagnostic procedure. I will be entering the hospital on December 21 to get this procedure done.
Non-elective = I went to the emergency room because I was having a heart attack. Blockage in a coronary artery was found and it has to be treated today.
Basically, if you schedule it ahead of time it’s elective.
BR
Hi Richard,
Yesterday I rewatched Dr. Lustig’s long lecture (from UCSF) on sugar, and went digging into some of the other things he’s written. One thing he mentioned in some other article is that in his view the ‘preventative’ cost argument of Obamacare only can work on diseases that fall under ‘Metabolic Syndrome’ if our diets are changed. That is, they are not something that can be fixed by medicalized services, so people will continue to get sicker and costs will go up. (The article in question was him railing against congressional republicans for trying to gut healthy diet guidelines at the USDA, I think.)
My question is, to what extent is what he’s saying being borne out in the insurance provider bottom line, if that data is available? I’ve long been of the opinion that we try to medicalize far too many problems, and that it limits the options for effectively responding to it, and I wonder if, as he says, that here medicine is actually powerless because it’s about what we eat.
grandpa john
@phein: I have had one done on two different occasions and I considered neither of them elective. The first of them was a situation much like yours. The second of them was done at 11 pm after a trip to the emergency room with severe chest pains ,and transfer to a hospital with a cardiac unit. My cardiologist told me latter that I indeed had a mild heart attack Both angioplasties involved blockages of greater than 90% and needed stints inserted.
WereBear
Only after forty five years of Republican dominance…
Schlemazel
@Fair Economist:
Ask your doctor if angioplasty is right for you.
I think a lot of doctors practice medicine in a ‘pushed by patients’ way. Some of it is understandable a lot of it is marketing.
I’m having a situation now with a doctor because I have a very unusual situation (my bladder holds 4 liters) and he does not seem to be able to wrap his head around that concept. He thinks the standard flush of 200 ml is sufficient & apparently can’t envision what 200ml looks like in a 1 gallon jug. The result is I constantly have to challenge his assumptions and treatments. In that case it makes sense but too many people are driven to request (or demand) specific treatments from doctors because they saw the ads (toe nail fungus anyone?) and too many doctors are willing to give in despite evidence.
Oatler.
As I’ve learned with my father, expensive surgeries are necessary whenever the insurance says it is. Can’t deny their hunger for a piece of it.
WereBear
Metabolic syndrome has been studied for a couple of decades now, and indeed, it seems to have a solid grounding in the effect of carbohydrates on the body, and the resultant hyperinsulinemia. I’ve been a member of a nutrition discussion group for several years now, and heard about amazing results in all sorts of health markers: drastically lowered A1bc, diabetes control without drugs, calcium score improvements, and slashed scores on PSA tests for prostate trouble.
Far better results than can be attained by surgery or pharmaceutical drug treatment.
So yes, I’d say Dr. Lustig is right, and it’s easy to figure out for yourself: get a free blood glucose meter and see what you eat does to your blood sugar. Eat to keep it low… and it will cover all kinds of problems: cardiac issues, diabetes, mood swings, even cancer and dementia prevention.
Books that concentrate on the different areas:
Wheat Belly by Dr. William Davis, cardiologist
Grain Brain by Dr. David Perlmutter, neurologist
Dr. Bernstein’s Diabetes Solution by Dr. Richard K. Bernstein, diabetes specialist
The truth is out there :)
Schlemazel
@WereBear:
well that certainly explains the huge problems of obesity, diabetes and heart attacks in nations that are so heavily reliant on grains in their diets. Thank goodness we in the US depend largely on meat unlike, say Japan, or we would have the sorts of health issues they are suffering
WereBear
@Schlemazel: The hormone based health problem I’ve been struggling with for a few years now would have been orders of magnitude worse had I not embarked on a healthier eating program, and drawn on the amazing knowledge of the nutrition discussion group throughout.
The low fat, high grain diet pushed as “healthy” throughout the developed world has been exposed as something that isn’t evidence-based, after all. Even good scientists are able to fall into a trap baited with preconceptions, biased grant procedures, and the cold & heavy hand of their bosses who have based whole careers on the Lipid Hypothesis.
phein
@Capri:
Capri (and grandpa john),
Thanks. I wonder, Capri, about the scheduling in advance. My cardiologist scheduled an angiogram, but wasn’t expecting to find any significant blockages (male, 41 years old, in otherwise good health). I’ll never forget what he called out after the first squirts of dye were injected: “Cancel all my appointments this morning. We’re going to be here a while.” It’s what was found during the angiogram that led to the angioplasty. I think it was obvious (to my cardiologist) that diet and exercise weren’t going to reverse the blockages before I did have a heart attack.
a hip hop artist from Idaho (fka Bella Q)
@Schlemazel: Well, there’s that. In many of those grain reliant cultures, there may not be as long a generational history of exposure to endocrine disruptors. In the US, at least 3 generations now have been raised surrounded by endocrine disruptors and there’s pretty reliable data that it’s a factor in metabolic syndrome. I don’t have citations handy, though I hear there are search engines that be be useful in finding some.
Schlemazel
@a hip hop artist from Idaho (fka Bella Q):
so its not the diet, its the endocrine disrupters?
Mnemosyne (tablet)
@BR:
Did he also take tobacco into account, or was he strictly anti-sugar?
There were five contributing causes of death listed on my father’s death certificate, and every single one was tobacco-related. Despite his not-great diet and lack of exercise, he had virtually no heart problems — it was all kidney and respiratory issues because he smoked for 50 years.
Germy
I remember Harpo Marx’s autobiography, after his second heart attack his doctor told him he couldn’t eat egg yolks, only the whites.
He used the egg yolks in his paints (his hobby was painting).
His brother Gummo told him to see Debakey (spelling?) for surgery and unfortunately Harpo died on the operating table.
a hip hop artist from Idaho (fka Bella Q)
@Schlemazel: It’s much more complex than just “the diet,” and endocrine disruptors play a large role.
phein
@WereBear:
Two cups kale
1/2 cup cucumber
1/4 cup carrot
1/4 cup celery
1/4 granny smith apple
4 raspberries
Squeeze of lemon
1/2 t olive oil
1/2 water
Blend the @#!% out of it (Blendtec or Vitamix; Ninja won’t get it).
Add ice, blend some more — cold kills the taste.
[What was it a forty-something year old MLB player said? “If you want to be in good shape, you have to stop seeing food as a source of pleasure,” or some such.]
I drank this every day prior to heading to the gym from January 3rd through April of this year, and watched my A1C go from 7.7 down to 5.8. Blood pressure similar reductions.
Ice cubes! Don’t forget lots of ice cubes.
Sister Rail Gun of Warm Humanitarianism
@BR: I … have a lot of trouble taking metabolic syndrome seriously.
My last really bad doctor was all about metabolic syndrome and wanted to treat me with a cocktail of lipitor plus some expensive blood pressure medicine. He was also pushing bariatric surgery so hard that I suspected that he owned a share of the practice he tried to refer me to.
Amazingly, the basic signs of metabolic syndrome cleared up after I changed doctors to one who was willing to treat borderline hypothyroidism.
Many years of untreated hypothyroidism have left other issues, of course. We suspect the triggering event was a mild case of tetanus that went undiagnosed and untreated. Well, improperly treated; my then-docs listened very gravely to my complaints of back aches/joint aches/shortness of breath/muscle fatigue, reassured me that it couldn’t possibly be a reaction to the emergency tetanus shot, and handed me Prozac.
WereBear
@Schlemazel: The theory goes that we are surrounded by plastics and pesticides and other “false estrogens” that have a highly inflammatory effect. But then again, we are all eating wheat that has an increased protein content, to combat world hunger, but people who never had a problem with wheat before now have increased inflammation response to it.
Europe, which has clung to traditional farming, has less of this problem than we do.
It’s definitely a multi-factorial issue.
Schlemazel
@a hip hop artist from Idaho (fka Bella Q):
I don’t know, seems it was just the diet that was being blamed & when I pointed out that the diet seems to impact Americans differently you brought up the disruptors. If we are to eliminate the cause then we need to understand the cause. Can I eat a high grain diet if there are no endocrine disruptors? If so I wouldn’t blame the diet I would try to eliminate the source of the problem.
Mnemosyne (tablet)
@phein:
From the article, it sounds like they were doing angioplasties on people who didn’t have any blockages (or at least no major ones) to see if it would prevent problems later. Verdict is, preventative angioplasties don’t help.
I’m pretty sure that any procedure where they have you sign a consent form for surgery ahead of time just in case they find something bad doesn’t count as “elective.” That would be like saying my father-in-law’s emergency bypass surgery was really “elective” because the blockages they found were so severe that they put him under and operated that same day.
Sister Rail Gun of Warm Humanitarianism
@Schlemazel: And don’t forget the heavy antibiotic load in our food. There’s more and more evidence mounting that responses to various foods are directly traceable to the bacteria population in our bodies. Someone here linked a couple of weeks ago to an Israeli study that strongly suggests that what counts as a high glycemic index food may be different for each person.
rikyrah
Thank you for bringing us more good info.
BR
Lustig’s focus is on sugar (fructose and sucrose), though he also points out tobacco and alcohol cause similar problems.
His whole point is that high-fat diets (e.g. atkins) are sometimes fine, as are high-carb diets (e.g. Japanese) as long as the diet is low in sugar and high in fiber.
Sister Rail Gun of Warm Humanitarianism
@WereBear:
I just want to emphasize how much I agree with this. For WereBear, the spikes were clearly from grains. For someone else, it might be from nightshade veggies/fruits like potatoes and tomatoes, and bread might barely move the numbers.
There are a lot of old dietary theories falling by the wayside these days. I admit I get a vicious joy out of kicking certain people who still try to use the Inuit diet to support their advocacy of Paleo eating. It now looks like the Inuit diet isn’t going to be beneficial unless you have the Inuit population’s specific gene mutations.
Punchy
Done.
Schlemazel
@Sister Rail Gun of Warm Humanitarianism:
But, again, this does not argue against a grain based diet. If these things are dangerous (and I believe they are) cutting out bread and crackers from your diet is not going to save you because they are not the problem. The problem is the overuse of antibiotics and endocrine disruptors not oatmeal.
Every few years it seems someone (often a real doctor, like Dr, Carson) comes along with a simple, no pain solution to all health problems. There is always a book and lecture tours and videos and claims of great evidence. The evidence so far always has fallen apart once examined. So lets say this time these guys got it right & your morning cream-o-wheat is making you fat and killing you, show me that by putting US grain consumption against other nations and correlate those levels with corresponding disease/death rates. Saying it is antibiotics and/or endocrine disruptors is saying it is not malt-o-meal but those things that are the cause & must be eliminated.
a hip hop artist from Idaho (fka Bella Q)
@Schlemazel: @Sister Rail Gun of Warm Humanitarianism:
Antibiotic overconsumption is also an important component. The gut microbiome is an important regulator of all kinds of things, including inflammation and metabolism of food – even mood (in both the general and clinical sense). And even people who carefully avoid taking antibiotics are exposed by eating. Factory farmed meat and poultry generally includes “hidden” antibiotics – since the drugs are used raising the critters. Milk also, since even milk cows are often plied with those drugs – and hormones. And eggs…
To avoid that exposure, you generally need to eat only pastured meat, poultry, and dairy, since the farms that make the effort to raise pastured usually avoid meds as the animals are less stressed. And eating a diet that’s much closer to what they are designed to eat. Fatty acids are another component.
It’s complicated. : )
Eric U.
I can’t imagine getting a surgery that serious done without really needing it. I probably err the other way. The way I look at it is I only have so many years left, and I don’t want to spend them recovering from surgery. I can live with a little pain, that’s for sure.
Sister Rail Gun of Warm Humanitarianism
@Schlemazel: Hon, I’m not disagreeing with you in the slightest.
I react badly to the lifestyle evangelists because they inevitably want me to stop eating something I can eat (grains or meat/cheese, usually) and begin eating something I can’t (potatoes, cauliflower, most beans, a few other vegetables) or something that I simply can’t stand the taste of (nuts, quinoa, most other vegetables). I always end up limited to three or four allowed foods. They are going to have to have rock solid proof before I jump on the bandwagon with them.
And they never do.
WereBear
@Sister Rail Gun of Warm Humanitarianism: I found the book Death by Food Pyramid an excellent rebuttal to a lot of dietary dogma.
This was the first book to really explain why the best way I eat might not be the best way YOU eat. A lot of it is enzymes, apparently. I don’t have the enzymes to get protein from plant sources, and I get along fine with dairy. That’s what happens when most of your ancestors come from Very Northern Europe.
And why I can’t even be vegetarian, much less vegan. Which would probably kill me in short order :)
Joel
I am extremely skeptical of endocrine disrupters; the commonly cited example of soy and estrogen has been thoroughly debunked. That’s not to say that we’re unwittingly exposed to chemicals that disrupt normal physiological function, but that the extent is overstated.
J R in WV
Mrs J was hospitalized for a long time when she developed septic shock from a non-obvious case of pneumonia. In the course of treating her very serious illnesses, she also received pretty total investigative workups on a daily basis, as she could have suffered any sort of new problem at any time.
One day she had a sudden spike in a protein indicating a cardiac problem, although her BP and other cardiac indicators remained the same, and the protein level almost immediately dropped back to a near normal level. They decided that since things had returned to near normal they wouldn’t attempt to do an angiogram until she was more nearly recovered.
When they did the heart cath procedure, she basically passed well. But when they did the pre-op paperwork, we pre-approved pretty much any cardiac procedure the heart guys proposed, from stents to by-pass surgery, which was pretty scary. I was a little dubious, but the cardiac guys were recommended by our family doc, who we’ve been seeing for more than 30 years. His role in Mrs J’s septic shock treatment was to designate the best specialists he knew for each of her developing problems, which worked out well, as she now has basically no after effects from that very serious hospital stay.
Basically, if you get the best local guys capable of treating whatever, you probably need to trust then to do the right thing. I studied every night what I saw and learned that day, but Google isn’t a medical education. I’m lucky to know a good doctor who didn’t mind late night calls about medical conditions developing and being treated, and he was usually supportive of the work being done.
I’m sorry some of you have had such negative experiences with your medical care. It’s a scary thought, but the Med students at the bottom of their class usually become practicing doctors just like the ones who are at the top of their class. Think Sen McCain at the bottom of his Annapolis class – yikes! Still became a pilot, senior officer, senator in charge of Meet the Press, etc.
Ruckus
@phein:
Add ice, blend some more — cold kills the taste.
I find that I can eat lots of things that I used to hate. Very limited sense of smell and taste. All part of my on going fun with medicine. Basically I eat for nutrition and texture any more.
a hip hop artist from Idaho (fka Bella Q)
@Joel: I’m not certain “thoroughly debunked” is quite accurate, since there is a 2015 article in the International Journal of Andrology describing support for the hypothesis that exposure to endocrine disruptors at critical developmental periods – like perinatal – correlate to adverse health effects later in life. Whether they are phytoestrogen consumption or chemical exposure.
Is it as simple as quacks like Mercola claim? Of course not, but there are (mainstream medically respected) research specialists who assert that it’s a component in health.
Capri
@WereBear: It doesn’t have much to do with that. You can’t practice evidence based medicine without the evidence. There aren’t large, multi-center prospective trials for every condition out there. Like it or not, there is still quite a bit of art involved in the art of medicine.
Ruckus
@Sister Rail Gun of Warm Humanitarianism:
One thing I used to say when fitting people for racing bicycles, “On a global scale, we are all the same, on an individual scale we are all a bit different.” We all work in basically the same ways, movement, muscles/levers, digestion, etc, etc. What is different is the exact mechanisms, how we react to sugars, fats, proteins, etc. Some will develop MS or Parkinson’s, many will not, some will smoke for decades and not develop lung cancer, others never smoke and die of it. And on and on. What we ingest is of course important, some things after all are poison in any amount, some are very helpful in small doses. In medications things like Warfarin can be vital to some while mice and rats don’t like it at all and over dosing is very dangerous. Foods are no different, in my own case too many carbs spike my triglycerides drastically, while leaving the rest of my numbers just fine. And yet too few carbs leaves me without any get up and go. Balance is always required.
Mnemosyne (iPhone)
@Sister Rail Gun of Warm Humanitarianism:
Thank you! I was trying to find that study but I had to leave for work. Apparently it’s been known among diabetes specialists for quite a while that different foods cause different blood sugar reactions in different people, but the news is just now getting out to the general population.
I wonder sometimes if this stuff gets so complicated in the US because most of us are genetic mutts, so it’s hard to figure out which guidelines apply to which people of which genetic background, partly because we don’t know which part of someone’s background is being expressed.
Two of my best friends (who are married to each other) have gone vegan because he has serious heart disease in his family (his father died of a heart attack in his 40s) and she has a strong family history of Type II diabetes. So far, so good for both of them, but they’re concentrating on whole grains and fresh fruits/veggies and avoiding excess sugar anyway. Conversely, I know someone who does really well on a Paleo-type diet because she’s severely allergic to grasses, so cutting out grains really helped some of her underlying asthma/allergy issues.
Fair Economist
@phein:
That doesn’t sound bad. I’ve had cooked kale with fruit sauce that had pretty similar components and I liked it. I’ll grant *raw* kale has a nasty flavor to it, but does it need to be raw?
Brachiator
@cmorenc:
Shouldn’t all physicians be concerned about this?
The old complaint was that insurance companies were interfering with doctor’s decisions purely on the basis of cost saving (profit) motivations. The sticking point of any regulation is whether those overseeing or approving payments have sufficient information and medical expertise to second-guess doctors.
Capri
@a hip hop artist from Idaho (fka Bella Q): Actually, antibiotic use in lactating dairy cows is extremely highly regulated, and every tank of milk is tested for antibiotics before it enters marketing channels. The only hormone that can be given is growth hormone, but very few dairy cows get it – they get more infections and so the cost/benefit of buying the drug and giving it isn’t there.
The likelyhood of consuming antibiotics in any animal products is quite low. Many beef catle are given hormones and antibiotics while they are growing, which may change their own microbiome. But the withdrawal times are such that the drugs are out of the animal’s systems before they are slaughtered.
WereBear
@Mnemosyne (iPhone): Not only that, but how you eat them can make a difference. If I have fruit as my dessert, I’m fine. Trying to eat it alone, as a snack, creates a tsunami of hunger that messes up the rest of my day.
I am also better off if I don’t snack :)
Tyro
patients who chose medication and lifestyle changes over angioplasty were no more likely to die than those who chose the procedure.
The problem, of course, is that many patients will not comply with the lifestyle changes.
Ruckus
@Brachiator:
SOME doctors need to be second guessed. Sure it’s better that they get second guessed by other doctors rather than bean counters but they still need it.
Sister Rail Gun of Warm Humanitarianism
@Mnemosyne (iPhone): A family history of Type II diabetes is the only time I won’t try to talk someone out of bariatric surgery. They’re not sure of the mechanism yet, but there’s one type of the surgery that resets the insulin response in about half the people who have it.
One of my coworkers had the surgery for that reason. Her family history was full of hard-to-control Type II. When she went pre-diabetic, she researched her options and took the chance. It worked for her.
liberal
@WereBear:
“Don’t have” seems highly dubious. There might be other things related to those metabolic pathways, but the claim you don’t have them is pretty far out there.
liberal
@Brachiator:
No, the sticking point of any regulation is that doctors—who on the whole don’t know a damn thing about epidemiology, statistics, cost-benefit analysis, etc—don’t want to be regulated.
liberal
@Ruckus:
It’s not even a matter of being “second guessed”. It’s a matter (for many of them) doing what they damn well please, regardless of what the evidence says, or not.
MD Rackham
What about the other categories: angioplasty with lifestyle/diet change, and no angioplasty and no lifestyle/diet change?
I’m trying to be in the “both” category, but it seems to me that if you eliminate “unnecessary” angioplasties, then those patients (the majority?) who can’t/won’t make the necessary lifestyle/diet changes are going to see an increase in mortality.
The changes should be a “no brainer,” but they are damned hard after 50+ years of a certain way of doing things. I’m not sure writing those people off for some cost saving is the right thing to do.
Brachiator
@liberal:
I agree with you about some doctors, and even have some personal experience with this issue.
But this leaves us with a circle of ignorance. I don’t know that regulators would know squat about epidemiology, statistics, cost-benefit analysis, etc.
Sister Rail Gun of Warm Humanitarianism
@MD Rackham: From the article:
There’s a new follow up in the Nov 12 issue of the NEJM:
A quick skim of the article doesn’t say anything about assessing cooperation with the lifestyle changes.
Mnemosyne (iPhone)
@Sister Rail Gun of Warm Humanitarianism:
Their family history (she and her siblings) is that they’re at a reasonably normal weight (BMI of maybe 26-27, tops) but get T2 anyway — her teenage nieces started getting kidney stones and similar precursors, plus she and all of her sisters had borderline gestational diabetes when they were pregnant. So going vegan seemed like a reasonable solution.
Interestingly, she and her sisters are of 100 percent Polish descent on both sides of their family. Not sure what that portends, but it’s an interesting anecdote.
Mnemosyne (iPhone)
@Brachiator:
IIRC, the board that decides these things is made up of doctors and epidemiologists who examine all of the available studies before making a decision. I’m more willing to trust them than individual doctors who might be quacks or just uninformed about the current literature.
Stella B
@WereBear: Metabolic syndrome has been labeled that since the 1940s. Dr. Lustig is an example of someone who doesn’t practice evidence based medicine, but is quite certain that his practices are the best choice (could be, but we don’t actually know). He’s no different from a cardiologist who assumed — absent any data — that bypass was a good treatment for angina.
Glycemic index pops up now and then. It was popular in the 1980s and early 90s, but it’s such an inexact number that it’s not particularly useful and fell back out of popularity. Check the glycemic index for ice cream. Glycemic index doesn’t work unless you eat only one food at a time and even then it’s highly variable from person to person. Also, it’s not evidence based either.
Dr. Lustig talks convincingly, but that’s still not evidence based medicine. Glycemic indices sound like a valid idea, but they still aren’t evidence based medicine. It’s tricky, isn’t it?
Sister Rail Gun of Warm Humanitarianism
@Mnemosyne (iPhone): I’m increasingly convinced that obesity and Type II are both symptoms of something else, not a cause and effect relationship by themselves.
I’m also convinced that the more we study the genomes of populations, the more we’ll find mutations linked to certain areas of origin. Which reminds me, I need to get moving on that DNA test….
WereBear
@liberal: I tried to make it work for nine months. Wound up sick, pale, plump, and exhausted.
It’s the best explanation I’ve gotten in 20 years since, especially the one that claims “I was going it wrong!” when I was coached by dedicated ladies for whom it worked like a charm.
Mnemosyne (iPhone)
@WereBear:
As I’ve said before, there’s very little evidence that “gluten intolerance” exists, but a lot of people feel better when they cut out the grains that have gluten in them. Turns out that those people may be sensitive to the fructans in the wheat and other grains, not the gluten (IOW, it’s the FODMAPs, not the gluten).
So I think Liberal’s point is that successfully identifying a problem food doesn’t necessarily mean you’ve successfully identified WHY it’s a problem. And, honestly, I don’t think it’s important to know “why” as long as you figure out it’s a problem and are otherwise eating well (ie not being so restrictive that you’re missing out on important nutrients).
Ruckus
@Mnemosyne (iPhone):
I know someone who has a very restricted diet and is doing just fine at 70. It took her years to find all the things that affected her and to find things that she can eat but it works for her. I’m of the group that says if eating a certain food is a problem, then don’t eat it. It may be good for most but nothing is good for all. OK water and oxygen are pretty much staples. But there are even exceptions for the amount of water some can ingest. This person is just way out there on the curve of what works/doesn’t work for her.
Ruckus
@liberal:
Many things are possible in our bodies that seem quite unusual. It is possible that she has the enzymes but they are ineffective or the level is too low. Not necessarily an absolutely true statement of no enzymes but effectively a true statement.
Mnemosyne (iPhone)
@Ruckus:
My one caveat is that people with an extreme diet should consult with a registered dietician (NOT a “nutritionist”!) to make sure they’re getting the nutrients they need to avoid bone loss or muscle mass loss and supplement as necessary (vegans need to supplement with B vitamins, for example). Other than that, the sky’s the limit.
WereBear
@Mnemosyne (iPhone): I agree: the first few months I ate my radically different diet I tracked everything and was pleased to discover most of my nutrients actually went UP, not down. All were within the RDA, etc.
And the RDA was designed to prevent scurvy, beriberi, and rickets. Not the problem these days.
WereBear
To get back to the original point:
Why should we give it to people just because they want it?
Ruckus
@WereBear:
Wanna bet it’s so they don’t get sued? Which would cost them more. Especially if they didn’t do it and the woman died.
Gregory Gerner
@peach flavored shampoo: Dear Peach Flavored Shampoo, While I definitely appreciate where you’re coming from vis-a-vis the massive and well-known derpitude of the great state of Kansas, the simple geographic reality is that the Kansas City Star is physically located in Kansas City, MO. Regards,
some_doc
@phein:
What you’re describing is pretty much what they mean by “elective”.
There are probably still some Cardiologists out there who say “Well, maybe you run marathons but you’re 45 now so let’s take a look, shall we? Oh, found a 50% blocked artery, let’s stent that sucker!” That’s clearly harmful. This may not be far off from what happened to George W Bush.
Much more common is “‘I’ve been noticing tightness in my chest when I shovel snow, and maybe getting more winded than usual walking up that hill to the store.’ Well, you have high cholesterol and/or diabetes, risk factors for heart disease, so let’s do an angiogram. Wow! Look at that, 90% blockage in one artery and 60% in another! Cancel my appointments, time to stent!” This is most of the patients in these studies. The stents do not prevent heart attacks or improve survival, but may have some short-term benefit in improving the chest pain or shortness of breath with exertion. Importantly, we’re pretty sure now that even those 90% blockages don’t usually cause heart attacks. The heart attacks tend to come from other, less obvious, areas. To reiterate the key point, stenting 90% blockages does not prevent heart attacks.
So what does “non-elective” look like? “I woke up at 3am with crushing pain in my chest, I can’t breathe, I’m sweating like a pig, and I think I’m going to die! I called 911, they took me to the ER where they said I was having a heart attack. They took me right to the cath lab and found a completely blocked artery, which they opened and put a stent in.” Opening completely blocked arteries during an actual heart attack is a good use of stents, and saves lives.
Naturally there’s some gray area, and heart attacks come in a few different shapes and sizes with varying necessity for angioplasty, but in general stents are only clearly indicated if you’re actually having a heart attack.
The other upshot of all this is the realization that the medicines we have for heart disease really do work quite well! They do prevent heart attacks, and do save lives.