Pill Popping as Primary Prevention - The common practice finally comes under fire

If we could redirect nearly $3 Billion in Canada and nearly $30 Billion in the US in wasted health care costs to something useful would that not be logical?  Basically that is the conclusion of several publications and editorials released this week on the impact of purchasing vitamin products that have no proven value.

Duel winning Nobel prize winner Linus Pauling popularized the concept of pill popping Vitamin C, multivitamins and other dietary supplements starting in the mid – 1960’s.  The supplement industry has evaded drug regulatory approval and oversight, actively resisted attempts at Canadian regulation even with provisions for grandfathering, and self-promoted to the point that the majority of North Americans consume at least one supplement, with the industry still enjoying healthy business growth.

So the release of the studies is met with fanfare and reasonably expected skepticism from those addicted to what are mostly glorified placebos. Over half of the adult population regularly takes one of the products that the studies have demonstrated as ineffective.  

Pauling was sometimes referred to as the father of quackery.  Charlatan approaches to extracting money from those suffering where time was the essential curative agent.  As time allows body healing, some therapies become perceived as the reason and then easily promoted.  Vitamin C being touted as the cure for a common cold which will run its natural course in a few days.  And, as most vitamins and dietary supplements have minimal effects -  there are few side effects that warrant hesitancy. 

Dietary supplements are not going to disappear quickly, but perhaps now health professionals can make informed and appropriate guidance on the limited value, leaving recommendations where proven efficacy has been demonstrated such as during pregnancy. Many colleagues have recommended vitamins and other supplements knowing that the value was not dissimilar to that of a placebo but wanting to appear that they are "doing something good" for their patient/client/consumer. 

The whole industry of non-traditional health services including naturopathy, homeopathy and a host of others will most likely continue to promote and advocate for expanded use of such therapies in the wake of the same “science” that has not demonstrated their value and attracts a clientele wishing to rebel against what has become known as traditional medicine.

Popping pills was first a way of treating illness and then a lifetime investment in preventing existing illness from getting worse.  These studies challenge the thought that pill popping is a way of preventing disease.  CTV coverage is enhanced if you take the time to read the comments, many of which speak to individuals justifying that they are special or different and hence rationalize continuation of current practice despite the mounting evidence.  

There are better things like taking a walk in the park.  

Antibiotic soaps are getting a cleansing. Are they a victim? or the cause?

Those working in the field of antibiotic resistance have often aimed, and perhaps misdirected, their control efforts at use of antibiotics in the livestock industry and in handwashing.  The issues of general antimicrobial and superbugs have been touched on previously  Superbugs and Canadian response, Political expression of superbugs  plus mentioned many other times, and antimicrobial use in livestock industry at     AMR and livestock,  

Thus the Food and Drug Administration focus on antimicrobials in customer products is a refreshing look at an old problem.  As typical in health, the previous concerns have related to the negative impacts of such products.  The FDA focus introduces the question of whether such claims on protecting health are valid.

 

A nice FDA overview document not only lays out the evidence, regulatory action and recommendations, but links to key science analysis of the main product, triclosan which was undertaken by the EPA.  Such cross government collaborations are uncommon and speak to better regulatory practices in the US as well.   It is notable that the triclosan review was undertaken in 2008 and the FDA review was promised for the winter of 2012, so only five years in the making for a policy direction. 

Triclosan is unrelated to other human antibiotics, hence its role in facilitating antimicrobial resistant organisms in general has been challenging to extract.  The novel FDA asks the more fundamental question, is there evidence that triclosan containing products can care any health claim on preventing illness?   Handwashing is predominately a mechanical scrubbing process for cleansing.  Disinfectants like iodine, chloride and alcohol used in clean settings like operating rooms have proven beneficial in reducing contamination.  Hence the use of antibiotics in handwashing soaps was an extension of infection control practices.

Hence the proposed FDA rule does not negate addition of triclosan like products, but does limit health claims about using the word “antibiotic” in labelling as the public perceive such labels as being more protective.     A variety of other products have used antibiotic claims including toilet seats, however the proposed rule only addressing body applied products such as soaps and washes. There are numerous other agents other then triclosan which will be subject to scrutiny concurrently, but the public focus has and will be on the triclosan-like products.   The rule is now out for a 180 day comment period.

For those intrigued, a careful read of the proposed rule will raise a few eyebrows.  Well written from a regulatory perspective, its conclusions are based on shaky evidence and dismissal of the bulk of existing research as methodologically unsound.  Such comments should raise concerns from an industry that might just be interested in protecting its current practices, and who may be justifiable concerns at the potential implications of the ruling.  Given most mild illnesses are viral in nature, antibiotics are of no value compared with certain disinfectants.  Scientific studies where the outcome of interest is a only small contributor to the general outcomes of interest are methodologically very difficult. 

Given the limited value, it is likely a good thing to eliminate an unnecessary chemical exposure. However society works on a different principle, that of generally safe, it means demonstrating true harm is being caused by products rather than proving value.  The FDA is taking a bold step to question the generally safe current status. 

Two closing comments

1.        It requires at least twice as much evidence to take something out of common practice in comparison to what we accept before putting something into practice.

2.       Antimicrobial resistance (AMR) is driven predominately by prescribing of antibiotics for human illnesses.  Addressing minor issues like triclosan containing products or growth promotion use will do very little to alleviate AMR problems and more likely as this case shows, focuses attention away from the prime concern. 

Oil and Gas - the untold story of community left behind

To conclude the series on oil and gas, we asked a dedicated social media enthusiast colleague to reflect on the consequences of the boom and bust cycles on communities that have given up their healthy predominately males to support the boom. Follow her on Twitter with her over 1500 other followers at @Monika_Dutt

As a Medical Officer of Health (MOH), I work to approach issues surrounding resource development from an evidence-based perspective, weighing risks and benefits, and adding my voice to discussions as warranted. This may mean a range of activities including participation through the Environmental Assessment process, responding to concerned citizens, attending community meetings, or discussions and planning with local councilors and other partners.

As someone who is now, and has been in the past, an MOH in post-industrial communities, I’m also acutely aware of the toll industry can take on communities. As a Deputy MOH in northern Saskatchewan, I walked through the eerie setting of Uranium City, the town that once housed about five thousand people who were centred on uranium mining. When the mines closed in 1982, the town collapsed economically, and most residents left. Now what are left are crumbling houses, many with appliances still visible, the Candu High School with writing on its chalkboards, and a desolate skating rink. About two hundred people still live in the community.

I came to Cape Breton in 2012, where I witnessed the end of another environmental health saga. The waste that was contained in the Sydney Tar Ponds from coke ovens was globally infamous. In September 2013, a stunning park opened on the site, marking the culmination of years of controversy, work, and financial investment.

The closing of the steel factory on that site, as well as the closing of coal mines across Cape Breton Island, has left both a strong sense of history, as well as wide social and economic gaps that the residents of the island are struggling to rebuild from. Many have felt compelled to leave the island to participate in another boom economy, that of the oil sands in Alberta. Strident efforts are being made to reinvent the local economy, but that process takes time.

Although anecdotally most Cape Bretoners can name friends and relatives working out west, there is little sense of the number of migrant workers or the health impacts this phenomenon is having on the island. One researcher at Cape Breton University, Dr. Doug Lionais, has completed qualitative studies assessing the health impacts on the workers, usually men, and their partners, usually women. Many partners described a sense of hopelessness, as having no other alternatives for income, and as connecting emotional and physical ailments with their situations. Many workers described liking their jobs, but resenting the living conditions, and described having to shut parts of themselves down when going to work.

Further research is underway to gain a better sense of individual and community health impacts of having workers in Alberta while having a partner and/or family in Cape Breton. It seems the impacts are significant, and it is difficult to determine whether the benefits outweigh the costs.

Greater understanding of the health impacts of boom economies, both in the immediate area of the resource development, as well as more distant areas they might impact, are necessary in order to truly make decisions about whether to proceed with resource development. In line with this imperative, Dr. Eilish Cleary, the Chief Medical Officer of Health of New Brunswick, completed a health impact assessment in September 2012 on shale gas development in that province. In it she provided recommendations in these areas:

1. Protection of Health and Community Wellbeing Related to Changes in the Social Environment
2. Protection of Health Related to Changes in Both the Social and Physical Environments
3. Protection of Health Related to Changes in the Physical Environment
4. Protection of Future Generations
5. Implementation and Oversight

This type of assessment is essential, in particular with significant resource development projects. The implications of the projects can be great in the present and the future and need to be factored into risk/benefit. The benefits that resource development brought to Cape Breton, and the downfall that its ending created, are a lesson, the ramifications of which are still being explored and experienced. The lessons connected to resource development continue here, given the presence of the Alberta oil sands and the understandable lure for Atlantic Canadians seeking work.

The cost of eating healthy.

It is a story that has gotten considerable traction.   Eating healthy costs a whole bunch more than unhealthy.  Perhaps it is just conclusion that most of us already knew that attracts attention. That the media have picked up on the story is a strong reflection of social conscious and attention to items that determine health.   The most blatant finding is that somebody went and proved the obvious.  

Or did they?

The stories ranged from lowers costs ranging from $550-$2000 per year.   When discrepancies occur, and perhaps an underlying theme of this blog site, dive for the original article – in this case accessible at BMJ Open.

A meta-analysis of over two dozen studies covering ten countries.  Most of the studies were market value studies looking at shopping list comparisons.   In essence it was a comparison of what additional costs were required to meet a specific “healthy” diet.  Items compared included chicken that was de-skinned versus skin-on.  Healthier snack options such as whole grain or unsaturated fat choices.  Hence the question was not whether one could eat healthy or not, but to choose a healthier option between two items tended to cost more.   

There were broader studies that compared two types of diets such the Mediterranean diet compared to “typical” Western diet.  The study strength was specifically self identified as comparing costs per food group rather than diet patterns in total.

There were marked differences when looking at cost per service, cost per calorie or when looking at specific nutrient components such as fat content. The authors also acknowledge that there is considerable variability amongst the studies. Notable is that if the issue is obtaining calories, cost for a less “nutritious” meal is lower per calorie. 

The study is to be commended for tackling the question of cost of eating well. For someone who is challenged with obtaining sufficient calories, the study likely confirms that they are making the right choice in less nutritious options in favour of calorie-dense foods.   For those with sufficient resources to making choices, there is a cost. 

The average Canadian currently spends about $215 per person per month on food eaten in the home (and yes at $275 each, teenage boys outeat the rest of us – no surprise there) .  Budget experts flag that currently we spend almost an equivalent amount per person per month on eating out.   Suggesting that there may be an easier way for those wanting to choose a healthier diet.

Kudos to the Harvard group for addressing the issue of the cost of food.  The details on linking purchasing behaviour with diet would appear to be far more complex.  

Pesticides for cosmetic purposes – do bans make things better or not?

For some of Canada a ban on cosmetic pesticides has been integral to normal operations for over two decades since the town of Hudson Quebec passed its bylaw in 1991.  The by-law has been subjected to Supreme court decision in 2001 affirming that there is both the authority and value in such action.  

Despite adoption of pesticide bans in both provinces of Ontario and Quebec (Nova Scotia and New Brunswick have bans on a single pesticide product), and over 150 other municipalities in the country, the value of such actions remains hotly debated within the public health community. 

Hence a review by the National Collaborating Centre on Environmental Health of the public health value of cosmetic bans is a welcomed contribution.  The review appears to have been requested by the Chief Medical Health Officer in BC, a province with a recent history of local community fights and what appears to be split opinions amongst public health practitioners. 

The detail of the potential benefits of harms and the extent of the review make the material seminal in terms of currency and well worth a read for any community with a current ban or exploring any restrictions. 

While acknowledging the challenge in quantifying the benefit, the statement expresses appreciation for some of the value in an environment of some uncertainty.  

•        The impact on population health of exposure to pesticides used specifically for cosmetic purposes is difficult to quantify.

·         There is poor quality of evidence pertaining to the direct health impacts associated with exposure of residents to pesticides used for cosmetic purposes.

·         Acute and long-term toxicity has been demonstrated for many of the common pesticides used for cosmetic purposes, acutely in documented poisonings, and long-term, typically in studies of experimental animals, applicators or farm families exposed at levels well above those associated with cosmetic applications.

·         Relative exposure to the active ingredients of cosmetic pesticides used in lawns and gardens compared to exposure to the same agents used indoors, in agriculture and commercially, is not well characterized, but likely is small.

·         Possible harms resulting from a provincial ban of cosmetic pesticides may be the illegal use of toxic pesticides and musculoskeletal injuries among householders using manual methods to

remove weeds.

•        With regard to provincial public health actions, children are particularly vulnerable to exposure

and effects of toxins at all stages of development and would most likely benefit from measures to reduce exposures to pesticides from any source.

Credit to the NCCEH for having restraint in not issuing an opinion on the need for or against such limitations.  The full document can be accessed at the NCCEH website or directly at Cosmetic Pesticides

Fracking and public health risk

It seems the best work on public health impacts of fracking is being done in those areas where the fracking is not already occurring. First from New Brunswick and discussed at the most visited DrPHealth posting at  Fracking an obscene word . Now out of the UK comes an excellent review of the potential public health impacts and a solid contribution to our understanding.

Notable in its conclusions are that well managed and executed fracking is unlikely any risk to public health.  The threat is in the management of materials on the surface and the integrity of the well casing.  

Contamination of ground waters where it has happened appears secondary to poorly sealed wells or surface spills, putting the emphasis back to the development and operation of the fracking as the concern if any. 

What the document does well is break out in a health risk assessment approach to the relative potential threats, reviews existing evidence in areas such as air pollution, radon and other radioactive materials, water, wastewater, and chemical contamination.

Most public concerns seem to centre around water contamination.  The report details a review of 43 documented incidents of water contamination.  It also emphasizes that natural gas fracturing occurs at typically 1 km or more, whereas even the deepest ground water supplies do not approach this depth.    

The report provides excellent recommendations on further research needs.

Check it out at Fracking HP England

Preventing food allergies in Children: How little we know about an emerging public health crisis

Sorry for the gap in posting.   It is now December and perhaps the world will begin to turn more slowly.  Thanks for your patience.

Perhaps it is a sign of the times, but food allergies were rarely diagnosed in the past and while now likely overdiagnosed, the number of student with peanut, egg  and ‘milk’ allergies in school has become a challenge for schools grappling with having emergency procedures in place to manage anaphylaxis and classroom food policies.

In this changing milieu, a statement from the Canadian Pediatric Society is worth reviewing for its excellent review of the topic. 

Despite the increased interest in food allergies in children, and in anaphylaxis issues in students, the article provides no definitive conclusions beyond stating that delayed introduction has no benefit. Newer thinking is exploring whether early introduction can actually be preventive.  Even the value of breastfeeding is based on weak evidence and becomes questionable which will lead to horrific rebuttals from some biased professionals.  

 Two current studies in the United Kingdom LEAP and EAT (obviously somewhere somebody has a full time job developing catching acronyms for research studies) hope to provide further information on appropriate interventions.   

If there is a consistent message on food allergy prevention, it is “we really don’t know, but perhaps we will know more in the future”.   Read the full statement at CPS position on food allergy prevention

Regardless of the lack of evidence, the CPS in conjunction with Canadian Society of Allergy and Clinical Immunology produced a set of recommendations.  Note that the only recommendation which has better than Grade 2B evidence is on selection of formula where breastfeeding is not indicated.  2B is considered weak evidence generally of low quality methodologies.

·         Do not restrict maternal diet during pregnancy or lactation. There is no evidence that avoiding milk, egg, peanut or other potential allergens during pregnancy helps to prevent allergy, while the risks of maternal undernutrition and potential harm to the infant may be significant. (Evidence II-2B)

·         Breastfeed exclusively for the first six months of life. Whether breastfeeding prevents allergy as well as providing optimal infant nutrition and other manifest benefits is not known. The total duration of breastfeeding (at least six months) may be more protective than exclusive breastfeeding for six months. (Evidence II-2B)

·         Choose a hydrolyzed cow’s milk-based formula, if necessary. For mothers who cannot or choose not to breastfeed, there is limited evidence that hydrolyzed cow’s milk formula has a preventive effect against atopic dermatitis compared with intact cow’s milk formula. Extensively hydrolyzed casein formula is likely to be more effective than partially hydrolyzed whey formula in preventing atopic dermatitis. Amino acid-based formula has not been studied for allergy prevention, and there is no role for soy formula in allergy prevention. It is unclear whether any infant formula has a protective effect for allergic conditions other than atopic dermatitis. (Evidence IB)

·         Do not delay the introduction of any specific solid food beyond six months of age. Later introduction of peanut, fish or egg does not prevent, and may even increase, the risk of developing food allergy. (Evidence II-2B)

·         More research is needed on the early introduction of specific foods to prevent allergy. Inducing tolerance by introducing solid foods at four to six months of age is currently under investigation and cannot be recommended at this time. The benefits of this approach need to be confirmed in a rigorous prospective trial. (Evidence II-2B)

·         Current research on immunological responses appears to suggest that the regular ingestion of newly introduced foods (eg, several times per week and with a soft mashed consistency to prevent choking) is important to maintain tolerance. However, routine skin or specific IgE blood testing before a first ingestion is discouraged due to the high risk of potentially confusing false-positive results. (Evidence II-2B)