What will happen in Medicine in 2019

What will happen in medicine in 2019?

I believe this is a time of great change, where the cost of many treatments will be beyond the reach of both patients and governments, and a lot more "back to basics" therapies, which are probably just as effective, will return.

Cancer – our understanding of cancer, and the enormous expenditure on finding specific treatments for specific forms of cancer have lead to an explosion of new drugs. These are incredibly successful compared to previous therapies, but how are we going to pay for them? Supplements and herbs such as turmeric, garlic, mistletoe, and others are becoming accepted by oncologists, and I believe that the ketogenic diet which starves the cancer cells of sugars will become 1st line treatment.

Heart disease – over recent years there has been an explosion of angioplasty and stents for all forms of angina, but many studies have shown that only in cases of unstable or uncontrolled angina are these any better than medical treatment. Many predict that the number of stents being inserted will drop dramatically. High doses of fish oils (greater than 2 to 3 g a day) have been proven to be beneficial, as well as regular gentle exercise, and Coenzyme Q10. Interestingly around the world the incidence of heart attacks appears to be dropping.

Diabetes – drug treatments and diets have all been unsuccessful in reducing the incidence of the horrible side-effects of this disease. The ketogenic diet with or without intermittent fasting can virtually cure type 2 diabetes, and with great care can also be helpful in type I. (I'm writing a booklet on this which will be available in the next few months).   Gastric bypass surgery will also become more available.

Alzheimer's disease – the incidence of this continues to rise, and we really don't know why. The ketotic diet, or taking ketone supplements does seem to improve the symptoms, and some have suggested that intermittent fasting might help clear the nerve cells of the buildup of amyloid tissue which seems to cause the condition.

With drugs are becoming increasingly expensive, health professionals are beginning to look back towards the benefits of lifestyle, diet and supplemental treatment, leaving the introducing drug treatment as late as possible.

Omega-3 fish oils reduce heart disease, vitamin D and fish oils do not seem to affect cancer.

At the recent American Heart Association and Congress of Cardiology, two very important studies were presented. The first (VITAL) trial followed 26,000 people over five years, some had vitamin D, some had fish oils (1 g daily), some have both and some have none. They looked at the incidence of cancer, and also cardiovascular events which they described as heart attacks, strokes and heart deaths. The conclusion was that there was no significant benefit from either vitamin D or fish oils, however, when they looked at just heart disease (and removed stroke) there was a 30% reduction in heart attack and heart deaths. (Because this was not prespecified, and was called a subgroup analysis, people are saying this is a negative trial!)

At the same meeting, the REDUCIT trial was published, with 3 g of fish oils taken daily, and in the study there was a 25% reduction in heart attack, cardiac events and death. This was incredibly significant (p<00000005), even more so because many of these people were already on full medical management including statin drugs.

It is amazing how the profession does its best to ignore complementary treatments, but I don't think there is any doubt now that omega-3 fish oils, provided it is quality oil (mercury free and pure) and taken an adequate doses does make an enormous difference to people with heart disease, or more importantly people at risk of heart disease. It is such an easy and innocuous preventive treatment, particularly when compared with most of the drugs we have available.
I believe that everybody at risk of heart disease or with disease should be taking 3 g of omega-3 fish oils per day.

Fish oil supplements are fantastic for heart disease!

Fish oil supplements are fantastic for heart disease!

Recent publications have suggested that fish oil supplements in low doses make little difference to heart disease, and people have been advised not to take them. Note I discussed this in my blog three sections down.

However, this has been turned upside down in a recent huge study called the REDUCE-IT trial used 4 g of fish oils daily, in a double-blind randomised trial involving 8179 patients followed over 4.9 years. The results were incredible. All cardiovascular events (death, non-fatal heart attack, non-fatal stroke, need for angioplasty or bypass surgery or unstable angina with all reduced over 25%.
This result is incredible and better than anything claimed by the statin drugs.
It obviously shows that omega-3 fish oils are extremely effective in people at risk of heart disease, but you need to take enough, and it does need to be a quality product.
A smaller study performed in Japan (JELIS trial) using a slightly lower dose of 1.8 g daily achieved in 19% benefit.

So fish oils are very beneficial to people at risk who want to avoid heart disease, or who already have it., But you need to take enough, and I would personally recommend 2 g twice a day of a quality product. There are no significant side-effects, and we have no medicines that can compete with these results.

Dairy is good for us

Dairy consumption coming out of the closet!

For many years Heart Foundations and Associations have been strongly recommending their patients eat a low fat diet, and the current American Heart Association recommends "fat-free and low-fat dairy products as part of healthy eating pattern".

A recent study published in the September 11 online Lancet medical journal has thrown considerable doubt on this. The PURE study looked at over 136,000 adults in 21 countries (both rural and urban) and followed them for nine years, showed that those who ate two or more servings of whole fat dairy products per day at a lower rate of cardiovascular disease, mortality and total mortality than those who did not. The incidence of stroke was also halved in those individuals who consumed dairy products.
Previous studies have also demonstrated the positive benefits of dairy products, most have been conducted in North America and Europe, and this study coordinated from Canada has suggested that we should be taking a very different approach to dairy products, and probably saturated fats.
There is quite a strong emphasis around the world to reduce sugar intake which is leading to the epidemic of obesity, and the only way to do this is to replace the sugar with fats. The study confirms that doing so is highly unlikely to do anything other than good!
It also means that diets such as the Paleo and ketogenic diet are a great deal safer and in fact more beneficial than the conventional authorities have recommended in the past.

I suspect in the not too distant future the guidelines on fat intake will be making a significant U-turn.

Should we be taking aspirin

Should we be taking aspirin?

Even though doctors have been recommending patients to take aspirin for many decades, there is still considerable uncertainty on whether we should be making this recommendation, and if so to whom, and what dose?

A recent study suggested that perhaps when people were larger they needed more aspirin, rather than the conventional dose of 100 mg. Two large papers coming from Europe (one involving more than 15,000, and the other more than 12 a half thousand people) have fortunately clarified the situation and confirmed that 100 mg is fine. (More greatly increases the risk of stomach bleeding, with little or no benefit). Large and small people should all take the same dose (100mg).

Primary prevention – people with no evidence of heart disease, we don't have enough evidence to suggest that this is beneficial, and the risk of stomach bleeding is far greater than any possible benefit. Sadly the studies do not confirm that aspirin has any benefit in preventing cancer. Conclusion - don't take aspirin as a preventative.

Those at higher risk – i.e. people with diabetes or family history, again we don't have enough evidence to suggest that this is necessary or beneficial.

People with established heart disease – the data suggests that taking aspirin does reduce the risk of further heart events by about 12%, and I don't think is any doubt that unless there is some contraindication, people who have angina or a heart attack, had angioplasty or bypass surgery should be taking 100 mg of aspirin.  There is a slight increase in the risk of bleeding (usually from the stomach of between 0.5 and 0.9%)

Should I throw away my fish oil supplements?

Should I throw away my fish oil supplements?
Not yet, not if you are taking the right dose or the right brand!

Three recent studies have thrown doubt among the population on the benefits of fish oils, despite many years of evidence from populations on the benefits from cardiovascular disease, rhythm problems and strokes. I have reviewed these below, but in summary, they have all used a low dose of fish oils, and the quality of the fish oils used is almost certainly suspect. Two trials did show a slight improvement in heart attacks and rhythm problems, and suggested that perhaps if a higher dose had been used the results may have been different.

The take-home message is yes use fish oils, they can do absolutely no harm, and if given in sufficient doses using a quality supplement, could make a major difference in heart attacks, strokes and rhythm problems.

Is today's world affecting pacemakers and defibrillators? Electric cars.

More and more people are having pacemakers inserted, and a large number of internal defibrillators are being used in patients with serious heart disease. These can be affected by magnetic fields, in fact, when the pacemakers are checked different magnetic signals are used to interrogate (find out previous rhythms) and also program these very complicated electronic machines. It is potentially possible for strong magnetic fields either to turn off the pacemakers or defibrillators temporarily or possibly even reprogram them.
I've discussed this a little more on my website (click here) .
Metal detectors at airports can make a temporary change in pacemaker function, and people with pacemakers should be encouraged to walk relatively rapidly through these. Also asked the man or lady with the wand detector to move the wand past the pacemaker area fairly quickly.

One recent real concern, however, has been electric cars which are becoming increasingly common, and with the electronic fields created by charging, and also the magnetic component of the motor and possibly batteries – could this affect pacemakers? In a recent study reassuringly the modern electric vehicles appeared to make no difference to either pacemakers or implantable defibrillators. The magnetic fields are highest when the cars are being charged, so it is probably best not to sit in the front seat of the car or near the batteries while the car is being charged. The message, however,
is very reassuring. Whether this will apply to the new super-sized electric cars or extremely rapid charging we do not know, but at the moment they appear to be to be very safe.

But  doctor, can't I have just 1 cigarette per day?

Almost everybody realises these days that cigarette smoking increases the risk of heart disease, stroke and cancer, and do their best to stop. Nicotine is probably one of the most addictive of all substances in some people, and many find it almost impossible to stop, and cut down to one or 2 cigarettes per day, in the belief that this dramatically reduces the risk. If you smoke 20 cigarettes a day and cut down to one, the assumption is that you reduce your risk 20 times.

Unfortunately a recent paper in the British Medical Journal is bad news for these people. They reviewed over 200 studies between 1946 and 2015, involving over 3 million men and 2 1/2 million women, and looked at the risk of having a heart attack or stroke if they smoke 20 cigarettes a day, or just one.
In men compared to non-smokers, the risk of having a heart attack was increased by 150% with one cigarette, and 200% with 20.  In women it was 220% and 390%.

So it appears that much of the damage is done by just one single cigarette, and complete abstinence is the only answer if we want to reduce the risk of heart attacks.
The incidence of stroke is similar.

To quote the paper: "smokers who cut down the number of cigarettes believe they can benefit from large reductions in the risk of cancer and cardiovascular disease. The study shows clearly that there is no safe level of smoking for cardiovascular disease, and light smokers cannot assume that continuing to smoke does not lead to harm. Smokers need to quit completely rather than cut down."

Bariatric surgery – why aren't we doing more of this?

In the Western world obesity is an enormous problem, which we are tending to ignore - quite literally
the elephant in the room. Thousands of books and magazines discuss different diets to lose weight, almost all of them provide short-term but no long-term benefit. The fact that there are so many diets confirms that none are successful.
There is no debate that the major cause of this as we are eating far too much sugar, and medical advice in the past to not eat fat makes the profession equally as guilty as their patients. We are talking about taxing sugar, soft drinks, making them R16 etc. and while this may well make a difference in the long term, there are tens if not hundreds of thousands of people who are moderate to morbidly obese who have been left in limbo. If diets don't work, how can they possibly lose weight?
The medical profession and many others look at them and say "it's their fault"  they eat too much and don't do enough exercise. But losing weight and keeping it off is extraordinarily difficult. At the same time people with severe obesity developed diabetes, hypertension both of which lead to heart attacks, heart failure, strokes and possibly cancer. The cost of both the medicines to treat these diseases long-term is significant, and is a great deal more expensive than one single operation!

2 recent studies in the Journal of the American medical Association show just how effective bariatric surgery is.
In one study 932 people had an operation and the 956 were treated medically with intensive dieting advice, followed for 6.5 years.   High blood pressure was "cured" in 32% of the surgical compared to 12% the medical group. Only 2% of the surgical group developed high blood pressure over 5 years while 12% of the medical group did.
Diabetes was "cured" in 57.5% compared to 14.8% of those treated optimally medically, and only 0.3% developed diabetes compared to 7.5%.
In the second study looking at diabetes, of the 40 patients having gastric bypass, at 5 years 55% had their diabetes controlled against 14% of the intensive medical group.   They did however, not surprisingly, have more gastric surgical complications (66 vs 38 events).   So the surgery should only be done by skilled gastric surgeons.

50% reduction in diabetes and 32% reduction of high blood pressure - These benefits are huge, and will represent an enormous difference in medical costs over the years, save many lives, and reduce the misery of these patients.
Surprisingly compared to other studies there is an increased incidence of depression (8.9 compared to 6.5 in the medical group) on those who had the operation.

I believe bariatric surgery should be available to many more people, it will save lives, improve quality of life and saved medical expenses far outweighing the cost of the operation. Obviously people who have the operation should be followed up carefully, and any psychological problems discussed. I have a suspicion that many people after the operation are discharged as "cured".
It's also extremely likely that the bypass will affect the absorption of some nutrients, particularly vitamins and minerals, and these patients should be given good multivitamins and multi minerals, fish oils and probably calcium and magnesium on a regular basis. They also need to have their vitamin B12 checked, as the intrinsic factor created in the stomach is essential to absorb B12, and they may require B12 injections.

Hopefully in the future when we can cut down on the sugar this will no longer be a problem, but I think we do need to be holding out a helping hand to the current generation of obese people that the medical profession and food manufacturers have created.

Supplements and Cancer

Supplements which can help cancer.

I was recently asked by a patient's specialist to justify the supplements I suggested he could take to help in his fight against cancer.
I thought I might place the answer here on my blog as well:

In response to your doctor's letter re the value of supplements and cancer:

It is important to remind people, especially the medical profession, of reality. Requesting "need to justify this advice with clear evidence from medical literature for the use and the client scenario", suggests that "conventional medical treatment" has passed through the same rigorous process, whereas we know this is not true. For example in writing an editorial in the British medical Journal, Dr Richard Smith the editor states "only about 15% of medical interventions are supported by solid scientific evidence….This is because only 1% of the articles in medical journals are scientifically sound and partly because many treatments have not been assessed at all." (British Medical Journal, 1991:303:798) The vast majority of papers written to support the value of drugs are either initiated by, sponsored by or paid for by the pharmaceutical industry manufacturing the drug, and in many cases the articles are ghostwritten by the pharmaceutical industry. Fortunately these days the situation is improving as people are realising just what has happened in the past. As far as the newer anti-cancer treatments are concerned, and to some extent the older ones, the pharmaceutical industry is deeply involved in the studies and reports.

It has been quoted that to do a study that would be acceptable, costs about $2 million dollars, making it extremely unlikely that most nonpharmaceutical therapies will ever have "acceptable" scientific evidence, no matter how effective they are.

So accepting that the scientific evidence behind many drug treatments is poor, and the same can be said for complimentary therapies, the logical answer is to use what appears to be scientifically and logically the best therapies for the individual patient.

Having said that, I would like to justify my recommendations for additional treatment for your patient:

I believe that he should be being treated with what is potentially beneficial, should do little harm, and would not interfere with current medical therapy.

Optimal nutrition – Undergoing chemotherapy is an arduous time, and I don't think anybody would restrict the food intake of a cancer patient, with the possible exception of high levels of sugars. Unfortunately chemotherapy does blunt the appetite, may possibly affect absorption, and certainly makes it more difficult to receive all that the body requires. Many physicians suggest the patient should graze rather than have 3 large meals per day. It thus seems logical to add a quality multivitamin and multi mineral supplement to provide complete nutrition.

In addition to the chemotherapy and radiotherapy, the body's immune system is a major if not the major component in suppressing and hopefully killing the cancer. To optimise its function the immune system needs optimal nutrition.

While it is possible to provide supplements individually, it does seem much more logical to take a single multivitamin and multi mineral tablet.
Just to comment on a few of the contents of a multivitamin and multi mineral:

selenium – this has been shown to have anti-cancer effects in animals and also humans, and in the Arizona study (Journal of the American Medical Association 1996, December 24) of 1300 patients, half receiving supplementary selenium and half not, those taking selenium over 6 years have a 63% reduction in prostate cancer, and a 50% reduction in cancer deaths.. These deaths suggest that many of the patient's had cancer before they started selenium.

Multivitamins – In the women's health nurses study, women who took multivitamin tablets for more than 15 years reduce the risk of developing: a number of other cancers by between 50 and 70% (Annals of Internal Medicine 1998, October: 517)

Individual vitamins – while there is some cloud over vitamin A and beta-carotene in large doses, the B vitamins have many beneficial effects in patients receiving chemo. For example it is highly likely that B12 and folic acid would be beneficial in reducing the incidence or severity of peripheral neuropathy very common with chemotherapy, vitamin C is an antioxidant and given intravenously does seem to have anti-carcinogenic effects, but even orally in the production of collagen it is likely to be beneficial in strengthening the tissues and maybe even reducing spread.

Vitamin D has been postulated in many cases is having anti-cancer effects, (https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1470481/) unfortunately the amount of vitamin D allowed in tablets in this country are less than desirable, but nevertheless the amount of a good multivitamin tablet must have some beneficial effect.

Vitamin E is an antioxidant, provided it is not given in high doses which could potentially or theoretically affect chemotherapy, can reduce the side-effects of chemotherapy, as well as protecting the body from free radicals. Vitamin K has also been suggested as having anti-cancer effects .

As far as minerals concern, we have discussed the trace element selenium, but it is very likely that other minerals might also be beneficial in the routine amount found in a normal diet, which is what a multivitamin should be providing. Magnesium for example does relax smooth muscle, and can reduce cramps and possibly some of the other peripheral effects common in patients with chemotherapy and also cancer.

While it is possible for all of these to be achieved by taking the products individually, taking one or 2 good multi tablets a day does seem to be logical and practical.

Lycopene found in tomatoes this does appear to have a beneficial effect on prostate cancer, and the Harvard University study (Journal of the National Cancer Institute, 6th of March 2002, page 291) of 47,000 health professionals followed over 12 years those eating 4 to 7 servings of tomato sauce per week had 20% less prostate cancer, those having 10 servings per week had 45% less. This does suggest that lycopene has a beneficial effect upon the prostate, and it is likely to also be beneficial in the presence of cancer.
Lycopene is often taken with saw palmetto which is helpful for benign prostatic hypertrophy.  We do not know if it has and effect  on prostate cancer (but in animals it can increase the sensitivity of prostate cells to radiation.( https://www.mskcc.org/cancer-care/integrative-medicine/herbs/saw-palmetto)

Omega-3 fish oils are known to have numerous effects from the cardiovascular system through to the nervous system and are considered an essential oil. Eating a lot of fish will provide this, but usually provides a dose of mercury which in cancer patients would be undesirable. There is a small study in Sweden involving 11,000 men which showed a 2 to 3 fold increase in prostate cancer in those men who did not eat fish (Lancet 2001; 2 June: 1764) in addition it may also be beneficial in the peripheral nervous effect and other effects of chemotherapy.

Melatonin – this hormone is created in the pineal gland, and is very helpful for sleep, a problem often difficult in cancer patients. Apart from this beneficial effect, in the United States nurses study, those nurses who work night shifts (who are likely to have low doses of melatonin) for more than 30 years, had a 37% higher incidence of cancer, and in the review of 10 randomised trials (Journal of pioneer research, 2005, November, 39 (4): 360 to 6). Involving 643 patients, cancer patients given melatonin in high doses (10 to 40 mg at night, reduce the risk of death at 1 year by 34%.

Coenzyme Q 10 – one of the most debilitating symptoms of both cancer and particularly chemotherapy is the crashing fatigue which they develop. Coenzyme Q 10 which essentially carries the energy from the mitochondria in the cell to the nerves and myofibrils, may help with this. It certainly has been shown to improve energy in many other situations.

Turmeric or curcumin has been shown to have anticancer properties in animal studies some of them quite spectacular.  These are reviewed (http://www.cancerresearchuk.org/about-cancer/cancer-in-general/treatment/complementary-alternative-therapies/individual-therapies/turmeric) and although there are no blinded studies, many people (including oncologists) believe that this product is a useful adjuvant to chemotherapy and other cancer treatments.,

Milk Thistle this contains a number of compounds including Silymarin.   It has been shown to directly destroy prostate cancer cells and slow their growth, as well as increase the sensitivity of cancer cells to some forms of chemotherapy (http://www.cancerresearchuk.org/about-cancer/cancer-in-general/treatment/complementary-alternative-therapies/individual-therapies/milk-thistle-and-liver-cancer).

Frankincense – derived from boswellia tree has strong anti-inflammatory actions, and may possibly be beneficial in cancer, probably best put on the skin as aromatherapy.  Its uses are reviewed here (https://www.medicalnewstoday.com/articles/314366.php).

Low dose naltrexone – I am certainly no expert on this, but it is a very interesting development, and is being used by many of my colleagues. Naltrexone is used to assist patients coming off opioids and alcohol. This is usually at the dose of 50 mg and above. It works by blocking the opioid receptors. Low dose naltrexone (usually 0.5 to 1.5 mg taken at night blocks the receptors overnight. It is believed that this up regulates the receptor  sensitivity, and possibly even increases the number of receptors. During the day following this, the normal endorphans and similar hormones are thus potentially more active. This can reduce pain, and other symptoms without any obvious adverse effects. LDN is used in a number of situations including multiple sclerosis, lupus, inflammatory bowel disease, chronic fatigue syndrome , fibromyalgia, restless leg syndrome and depression. It has been suggested from animal studies  that it may also suppress tumour growth, although the mode of action has yet to be established. (Biochemical pharmacology 67, number 7 (April 2001: 7792786.)

While I would have no way suggest to Stephen that LDN is essential for his cancer, it might possibly reduce some side-effects symptoms.

As mentioned in my opening paragraph, the evidence for many therapies is not strong for the scientists, but in the situation where we are doing our best for our patients, logical therapies combined with Hippocrates "1st do no harm" philosophy is what most doctors try and practice.

In Stephen's case he has not been well served by the profession, he is very likely to get side-effects from both the cancer and the chemotherapy, and the above supplemental recommendations potentially may help him, but given in physiological doses, will do him no harm.

I would like to stress again that we need to be supporting our bodies a great deal more than we currently do.   Our immune system and body's defences have been ignored in much of our current medical therapies.

Dr Gerald's Website

Visits in the last week

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