White Coat Underground

I’ve never done this before, but the previous threads are getting rather messy and I’m closing them down. Feel free to use this thread for your ongoing discussion. A few thoughts first.

Obviously some of the rhetoric is heated, which is fine. But if you’re going to throw around invective, don’t complain if it’s thrown back. Also, please remember that an ad hominem argument is invalid if it substitutes for substantive argument, but that insults that simply color, rather that replace and argument are not invalid, just, well, colorful.

Also remember that when trying to understand how to take care of the medical needs of our fellow human beings, the goal is to use the best evidence we have to help them. We can’t just make things up. We need to be open to rejecting our beliefs if they are disproved, and to accepting new ideas if they do not require overturning chemistry, physics, and biology as they are currently understood.

Have at it.

Comments

  1. #1 duckdroppings
    April 18, 2009

    Can we vote Doug and John Williamson off the island??

  2. #2 PalMD
    April 18, 2009

    This being a benign dictatorship, no.

  3. #3 Joe Average
    April 18, 2009

    I appreciate the opportunity to continue this dialog. I apologize if I annoyed anybody in the other topic.

    Candida has two forms, an aerobic form which medical doctors are very good at treating.

    It also has an anaerobic form which grows in the gut, that is a bit harder to treat with common antifungal drugs.

    Defined Anaerobic Growth Medium for Studying Candida albicans Basic Biology and Resistance to Eight Antifungal Drugs(2004)
    http://www.pubmedcentral.nih.gov/picrender.fcgi?artid=434226&blobtype=pdf
    “Anaerobically grown C. albicans was resistant
    to all concentrations of amphotericin B, clotrimazole, fluconazole, miconazole, and ketoconazole”

  4. #4 duckdroppings
    April 18, 2009

    Damn.

  5. #5 PalMD
    April 18, 2009

    I’m glad you’re happy, Joe, but I’d venture to guess (and I hope I’m right) that if n-paths really get the education they say they do, they will gently explain to you why this whole candida thing is a farce.

  6. #6 Joe Average
    April 19, 2009

    The previous article seems to indicate that anti-fungal drugs don’t work against intestinal candida. Yikes.
    Note1: I will skip the discussion on Nystatin, the non-absorbed antifungal drug with key-yeast-killing-ingredient sucrose(sugar).
    Note2: It is unfortunate that Itraconazole was skipped in that study; it is a better antifungal.

    Since the common drugs are ineffective, according to the study, if one had a candida problem, he might be so inclined to look for alternative drugs that actually do work against candida (if one can’t shake a candida problem). Hence, a big oppourtuntity for Naturopathic doctors to exploit.

    If somebody were looking for a candida cure, they might be so inclined to study the biology of candida. Maybe the genetics. This is tough stuff, complicated, and might take years. To develop a new drug is a slow and expensive process.

    Hence, one might choose to side-step the process, and instead choose to study: A. Veterinary Medicine(how do they cure it in animals). B. Naturopathy/Homeopathy. C. Old antifungal drugs that Medical Doctors used to use to cure candida/fungal problems (Same as B). D. Scour the internet for new medical research on more antifungals that treat candida.

    We’ll start with D.
    Prevention of Candida albicans biofilm by plant oils(2008)
    http://www.springerlink.com/content/y8l2568677111185/fulltext.pdf

  7. #7 Whitecoat Tales
    April 19, 2009

    Or you know, instead of starting with any of those, we could once again explain: Candida infections are generally localized, if you have invasive candidiasis, you’re not going to have the whole gamut of symptoms, you’re just gonna be very very very sick. Fungemic sick infact.

    You’re tossing out all of these articles about obscure discussions on candida, without putting in basic articles establishing that candida is actually a problem.

  8. #8 HCN
    April 19, 2009

    How I learned what homeopathy was:

    About 16-18 years ago I heard a news report that a local school, Bastyr, was going to do a big study on homeopathy. There was a pan over to a scholarly guy choosing a little bottle from a set of shelves covered with lots of little bottles. It was then explained that homeopathy was where a tiny bit of a substance was diluted and “like cures like”.

    What made it more interesting is that I lived down the street from Bastyr, which was then located in a closed school building which had a little playground that I took my very young boys to play (it is now located at an ex-seminary across the lake, and its cafeteria has wonderful food, though the parking is very sucky!).

    That was before the internet, so there is no archived web page on the press release. Actually, I looked around and can’t find anything about it. Not in any google or PubMed search, nor on Bastyr’s website.

    I am assuming at least one of the participating naturapaths and ND students is at Bastyr. Does anyone know about that study and what happened to it?

    I’d also like to know where the real actual evidence there is for Andre Saine’s claim that homeopathy works better for rabies than present methods.

    Thank you.

  9. #9 John Williamson
    April 19, 2009

    To bsci:

    Yes, I now question your reading comprehension skills. I am going to assume you are not from the USA. It’s okay, English can be hard.

    As for the 20 years, you are the one that is wrong. Let me provide another reference, one that is even easier to understand.

    “The average drug takes between 10 and 15 years to make it from a scientist’s notebook to pharmacy counters.” (http://www.investopedia.com/articles/06/drugmarket.asp)

    So it has been established that an ANTIFOLATE DRUG, repeat antifolate drug, sounding slowly anti-fol-ate drug CAUSED, c-au-s-ed, sound it out caused birth defects (not may have caused by the way). From this point I am saying since it takes a drug 3-20 years (avg 10-15) to make it from a notebook to a pharmacy (yes through phase 1-3 and the FDA) that folic acid could have been tested and found important by obstetricians by 1979 (at the 20 year max point).

    I was not implying at all to start dosing everyone up with folic acid from that point. I asked for more significant studies but they never occurred, they just didnt happen. Are scientists that stupid, hardly?

    Perhaps this, perhaps that, are you serious? You know what the beauty of drugs are? They have VERY SPECIFIC actions in the body or we couldn’t rely on them. Aspirin for instance is a cox 1 and 2 inhibitor. By understanding biochemistry we understand what this causes in the body, what pathways are affected, what happens. You see the study in 1959 utilized a drug whose mechanism of action was anti-folate. Therefore, researchers concluded that antifolate drug CAUSED, ca-u-s-e-d birth defects, anti-folate meaning folate was low and deficient.

    Yes it would have been easy to set up a randomized double blind placebo controlled trial shortly after that. Group 1 is placebo. Group 2 gets x amt, group 3 gets y amt, group 4 gets p amt over a course of pre-to post pregnancy. Compare the groups for birth defects. Get the P value. Of course, animal testing would have preceded human testing for toxicity ranges.

    Thanks again for helping to prove my point. I really appreciate it. Who knows maybe I can help you on the TOEFL if you want to become a citizen of the USA.

    John Williamson

  10. #10 John Williamson
    April 19, 2009

    To D.C. sessions,

    The drug was approved in nearly 100 countries within 10 years of being introduced and caused at least 10,000 birth defects. Nice try, though.

    By the way, the drug was approved in 98 (in the USA) but it did not take 40 years of testing on a specific disease to be approved. You can’t count its introduction as an antiemetic in the 60′s. It failed that test and had to begin new testing on different disorder (in the USA).

    It’s funny that the only drug you can come up with is a drug that caused massive birth defects and intense media scrutiny as well as new FDA guidelines for pregnant women.

    Nice try though.

    John Williamson

  11. #11 Whitecoat Tales
    April 19, 2009

    I’m going to leave the vaguely xenophobix, highly offensive crap about the english language for later.

    So it has been established that an ANTIFOLATE DRUG, repeat antifolate drug, sounding slowly anti-fol-ate drug CAUSED, c-au-s-ed, sound it out caused birth defects (not may have caused by the way).

    Ok, John I understand that you only enjoy addressing arguments that contain only small words, but I already addressed this point.

    Antifolate drug caused birth defects.
    Please note, we did not say “Low folate caused birth defects”

    Why is this important?
    You said this

    You know what the beauty of drugs are? They have VERY SPECIFIC actions in the body or we couldn’t rely on them

    Your lack of knowledge is disturbing. Drugs often have unintended consequences, unintended effects, and mechanisms of action we don’t understand.

    Fittingly, in your hubris you earlier brought up thalidomide.

    Thalidomide, at the time, was thought to be only a “sedative hypnotic.”
    Now, after it caused birth defects, if YOU had been the researcher you would have said “So it has been established that a SEDATIVE HYPNOTIC, repeat sedative hypnotic, sounding slowly sed-a-tive hyp-not-ic drug CAUSED, c-au-s-ed, sound it out caused birth defects (not may have caused by the way). ”

    And then what would you have done? proposed too much GABA stimulation as the cause of phocomelia and suggested anti GABAergic drugs as mandatory prescriptions from OBs?

    But of course we know better. It’s not thalidomides sedative hypnotic mechanism thats the cause of its teratogenicity. It’s not entirely known what causes the teratogenicity. It might be its anti angiogenic properties. Its absolutely not the same as its sedative hypnotic mechanism.

    So based on 1 paper implicating anti folate drugs in birth defects, how do you prove that its the anti folate activity, rather than some other mechanism of toxicity.

    Who knows maybe I can help you on the TOEFL if you want to become a citizen of the USA.

    As the child of immigrants, let me address directly the xenophobic and racist subtext of your commentary here. Your implication that the issue here is other peoples understanding of language because they’re “not american” is highly disturbing. English has become something of a lingua franca throughout the scientific world. Not that you’d know that, since you know nothing about science.

    Isn’t funny that a naturopaths threw out the bigot card, and then a naturopath threw out the bigoted behavior themselves?

    The hypocrisy is astounding, as always.

  12. #12 duckdroppings
    April 19, 2009

    John Williamson is a crackpot, c-r-a-c-k-p-o-t, say it slowly…crack-pot…

    You are proving a point, but it is not what you think it is.

  13. #13 Jimbo Jones
    April 19, 2009

    Whitecoat Tails said:

    Your implication that the issue here is other peoples understanding of language because they’re “not american” is highly disturbing.

    Not the least of which is because Americans don’t speak English… :p

  14. #14 Andrea LaCoss
    April 19, 2009

    HCN: I haven’t been ignoring your request for Andre Saine’s “proof” that homeopathy works better for rabies than present methods. I just haven’t had the time to look into it. I am, however, curious myself. So, when I see my Homeopathy professor next week I’ll be sure to inquire (no, my prof is not Andre Saine). When I find an answer, you will be the first to know:)

  15. #15 Joe Average
    April 19, 2009

    To continue the topic of Candida-related diseases….
    The next one is IBS. Theoretically, some kind of infection as a possible cause of IBS doesn’t seem like so much of a stretch.

    The naturopaths claim that an overgrowth of candida in the intestines is 1 potential cause of IBS. Unfortunately, I can’t conclusively prove this one.

    In the previous link, though, Peppermint Oil(Menthol Acetate?) appears 2nd on the list for treating candida problems; It iss efective as fluconazole, and cures at least 1 fluconazole resistant strain of candida.

    Is there any evidence to suspect that candida may be a potential cause of IBS?

    Peppermint Oil, Fiber Can Treat IBS(2008)
    http://www.webmd.com/ibs/news/20081113/peppermint-oil-fiber-can-treat-ibs
    “Based on the combined data, the researchers estimated that one in 2.5 patients would get significant relief of symptoms if treated with peppermint oil, compared to one in five patients taking antispasmodics and one in 11 patients taking fiber.”

    Peppermint Oil has a 40% cure rate, followed by antispasmodics(20%), followed by fiber(9%).

    Note: Certainly the science behind this is much more complex than I’ve lead the average reader to believe. Acetic Acid(Vinegar) is an anti-infective. It kills Bacteria. It kills Mold. It kills Yeast. It kills alot of stuff.

    Additionally, it must be stated that Candida has 20 different species, and over 100 different strains. It must also be stated that there are 100 different strains of other pathogenic fungs that can infect people (Mallasezia Furfur, Trichophyton, Aspergillus, etc…) Hence, a Naturopathic Cure for candida, may kill other fungus’s as well, or even a secondary fungal infection.

  16. #16 John Williamson
    April 19, 2009

    To Whitecoat and ALL:

    You’re right. That did come across as wrong. I rescind everything bsci consider’s offensive. It was wrong and I did not intend for it to come across like that.

    As for drugs, you are the one that is wrong. Drugs have side effects yes, but they are from their mechanisms of actions for the most part. Didn’t you take Pharm? I can’t believe an MD student doesnt know that. The unintended consequences come about when drugs are mixed as in someone taking many (Say 10) then interactions are likely to occur. Drugs are metabolized by cytochromes in the liver and competition may occur for metabolism raising concentraion of several. Also, there are fast acetylators and slow. There may be competition for albumin or OAT in the kidney, etc. For the most part, we know what drugs do otherwise they wouldn’t make it as a tx would they. From understanding what they do then we understand what they can cause. Isn’t that what the beauty of phase 1-3 testing is all about or are drugs a mere pseudoscience? Why am I defending drugs, you should be.

    Seriously though? Your questioning of how thalidomide causes birth defects. Are you serious? You understand that a developing fetus undergoes rapid growth right? Rapid growth requires sufficient nutrients, growth factors, etc through the blood vessels. If blood vessels aren’t being produced (blocked) how are tissues to develop. Why would thalidomide be effective in cancer? cancer requires rapid growth doubles every 7 hrs as opposed to 24 (normal cell). The rapid growth requires sufficient blood,nutrients to grow. Why do you think the centers of some rapidly growing tumors have necrosis? The cancer grows so fast the tumor can’t keep up the rate and it necrosis on the inside.

    Oh yea, I don’t need to cite basic biochemistry as I have already stated. Go open a book, turn to HMG COA reductase.

    John Williamson

  17. #17 Whitecoat Tales
    April 19, 2009

    I did not discuss drug side effects.
    Yes yes, we all know in polypharmacy a large number of side effects are related to cytochrome interactions, your basic pharm lecture is wasted on this crowd.

    I did not discuss drug side effects, I did not discuss polypharmacy. I gave you an example of one drug. Oddly enough, real scientists disagree on whether antiangiogensis is the teratogenic mechanism of thalidomide, i encourage you to do a pubmed search.

    But you missed the point completely.

    Thalidomide was marketed as a sedative hypnotic. Noone knew then that it had antiangiogenic properties.

    If blood vessels aren’t being produced (blocked) how are tissues to develop

    Since when did sedative hypnotics knwon to be anti-angiogenic? Oh wait, they aren’t.

    You’ve proven my point yourself though, thalidomide is a drug, with at least 2 distinct mechanisms of action, only one of which was initially known initially.

    In conclusion: John Wiliamson is a huge tool whose reading comprehension is questionable, and understanding of science is abysmal

  18. #18 John Williamson
    April 19, 2009

    To whitecoat:

    Ah so ……you don’t like it when people dont answer your questions do you and go somewhere else that you weren’t even talking about? That was a taste of your own medicine and many responses I have got on here. You don’t like it do you.

    “And then what would you have done? proposed too much GABA stimulation as the cause of phocomelia and suggested anti GABAergic drugs as mandatory prescriptions from OBs?”

    As I already stated before if a drug caused birth defects the exact cause would have been investigated. This is exactly how it was initially discovered to be teratogenic. A physician found a relationship between women taking thalidomide and birth defects. He investigated it and found that it had teratogenic properties ASIDE FROM ITS SEDATIVE VALUE. So yes, the proposal would have started out as GABA agonist drug causes birth defects in children? The drug would have been investigated, the GABA agonist activity would have been dismissed after the drug showed interruption of embryonic development. Women would have been instructed not to take the drug and the exact mechanism of action for teratogenicity would have been found. And of course, it is blasphemy to think increased GABA can be so definitive in producing defects which was obviously known back then or Im sure the drug wouldnt have been on the market within 2 years.

    Again, as I already stated if an antifolate drug caused birth defects, the folate portion would have been investigated, folic acid deficiency research would have shown deficiency equals birth defects. If there was some other mechanism causing the defects (from some unknown interaction) then the antifolate portion would have been ruled out wouldn’t it have. What’s so hard to understand, you seem to miss the boat on everything?

    In conclusion, Whitecoat has demonstrated Newtonian knowledge and should now be the head of all research everywhere.

    John Williamson

  19. #19 Doug Cutler
    April 19, 2009

    Bigot = “To describe a person who is obstinately devoted to prejudices, especially when these views are either challenged, or proven to be false or not universally applicable or acceptable.”

    Fits you all perfectly. 100% even.

    Was the thread “messy” because you didn’t want to answer to this video of Science Based Medicine? http://video.google.com/videoplay?docid=-7758662442132419447&hl=en

    Hypocrite = “Write” for Science Based Medicine and then post statements that science and medicine have no controversies. Orthodox medicine and everything in it is doctrine and is the only acceptable medicine. Guidelines and protocols are doctrine. MD training is doctrine. Everything you post is doctrine because you “teach” this stuff for a living and have your band of “disciples” to praise you. No controversies right? Just that naturopathic doctors are this and that and are inferior in every way, shape and form based on your distorted prejudices.

    Let me help you, here is a “controversy” and a big ‘issue”. What are you going to do when our powerful antibiotics stop working? Oh, already happening – right, that is a little scary no? Might have to turn back to nature AGAIN, maybe? Nah, that is complete “woo” right? I mean, who in their right mind would use the properties of a fungus to fight off bacteria? That is “shaman” stuff. It isn’t in our scientific protocols to do something so so so so so, what is the word……….? I will leave it blank since you have all kinds of creative and bigoted names for us.

    Yes us, the ones that will have answers to where you have failed and have no answers to. NPCPs that won’t be part of the 3rd leading causes of death in the US – that would be iatrogenic causes.

    And if someone challenges “the system” then again they are labeled as charlatans, pharm shills and fill in the blank…… Nice game, but apparently “Science Based Medicine” approves, even though their logo says “Exploring issues and controversies in the relationship between science and medicine”. ISSUES and CONTROVERSIES!

    But hey, your money making blog moved up 84 points right? Just donate the check that you will receive to http://www.naturopathic.org because that is the ONLY reason you really moved up. We will use the funds to constructively work with real MDs who are not bigots and we will be here when the current health paradigm collapses. Actually, it already has collapsed. This just goes back to the obstinate of bigots that are holding on to their “old” ways.

    As John pointed out earlier. “The World Health Organization ranks the USA Healthcare system at 37th right in front of Slovenia and Cuba”. So please, will the real doctors stand up and challenge what we think we know? It definitely isn’t happening here on this blog, but hey “the white coat underground” is ranked #____. Want even better ratings? Change your name to “Bigots-r-Us” ©

    The race card needs to go back in the deck also. We wouldn’t want any “ad hominem” would we? Honestly, I have no idea what that word means. …. Just another way to shut people up I guess.

    John is not racist and the accusation that he is, is offensive to me. He was merely pointing out the reading comprehension of certain people which you have pointed out to me numerous times was very insufficient. That’s all, nothing major. He apologized – end of story.

    And are you still trained as robots? You don’t even act human. “Hey John, I accept your apology”. “Oh yeah, you are right and I am wrong”, “Didn’t think of that thanks”. Your patients are going to love that! But this goes back to being a bigot. Acting human would be a sign of “I am wrong, and you are right”. And no one proves a bigot wrong because they have answers for everything! This was bigot 101 btw for those who though it just dealt with race.

    I know, I know – I am rambling on to a cement wall. I am off the “unchallenged” island so no worries. Just wanted to say AGAIN that John is not a racist so pull the ego down and learn from him because when he arrives, he brings the fire!

    No pressure, John, no pressure. Just all entertainment and ratings – nothing changes in these parts. But man, we all need some changing to do!

  20. #20 Doug Cutler
    April 19, 2009

    John said: “In conclusion, Whitecoat has demonstrated Newtonian knowledge and should now be the head of all research everywhere.”

    LMAO!!!!! yes John because didn’t you know bigots are omniscient?

    I like ya Whitecoat Tales so don’t take that quote in any other way than being funny! It is human to laugh.

  21. #21 Dr Benway
    April 19, 2009

    John Williamson,

    I’m not catching the point of your argument. Perhaps you gave it earlier and I overlooked it.

    You seem to be arguing that scientists in the 1960s willfully overlooked the relationship between folate levels in pregnant women and birth defects. I’m guessing that, in your opinion, they turned a blind eye to folate because they couldn’t patent the molecule and so win bushels of money for themselves.

    Is this what you are saying?

  22. #22 D. C. Sessions
    April 19, 2009

    I love it. As soon as I take a break from reading MHA, White Coat Underground mutates into something closely resembling it. Now all we need are John Scudamore and Jan Drew.

  23. #23 PalMD
    April 19, 2009

    Oh, DC, don’t make me cry! I’ll have new content soon.

  24. #24 Michael Simpson
    April 19, 2009

    A thread-continuation thread. Almost PZ-like.

    Of course, I still see Joe Average spouting off a bunch of words, attempting to sound like he knows something. Quoting Web MD as a source would violate the principles of his much beloved Wikipedia.

  25. #25 Doug Cutler
    April 19, 2009

    D.C. Sessions said: “By the way, the insanity is still going hot and heavy on the original challenge thread. Our boy Doug has been writing Walter Mitty scripts where he’s a hero because he miraculously does everything right (sort of) in an emergency and manages to always ask just the right questions without ever heading down a ruled-out direction. (He doesn’t seem to do “rule out,” which isn’t exactly a surprise, is it?)”

    D.C. Sessions said: “I’m about to go into a grade-A EMT rant on him but know you could do a much better job of “you don’t get to write the script for this show” than I can. If I don’t see one from you I’ll have a go at it.”

    Translation: “Daddy, a mean boy Doug needs to be taught a lesson”.

    What, today isn’t the day to mutate into an “expert” to give your grade-A EMT rant? Like I said, I was willing to learn and would carefully listen to your response.

    But “apparently”, I understood basic emergency care and you want to continue the bigoted disease that is rampant on this blog.

  26. #26 Whitecoat Tales
    April 19, 2009

    Doug this isn’t bigotry

    In the scenario, you weren’t supposed to assume that the pt was hypoglycemic. You were supposed to start with a patient suddenly collapsing in your clinic, and explain your actions, starting with showing how you decide what the real problem is, and ruling out what the problem isn’t. Then showing your workup, and emergency treatment.

    The idea is to show whether or not you’re competant to do urgent/emergent care such as one might see in a primary care clinic.

    What you did was say “This is what it is, no reaosn besides that I decided it” and then show what you would do.

    Try again, showing thought process, and decision making skills.

  27. #27 Doug Cutler
    April 19, 2009

    Michael Simpson said: “Of course, I still see Joe Average spouting off a bunch of words, attempting to sound like he knows something. Quoting Web MD as a source would violate the principles of his much beloved Wikipedia.”

    I guess you didn’t catch the meaning of what an “Average Joe” is. You can look up it up on Wikipedia, but in the meantime pick on someone your own size. But that wouldn’t be too big since your only “expertise” is EX-medical sales right?

    Please enlighten us, oh bigoted one and “morph” away!

  28. #28 Whitecoat Tales
    April 19, 2009

    Average joe means nothing -Joe has explicitly said that he has expertise on candida and antifungals elsewhere on these threads.

    When you claim that you know what you’re talking about you’re fair game.

  29. #29 Doug Cutler
    April 19, 2009

    Whitecoat Tales:

    There isn’t a “try again” in emergency care. I wanted honest feedback because I need to get it 100% right.

    If my thought process and decisions were wrong then show me. Stop giving me bigoted responses.

  30. #30 Doug Cutler
    April 19, 2009

    Whitecoat Tales:

    My point exactly. Michael Simpson isn’t an expert on candida and antifungals either. He is an expert in EX-medical sales.

    Translation: He was probably a pharm rep that medical doctors consider to be an “expert” on the drugs that they will Rx: to patients. A “sales” expert.

    Oh no, there is that pharm shill again right?

  31. #31 Whitecoat Tales
    April 19, 2009

    Here is my honest response: Emergencies aren’t one size fits all, you need to learn how to work up a problem.

    Start at the begining: “Patient falls to the ground unconcious in the clinic”
    Then think: How do you determine what the problem is – rather than saying “well duh is hypoglycemia.”
    There are algorithims for this, I’m not going to do your homework for you.

    The honest feedback: If you want to be a good doctor someone telling you the answer to one question doesn’t count for “100% right”, you’ve gotta study the breadth of situations that can present and use a methodical approach.

  32. #32 PalMD
    April 19, 2009

    Ugh. I don’t have to be a physicist to know that if i jump off my roof, i’m gonna hit the ground hard. This is basic biology and basic medicine, two disciplines which you folks are basically subjecting to the written equivalent of involuntary sodomy.

    None of what you have written about mycology and health has any basis in fact. It’s quite awful.

  33. #33 Doug Cutler
    April 19, 2009

    PalMD:
    Aren’t you bored with your prejudices, oh ye bigoted one?

    And your comedic statements are definitely quit awful! They are not approved by the American Comedian Assosiation. Want me to link their “protocol” and “guidelines” for you?

    BTW could you please SHOW us personally what happens when you jump off the roof? We need “scientific proof”, but just make sure it is 8 story building. (see? Real comedy).

    In the meantime, continue with your bigotry – I am off to study real medicine.

  34. #34 Doug Cutler
    April 19, 2009

    Whitecoat Tales:

    Thank you, but again what was wrong with my though process and decisions?

    From Naturopath Challenge thread:

    “Scenario: Patient comes into office waiting for an appointment to address poor glycemic control that is clearly not being managed by current pediatrician. Patient is passed out when you come to greet him and his parents.” This was the “challenge” from Tsu to show what to do with a patient that is in a hypoglycemic coma.

    As I stated in that scenario: “A PCP or any doctor is required to understand that not everyone in a coma is a diabetic. In this scenario, I would know the history of my new patient and would assume that this was more likely an iatrogenic cause.” I made the Dx: ASAP to save the patient’s life.

    I followed the basic algorithms for basic emergency care and showed the steps: Go back and look.

    And as I stated in that same post “Whitecoat Tales: Do me a favor in the meantime and give an assessment of the above scenario because I honestly want to make sure I get it 100% right. I can see you would be the only one to be fair and honest on this entire blog. And really I don’t think anyone else would know.”

    But I am doubting that “fairness” and “honesty” now. I am disappointed because I read your “My Motivation” blog and really thought you would make an excellent doctor.

    Whitecoat Tales, you definitely commented a lot on that same post, but you said nothing about my thought process and decisions. If I made a major mistake or whatever, you would have been on it like “white on rice” as you have stated before in other posts. “Had you said this on rounds, my attending would probably have told you to go home before you kill someone.”

    Any doctor out there that wants to “teach” an “incompetent” naturopathic medical student? That is what real doctors do no? Teach? Not, a soccer mom who has “morphed into the doctor role”. A real freakin doctor!

  35. #35 Joe Average
    April 19, 2009

    Antifungal drugs have a lot of neat uses.

    As shown earlier, you can cure IBS(2.5 NNT).

    You can cure gum disease (40-50% of Americans have gum disease).

    You can cure age spots(Tinea).

    You can cure dandruff.

    You can grow back hair:
    http://en.wikipedia.org/wiki/Ketoconazole
    “One 1998 study showed that Nizoral 2% worked just as well as minoxidil 2% (brand name Rogaine) in men with androgenic alopecia.”

    Antifungal drugs do really cool things (on healthy people). It’s a bit unfortunately that they work so slowly.

  36. #36 PalMD
    April 19, 2009

    Doug and Joe, you guys are passing from debate to advocacy for dangerous lies. I hate to ban people but if you keep up your dangerous idiocy, you’re gonna have to move on.

  37. #37 Joe Average
    April 19, 2009

    Rosacea is also treated with Anti-fungals(Metronidazole, sulfacetamide gel).

  38. #38 PalMD
    April 19, 2009

    Yes, that’s true. So what?

    ANd no, they do not “cure” age spots or gum disease, and to say so shows a level of idiocy that is nigh unimaginable.

  39. #39 Average Joe
    April 19, 2009

    “Doug and Joe, you guys are passing from debate to advocacy for dangerous lies.”
    – I appologize for leaving my last post largely unsourced. Would you be so kind as to specify any claim that I have made so far that is in dispute?

    On gum disease, the FDA approved treatment is Chlorhexadine, which is an anti-infective that is also used to treat ringworm and candida in animals.

    There are other various protocols in Periodontal Journals and practiced by Periodontists that include Ketoconazole, which are not FDA approved.

  40. #40 PalMD
    April 19, 2009

    I have a very serious responsibility not to allow dangerous comments that could be construed as medical advice. You may not post those comments any longer.

  41. #41 PalMD
    April 19, 2009

    New rule/clarification:

    No one may use this blog to advance unproven medical and health claims. If you do make such a claim, it is your responsibility to back up your new, ingenious discovery, not mine to disprove it.

    If you are unclear on it, I will try to give you a warning before banning you.

  42. #42 daijiyobu
    April 19, 2009

    Is fungus the new ‘liver fluke’ for NDs?

    Hulda, repackaged?

    At least we don’t have to telephone Mexico!

    -r.c.

  43. #43 sND
    April 19, 2009

    Nice to see censorship now.

  44. #44 PalMD
    April 19, 2009

    sND, i hate to stop commentors, but there’s a difference between having a substantive debate on the issue, which folks like JenND etc engaged in, and making bat-shit insane medical claims on a prominent medical blog, effectively piggy-backing on my reputation. If I don’t do something it makes it appear as if i condone Joe and Dougs insanity.

  45. #45 Douglas Cutler
    April 19, 2009

    PalMD

    Really? Is this all you got “Dr.” Peter Lispon? To threaten to “ban” a naturopathic medical student for challenging your very own lies?

    Let me guess, “The Journal of the American Medical Association” is “lying” when they illuminate the failure of the U.S. medical system. 12,000 deaths per year due to unnecessary surgery. 7000 deaths per year due to medication errors in hospitals. 20,000 deaths per year due to other errors in hospitals. 80,000 deaths per year due to infections in hospitals. 106,000 deaths per year due to negative effects of drugs. Starfield, B. (2000, July 26). Is US health really the best in the world? Journal of the American Medical Association, 284(4), 483-485.

    3rd! Did you read that clear enough? That is you “Dr.” Peter Lispon and all your bigoted cohorts!

    “The U.S. health system spends a higher portion of its gross domestic product than any other country but ranks 37 out of 191 countries according to its performance”. Go read the report yourself!www.who.int/whr/2008/whr08_en.pdf. And guess what? They recommend naturopathic treatments as well!

    So go ahead and hypocritically preach to everyone about “dangerous lies”!

    And I understand you have your HON code to uphold. But don’t give me the hypocritical statements like you have posted in the “HONcode Certification” thread.

    PalMD said: “A blog is an interactive medium. If we didn’t have dissent, we’d never learn anything. HON and I went back and forth on this, and they agreed (both generously and cautiously) to give me the certification despite my resolve not to censor (most) comments. I’ve added to my standard disclaimer this paragraph:”………

    This is exactly why you are censoring the original “Naturopath Challenge” thread. Because your bigoted challenge blew up in your face! You had no idea that naturopathic doctors knew their stuff – some more than others! There was “dissent” from both side of the isle, MDs, NDs, DOs and non-bigoted health professionals.

    PalMD said: “HON is going to be watching, and if they think that the blog has the appearance of “sponsoring” the commenters and their beliefs, I may lose my certification.
    I’m willing to take that risk.”

    Bull $#%#! BULL $#%#! You aren’t taking that “risk”. You are caving in like a lawn-chair like most orthodox medical doctors do to “outside” influences.

    If HON is “watching” then by their own criteria you do not deserve a HON rating on your “weak” blog.

    IF YOU ARE MAN ENOUGH. Send me a private email dcutler@scnm.edu so it doesn’t “affect” your HON code farce.

    Give me a patient scenario “challenge” with the correct charting procedures. Not some “wimpy” two liners that you gave in the bigoted “Naturopath Challenge”. Give it in the proper way you would give to medical students. CC:/HPI/PMH/Surg Hx/Hospitalization/Medications:prescriptions,OTC/Supplements/Allergies /FHx/SHx/Sleep/Diet (24 recall)/Emotional Hx/ROS –head to toe/Assessing structure and function. General/HEENT/Neck/Resp/CV/GI/GU/Male/OB/GYN/Breasts/Musculoskeletal. Neuro/Endocrine/Skin/Vitals:BP/P/RR/T/Height and weight/Any physical exam findings/Any abnormal lab/test results.

    And I will give you my “naturopathic medical student” assessment/Dx:/Plan: that you can publish to the world to show how incompetent we really are. Plans, both from orthodox medicine and naturopathic medicine. Which you have clearly have shown that you don’t know neither.

    You see, this is the proper way to see your patients. Naturopathic physicians will continue to be outstanding PCPs. Be human. Thank us for cleaning up your mess!
    Seriously Whitecoat Tales? This is your mentor? This is what you want to “morph” into? DISAPPOINTING my friend, DISAPPOINTING! You have my email too, if you still want to come for a visit.

    “Dr”. Peter Lipson, you are Pathetic!

    I will ban myself now. Thanks!

  46. #46 PalMD
    April 19, 2009

    Thank you for banning yourself. Please stick to it.

    I’m sorry that reality doesn’t conform to your belief system. Perhaps you’d be better off in a faith-based helping profession such as the clergy.

  47. #47 daijiyobu
    April 19, 2009

    Doug,

    you are a [pseudo]credit to your [pseudo]profession, in that you have exemplified [pseudo]science and [pseudo]rationality. But, perhaps you are an outlier.

    Cheers. Please maintain your self-exile. I hope that’s not pseudo, and is quite outlying.

    I feel [pseudo]assured, I know where to reach you if your [pseudo]expertise is needed.

    Unsolicited advice:

    never stop thinking, and be willing to disassemble your most cherished assumptions, continually reconstitute them, and evolve your thought.

    -r.c.

  48. #48 Dr Benway
    April 19, 2009

    What I have learned from Doug:

    When you can’t cite references to back up your non-standard health claims… tu quoque and tantrum!

    Is this how people debate issues in naturopathy school?

  49. #49 daijiyobu
    April 19, 2009

    What I recall from ND school:

    the priesthood would decree, and either you would comply or you were blackballed.

    -r.c.

  50. #50 Joe Average
    April 19, 2009

    “ANd no, they do not “cure” age spots or gum disease, and to say so shows a level of idiocy that is nigh unimaginable.”
    – I retract my statement. It was poorly worded and irresponsible.

  51. #51 duckdroppings
    April 19, 2009

    Kewl, Dougie voted himself off.

  52. #52 Jennifer B. Phillips
    April 19, 2009

    Is this how people debate issues in naturopathy school?

    Based on the past week’s conversation here, I’d hazard a guess that precious little debate of any kind goes on in naturopathy school.

    PS, having just spend several hours in the ‘mergency room with my 6 year old, I just wanted to say a big thanks to all you stodgy, inflexible materialist docs out there. I’m immensely glad you have the training that you do.

    JBP

  53. #53 D. C. Sessions
    April 19, 2009

    “Scenario: Patient comes into office waiting for an appointment to address poor glycemic control that is clearly not being managed by current pediatrician. Patient is passed out when you come to greet him and his parents.” This was the “challenge” from Tsu to show what to do with a patient that is in a hypoglycemic coma.

    NO!!!!! this is not the question! The question is what to do with an unresponsive patient.

    You do NOT get to turn the patient into a nail just because hammering is the only trick you have looked up on Google. Again, you’re claiming to be qualified to be a PCP — and one of the joys/nightmares of “primary care” is that you get freaking everything. You don’t get to do only endocrine disorders, you don’t get to do only musculoskeletal conditions, you don’t get to do only opthalmic complaints. You get it ALL.

    If you can’t handle unexpected situations, if you — as you have here — can only follow a few scripts laid out to ask the questions you have on your crib sheet, you will end up hurting a patient. In the example given, you could very very easily end up killing one.

    As I stated in that scenario: “A PCP or any doctor is required to understand that not everyone in a coma is a diabetic. In this scenario, I would know the history of my new patient and would assume that this was more likely an iatrogenic cause.” I made the Dx: ASAP to save the patient’s life.

    Guess what, kiddo, people are PEOPLE — they’re not just “diabetics.” So much for “treating the whole person!” Diabetics’ lives don’t revolve around their blood glucose. They (gasp!) do other things too — which is one reason why EMT hammers “check for medic alert bracelets etc.” into us. Diabetics (and epileptics, and …) ski. They drive. They play sports. They get hurt for the same reason other people do.

    And then some nitwit who thinks that a person’s whole life is wrapped up in a chart: “I would know the history of my new patient and would assume” goes and boils it all down to a few lines. ASSUME!?! Do that on an ambulance run (don’t worry, people, he’s nowhere near qualified) often enough and you will kill people. Luck can only get you by for so long.

    I’ll throw out just one possible scenario that you didn’t cover to make the point:

    Patient had (as noted in HX) been having trouble with unstable blood sugar. Perhaps in consequence (and perhaps not) patient stumbled and fell, bumping head. Patient does not remember fall, patient’s parents did not observe fall, which is why it’s not in the freaking chart. Patient is not feeling well, patient’s parents bring patient to your office, and patient collapses in waiting room. You don’t notice the head injury, you don’t do basic neurological test, you ASSUME rather than check hypoglycaemic coma (in this case oxygen is good, BTW, but far from appropriate coma) and ship off a trauma case (without appropriate spinal immobilization, among other things) to be treated as an endocrine imbalance. Meanwhile the intracranial bleed continues.

    Nice way to kill a kid, “Doctor.”

  54. #54 D. C. Sessions
    April 19, 2009

    D.C. Sessions said: “I’m about to go into a grade-A EMT rant on him but know you could do a much better job of “you don’t get to write the script for this show” than I can. If I don’t see one from you I’ll have a go at it.”

    Translation: “Daddy, a mean boy Doug needs to be taught a lesson”.

    No, Genius, it means that I know my limits. I’m not a PCP and certainly don’t train them [1]. I can think of a few instances where you’d have killed the patient, but since my scope of practice is necessarily rather limited (I’m an engineer, Jim, not a doctor!) my ability to come up with nightmares for you is too.

    [1] As such. I certainly do train them in stuff not covered in their training but necessary for field work; proper field immobilization, for instance. A limited survey of very good physicians also shows that they can have serious issues in mass-casualty situations, too.

  55. #55 Kim
    April 19, 2009

    Not to detract from the mudslinging at hand, but I have a question for PalMD.

    In your original follow-up to the ND, you ask why she would put her patient on a strict low-carb diet and I was sort of surprised to hear you say there is no evidence to support its use. Coming from a “fitness nerd” perspective, it seems like I come across quite a bit of secondary material — much of it by MDs, by the way — with good cites that would suggest a positive benefit in type 2 diabetic people (granted, I think most if not all of the cited primary research is done on healthy overweight people rather than diabetics — since the materials I’m reading are not about diabetics, this is what I would expect — but the measures that improve seem like they would translate well). The model of insulin resistance at the cellular level, which also seems to have some pretty good primary material citations, also seems to be directly relevant to type 2 diabetes.

    I’m not a low-carb loyalist — as a hockey player, I really can’t be, since low carb diets destroy sprint performance — but it seems increasingly well-supported to me, so I was surprised you claimed an absence of evidence.

  56. #56 Dr Benway
    April 20, 2009

    …it seems like I come across quite a bit of secondary material — much of it by MDs, by the way…

    Sadly, thanks to the CAM movement, you can’t assume a person with an MD is capable of critically reviewing and understanding the scientific literature.

    Once you legitimize but one cult within a scientific community, everyone suddenly becomes a partisan. So you have to find out the party affiliation of the MD first before you can make sense of his opinion.

    The biologists would be going through this strange corruption of discourse now, had creation science won a place at the science table twenty years ago.

  57. #57 Dr Benway
    April 20, 2009

    The question is what to do with an unresponsive patient.

    They just don’t do differentials, do they.

    They don’t realize that it’s a doctor’s job to figure out everything the patient doesn’thave.

  58. #58 Dr Benway
    April 20, 2009

    I don’t remember if Doug said he’d start by telling someone to call 911.

    Most important part of CPR training.

  59. #59 dustbunny
    April 20, 2009

    There’s been some work done on type 2 diabetes patientsthat would justify the measurement of free/total testosterone as well as PSA in the discussed 65-year old male patient.

    Evaluating and treating a possible testosterone deficiency in a 65-year old man, especially with type 2 diabetes, strikes me as valid.

    I don’t think the part about giving the fellow a self-help book or advising him on relaxation techniques is medically valid.

    The comment above regarding low-carb diet also sounds quite relevant, since one of the goals in the patient’s care is to regulate his blood sugar levels. Even reducing the amount of rapidly-absorbed carbs i.e. sugar, sodas etc. should help to even out blood sugar levels.

  60. #60 PalMD
    April 20, 2009

    Kim, it depends on what your goals are. For diabetics, more important that strict carb restriction is carb-counting.

    As far as weight-loss in concerned, the majority of studies, including a terrific recent one in NEJM (http://content.nejm.org/cgi/content/short/360/9/859), show that calorie restriction, rather than restriction of a particular macronutrient, is most important.

  61. #61 D. C. Sessions
    April 20, 2009

    They just don’t do differentials, do they.

    Nope — hammer in a world of nails.

    I was hoping for someone else to chime in. IMHO it would be fun and enlightening to have a “challenge” where we all got to come up with alternatives fitting the waiting room collapse that TDN posted. I thought of several myself [1]. None of them involved direct patient harm [2] but there’s room for lots of indirect harm when someone comes in with what’s supposed to be a competent DX.

    Could I sweet-talk you or Our Most Generous Host into something like that?

    [1] Insulin shock isn’t the only kind diabetics can have, after all.
    [2] Or not much, anyway — I have reservations about using O2 willy-nilly on “it can’t hurt” grounds.

  62. #62 Joe Average
    April 20, 2009

    To rephrase my poorly worded statement on gum disease… anti-infectives(with antifungal activity), are commonly deployed as a treatment options by Periodontists to treat Gum Disease. Gum Disease is a complex disease with many known causes. I apologize for misleading the reader with my grossly inaccurate statement, commented on by PalMD.

    Overview of Periodonditis:
    http://en.wikipedia.org/wiki/Periodontitis

    More Info:
    http://adam.about.com/reports/000024_2.htm
    “In the healthy mouth, more than 350 species of microorganisms have been found. Periodontal infections are linked to fewer than 5% of these species.”

    Treatment Protocols:

    PERIODONTITIS TREATMENT PROTOCOL OVERVIEW PROFESSIONAL VERSION
    http://www.periodontaldiseasetreatmentguide.com/?p=PTPOPV
    “Conforms with the guidelines of the Board of Trustees of the American Academy of Periodontology as outlined in the position paper: Systemic antibiotics in Periodontics Journal of Periodontology, November 2004, 1553-1565; Primary author: J. Slots”

    Adjuntive Effects of Systemic Amoxicillin and Metronidazole with Scaling and Root Planning:
    A Randomized, Placebo Controlled Clinical Trial
    http://www.thejcdp.com/issue034/moeintaghavi/01moeintaghavi.htm

    Amoxicillin and metronidazole as an adjunct to full-mouth scaling and root planing of chronic periodontitis.
    http://pubget.com/article/19254119?title=Amoxicillin%20and%20metronidazole%20as%20an%20adjunct%20to%20full-mouth%20scaling%20and%20root%20planing%20of%20chronic%20periodontitis.
    “CONCLUSION: Systemic metronidazole and amoxicillin significantly improved the 6-month clinical outcomes of full-mouth non-surgical periodontal debridement, thus significantly reducing the need for additional therapy. | PMID: 19254119 ”

    Effects of Chlorhexidine, Minocycline, and Metronidazole on Porphyromonas gingivalis Strain 381 in Biofilms
    http://www.joponline.org/doi/abs/10.1902/jop.2003.74.11.1647

  63. #63 Tsu Dho Nimh
    April 20, 2009

    Dr. Benway –

    He said he’d have his assistant call 9-1-1

    Perhaps I set him down the track he took by stating the patient passed out FROM HYPOGLYCEMIA in his office. I should have said “passed out” with no other conditions.

    Doug, however, put a turbocharger on the limited information and went roaring down the track with the assumption that it was a visit because the previous pediatrician was unable to control the sugar, and that he had a full set of records from the previous doc, and that the mom would have IV glucose or glucagon in her bulging purse.

    And he never did explain what his “ABC’s” were that he would keep repeating.

  64. #64 docwimz
    April 20, 2009

    Very entertaining article for everybody on the post to read and comment on if interested.
    http://www.cnn.com/2009/HEALTH/04/16/longevity/index.html

  65. #65 The Perky Skeptic
    April 20, 2009

    Mmmm, calorie restriction. Today I’m trying to restrict myself into thinking celery = chocolate! :D

  66. #66 PalMD
    April 20, 2009

    As much as I love celery, that never works for me.

    Hope the kiddo is doing well.

  67. #67 Dr Benway
    April 20, 2009

    Ah, thanks Tsu Dho Nimh. I couldn’t recall if hypoglycemia were a given or a high probability diagnosis. Too hard to backtrack with several similar threads at once.

    So my “don’t do differentials” wasn’t fair to Doug in this instance and I apologize.

    In my defense, the naturopaths weren’t careful to distinguish the givens from their own elaborations, and that confused me–e.g., the pediatrician not managing the glucose appropriately, mom having something in her purse…

  68. #68 Kim
    April 20, 2009

    @PalMD: I’ve heard that NEJM study discussed quite a bit. 40/25/35 fat/protein/carb is not really low carbohydrate the way the low-carb people do it (on a 2000 calorie diet it’s something like 175g/carb vs. 50g or so). It’s on the low side for a sprint athlete, but I don’t know enough about sedentary person nutrition to say how it rates for them.

    But stepping back from that study in particular, it seems that the athletic nutrition and exercise physiology communities know things that aren’t leaking into the mainstream of medical practice. People who study athletes obviously aren’t going to interrupt their careers to work on sedentary people. The people who are interested in making ordinary people less fat or more healthy generally don’t seem to be paying attention to research on athletes. The fitness wonks are in their own little world where they may be selectively absorbing material from multiple sources depending on personal biases and doing research of varying degrees of quality (I almost wanted to scare-quote “research”, there’s so much variation between good work and “totally uncontrolled observations of my personal training clients”), but they seem to be in a good position to generate interesting hypotheses (even if those hypotheses need to be qualified with higher-quality work before anyone considers them seriously). Etc. I have no idea how diabetes research even interacts, or doesn’t, with any of the above.

    In any case, the piece that frustrates me is that it seems like none of this is synthesized such that it’s available to physicians in the community, even when the work is valid. The evidence available to physicians seems to be coming from a different slice of the research community entirely from the evidence available to someone who digs into athletic performance even just a little bit, and never the twain shall meet. At a time like this, when the fitness folks are positively obsessed with insulin (thank you Garry Taubes), it seems particularly unfortunate that diabetics are unlikely to see benefits from that obsession even in those cases where the work is solid (and I grant that much of it isn’t)…at least not any time soon.

    @Dr Benway: I’ve escaped from a pretty woo-friendly MD myself in the past — and I’ve seen how the fitness/paleo fringe wanders off into anti-vaccination territory and similar — so I know it’s more than possible. But when someone like Doug McGuff (MD) says “feel free to buy a mainstream metabolism text and follow along at home” it seems less likely that the situation is CAM-y. Is it possible that he’s pulling bad conclusions from good data? I assume so. But I’m not quite willing to put that in the same bucket as, say, homeopathy.

  69. #69 PalMD
    April 20, 2009

    But stepping back from that study in particular, it seems that the athletic nutrition and exercise physiology communities know things that aren’t leaking into the mainstream of medical practice.

    Well, that’s a problem, then, because the funding for this kind of research is out there. Dietary interventions are studied all the time, so if the data are lacking, either someone is very lazy, or the data aren’t great.

    Still, there is a great deal of data:

    This statement from the ADA summarized much of the evidence.

    This study of Adkins-type diets excluded diabetics, but did show some diabetes-related health benefits (but not others).

    One study showed low-carb diets (with high fat content) to increase risk of DM. This study also had rather mixed results.

    Finally, this study had rather promising results, in the short term.

    Despite a lot of study, no consensus has arisen about low-carb diets and diabetes. We cannot claim it has not been studied (PubMed is our friend), and were there a strong relationship, it should have shown up by now.

    Still, it is not an implausible hypothesis, and I’m not yet aware of any long term, large scale studies of the topic (which means they might actually exist). If we get good data, we can implement it. If we don’t well…

  70. #70 Kim
    April 20, 2009

    @PalMD: It seems to me not that people are lazy, per se, but that people kind of tool along on their own research threads with their own colleagues and without a lot of cross-disciplinary communication.

    The studies you turned up in your 2-second PubMed trawl were done in schools of medicine and public health (they were also all studies that had a mainstream media press release at some point, not that there’s anything wrong with that). I suspect that if I picked a representative sampling of studies from PubMed on the exact same topics — in some cases probably doing about the same experiment — coming out of kinesiology departments and combed the cites on both sets of papers, I’d see little if any overlap. And that’s really where my complaint lies.

  71. #71 PalMD
    April 20, 2009

    Kim, I’m starting to suspect an agenda here.

    What would a department of “kinesiology” have to do with diet and diabetic care?

  72. #72 antipodean
    April 20, 2009

    Kim

    You are confusing two completely different problems here.

    1 Research into diet in elite athletes for the purpose of increased performance.

    2. Research into diet for diabetic patients for the purposes of avoiding diabetic morbidity and mortality.

    So it’s no wonder you think that medicine and excercise physiologists aren’t talking to each other. They don’t need to. They are working on different problems.

    Of course they are in fact talking to each other when you start to discuss the public health issue of sedentary lifestyles- at least in my part of the world. And then there are sports physicians…

  73. #73 docwimz
    April 21, 2009

    PalMD;Which populations are you looking at? Native American populations diets prior to white contact? What were the rates of DMII in say, the Inuit population prior to reservation diet?
    The Hopi?, The Dakota Sioux? What changed? Just curious but, are you including in your research the pre-agricultural diet of Native American tribes, very different depending on the tribes and lands, but pre-agricultural diets had a much lower amount of carbs? Would be curious is, given your work as an internist you noticed this trend in the Native Populations and thought diet might be a factor if any?

  74. #75 Dianne
    April 21, 2009

    the pre-agricultural diet of Native American tribes

    Just to note that a number of Amerind tribes used agriculture prior to contact with Europeans. Indeed, the Mayan civilization may have declined because of over-farming.

  75. #76 docwimz
    April 21, 2009

    Diane:
    The Mayan communities weren’t looked at only pre-agricultural please see the data. Please look at at what I presented, and stick to the data.
    Diane, I am an anthropology major whose degree focused on the N. American communities prior to white contact.

  76. #77 docwimz
    April 21, 2009

    I sent a stack of research on DMII in N. American tribes that are pre-agricultural prior to white contact, pre and post health information and diet changes but it got lost in the spam filter. These included. For those who are interested in how dietary changes have impacted various communities I can also send the PDF formats. There is a great deal of information compiled on this subject via various Native American Health organizations. I feel the evidence that a high carbohydrate diet played at least a partial role in DMII is very well founded.

  77. #78 PalMD
    April 21, 2009

    That’s all quite lovely, doc, and i think anthropology is quite interesting, but what the real question is how diet influences moderns here and now—and so far the data is mixed.

  78. #79 Calli Arcale
    April 21, 2009

    Regarding the original challenge, I have to say that even I, a mere software engineer, knows that “patient is here for poorly glycemia control + patient is unresponsive = patient is in a diabetic coma” is a very foolish conclusion. Just because a person has one disease doesn’t mean that’s the only disease they have. A diabetic with narcolespy? Or an undiagnosed heart defect leading to congestive heart failure that the last doc missed? A stroke? Meningitis? (Having had meningitis, I can attest that it can develop frighteningly quickly.)

    Regarding diet, it is definitely true that diet is important to long-term management of the disease. I’ve known several diabetics in my life; they all made radical changes to their diet in order to avoid death. It didn’t cure the diabetes, and their modified diets weren’t at all analogous to hunter-gatherer diets. But I don’t think that’s germane when somebody collapses in your waiting room. Maybe once he’s stabilized, you can think about lifestyle modifications, but take care of the immediate problem first.

  79. #80 Docwimz
    April 21, 2009

    PalMD I think you are confused. The data collected is based on comparisons of data on populations of Inuit comparing DMII rates and diet, and monitoring diet in current populations eating traditional vs high carb foods. Please see the data put out by the health organizations working with these populations. I sent them and have more if you are interested.

  80. #81 PalMD
    April 21, 2009

    No, I’m not confused. This type of messy case-control and cohort studies can be used to identify risks, but they are not great at determining the success of interventions. This requires randomized controlled trials, and this topic is certainly amenable to such trials. The case control and cohort studies are more for background.

  81. #82 D. C. Sessions
    April 21, 2009

    I feel the evidence that a high carbohydrate diet played at least a partial role in DMII is very well founded.

    Well, we certainly wouldn’t want to disrespect your feelings.

    However, there were a lot of changes besides carbohydrate intake. The largest was change in exercise habits, followed by total caloric intake. Carbs were pretty far down on the list.

    Ad Our Hose points out, the epidemiological data is not precise enough to separate the exercise, total caloric intake, and carb percentage. However, since anecdotes trump epidemiology in Wooville, I present to you a very small uncontrolled experiment:

    I work for the White Mountain Apache Tribe in the winter. The White Mountain Apaches have the second-highest rate of DM2 in the United States (just after the Pima — who were farmers before the Europeans arrived.) Look at the pictures of their great-grandparents from a century ago and you don’t see anyone with a BMI over 20.

    Well, I know a number of youngish Apaches who are trying to revive interest in the old ways as a cultural and health measure — including long-distance running. The Apache used to be world-class runners, and these guys are trying to get back to that. Their diets are pretty standard US fare, including a hefty load of carbs — but they don’t add alcohol and they maintain reasonable portion control. That, and they burn it off.

    None of them are fat. Stocky builds, some of them, but you can bounce rocks off of their bellies. No diabetes, either.

    YMMV. HTH. HAND.

  82. #83 Dianne
    April 21, 2009

    please see the data.

    Ok. Could you provide a link to the data that you are referring to? I apologize if you did before and I missed it.

  83. #84 JPPhD
    April 21, 2009

    antipodean @ 72:

    “So it’s no wonder you think that medicine and exercise physiologists aren’t talking to each other. They don’t need to. They are working on different problems.”

    I respectfully disagree with your assertion. Exercise physiology is a nebulous field, but there is a branch that focuses on physical activity/exercise for the prevention and treatment of medical conditions such as type 2 diabetes and cardiovascular disease, among others. In fact, I used to hold a position as an exercise physiologist in a diabetes education center located at a community hospital. I worked with patients who were referred by primary care providers (mostly MDs with a few PAs and NPs). Most of the patients had type 2 diabetes or were at elevated risk. My programs were science-based and I was absolutely working on the same problems as the medical providers. The American College of Sports Medicine (ACSM) offers a registration for clinical exercise physiologists for individuals with master’s level training and the National Certification Board for Diabetes Educators allows qualified individuals with the ACSM registration to sit for the Certified Diabetes Educator exam.

  84. #85 antipodean
    April 21, 2009

    JPPhD

    You disagree with my assertion that somebody else thinks something???

    Read the comment again. I completely agree with what you are saying and I even stated that such collaborations exist.

  85. #86 JPPhD
    April 21, 2009

    antipodean @ 84:

    My apologizes. My first sentence after citing you should have stated “I must also respectfully disagree with your assertion Kim.” I was attempting to extend your comment about collaborations with a specific example. I wasn’t disagreeing with you at all, but I didn’t communicate well.

  86. #87 JPPhD
    April 21, 2009

    PalMD@71:

    I am not quite sure what you mean. “Kinesiology” programs vary in their scope, but it could include just about anything related to metabolism. This could include nutrition and glucose metabolism.

  87. #88 PalMD
    April 21, 2009

    Hmmm..didn’t know that.

    I have seen a lot of woo from people claiming to belong to the field of kinesiology, which i suspect is where kim was going (not you, of course)

    http://www.quackwatch.org/01QuackeryRelatedTopics/Tests/ak.html

  88. #89 JPPhD
    April 22, 2009

    PalMD @87:

    Yes, I think that another aspect of varying in scope could be woo. I haven’t heard the term ‘applied kinesiology’ in awhile, but I know that it is to kinesiology what alternative medicine is to medicine.

  89. #90 Dr Benway
    April 22, 2009

    What was that… a rabies drive-by?

  90. #91 PalMD
    April 22, 2009

    @DrB Yeah, I actually deleted it since it was just a copy of someone else’s rant.

    @JPPhD that’s what i figured

  91. #92 The Perky Skeptic
    April 22, 2009

    Still munching celery… I think it’s addictive! My Amazing Celery Diet works, but only as long as there’s no chocolate ANYWHERE within a mile radius! Think I can market that? ;)

    Yeah, I was going to liken “applied kinesiology” vs. kinesiology to astrology vs. astronomy. In fact, I’m surprised somewoo hasn’t already taken to calling astrology “applied astronomy” in trying to make a profit!

    The kid’s doing well, thanks PalMD, and he will be turning 6 this very weekend. :) I think my celery-fest is doomed.

  92. #93 JPPhD
    April 22, 2009

    D. C. Sessions @82:

    “Ad Our Hose points out, the epidemiological data is not precise enough to separate the exercise, total caloric intake, and carb percentage.”

    Not disagreeing, but I think that there is interesting data that is informative regarding the relative roles of energy expenditure and energy intake on weight gain and type 2 diabetes risk markers. For instance see:

    Salbe AD, Weyer C, Harper I, Lindsay RS, Ravussin E, et al. (2002) Assessing Risk Factors for Obesity Between Childhood and Adolescence: II. Energy Metabolism and Physical Activity. Pediatrics 110: 307-314. doi:10.1542/peds.110.2.307

    Swinburn BA, Jolley D, Kremer PJ, Salbe AD, Ravussin E (2006) Estimating the effects of energy imbalance on changes in body weight in children . Am J Clin Nutr 83: 859-863.

    Swinburn BA, Sacks G, Lo SK, Westerterp KR, Rush EC, et al. (2009) Estimating the changes in energy flux that characterize the rise in obesity prevalence. Am J Clin Nutr: ajcn.2008.27061. doi:10.3945/ajcn.2008.27061

    Also, the CALERIE study looked at the impact of different manipulations of energy balance and several health markers. I can post a partial reference list of publications from the CALERIE study if there is interest.

    Assessing macronutrient intake (outside of inpatient settings) accurately is challenging. Work with biomarkers is promising, but right now I think that it is generally hard to have a great deal of confidence in estimates of the role of specific macronutrients on health outcomes.

The site is currently under maintenance and will be back shortly. New comments have been disabled during this time, please check back soon.