May 01 2014
I always find it fascinating to read an opinion piece that, from my perspective, is entirely wrong. In general I like to confront views that differ from my own; it is a great opportunity to probe and understand your own position better. I also find it fascinating to dissect the process that could lead someone to a demonstrably wrong position. Are they just misinformed, is their logic flawed, or are they overwhelmed by bias and ideology?
Usually it is the result of all three of these things in a self-reinforcing echochamber, an ideologically pleasing narrative propped up by confirmation bias.
A number of people have sent me links to this opinion piece, and other articles about Dr. Terry Wahls, who claims to have cured her own multiple sclerosis (MS) with diet alone. She advocates a paleo-style diet to cure whatever ails you. The evidence for this claim – zippo.
The article in the Daily Beast, however, finds the story an indictment of the entire medical system. The author, Daniela Drake, is an internist, but by judging from her other articles she seems to have a clear “alternative” ideology. She writes:
But with a focus on managing—not curing—chronic disease, many thoughtful physicians know that chronically ill patients don’t get better—they get medicated.
This is cookie-cutter alternative medicine propaganda. The focus of medicine is always to discover any treatable underlying cause, and then to treat such causes. If there is a bacterial infection, then we give antibiotics. If there is an anatomical problem, it may be fixable surgically. If there is a toxic exposure, we eliminate the exposure to the toxin and help the body rid itself of what it was already exposed to. If there is a nutritional insufficiency or deficiency, we supplement.
Many diseases, however, do not lend themselves to a cure. This is not because doctors don’t look for curable causes or aren’t “focused” on a cure – it’s because we don’t currently have the knowledge or technology to effect a cure. This is not a criticism, it is the reality of the current state of our medical knowledge.
Alternative practitioners, however, make it seem like it is a flaw in the system, suggesting that they have the answer. This is pure nonsense.
This alternative meme also denigrates chronic management of illness. Right now we cannot cure type I diabetics, but we can manage their lack of insulin to improve their quality of life, functionality, and survival.
I cannot cure migraines. No one can. But I can manage them effectively. I first review with patients lifestyle changes, including dietary changes, sleep hygiene, exercise, and avoidance of triggers. Occasionally this is enough, but usually (at least in my headache specialty clinic) it isn’t. I also check for nutrient levels that can affect migraines, and supplement as necessary. I rule out underlying causes that can be treated or cured (about 2% will have a secondary cause). For those who need it, I then develop a plan for medical management to both prevent migraines and stop them when they occur.
Compare this to the silly caricature painted by Dr. Drake. She creates a false dichotomy between curing and managing patients, and another between medication and improved health. Sometimes medications are curative. That, however, does not appear to fit her ideology.
Next up is the downplaying of the effectiveness of medical therapy:
Indeed, by conventional standards, Dr. Wahls received great medical care. She had sympathetic doctors who prescribed cutting-edge drugs. Those drugs cost around $5,000 a week but are only marginally effective. “Studies show these medicines reduce acute relapses, but they don’t affect time-to-wheelchair,” Dr. Wahls told me. “And some medicines can have very serious side effects.
The claim that current MS treatments do not slow disability progression is flat out wrong. Coming from one doctor quoting another doctor, it represents outright incompetence in medical reporting.
We now have many drugs in MS that are considered disease modifying. There are several ways to follow MS activity to see if a drug is helping. We can count the number of relapses, their severity, the number of lesions on MRI scan, disability through a standard rating (EDSS is the most common), and others. In relapsing forms of MS (which is clearly what Dr. Wahls is referring to since she mentions relapses) treatment absolutely slows progression of disability.
In one study, getting consistent disease modifying treatment reduced disability progression by 45% over those getting little or no treatment. Tysabri in particular is very effective, in one study stabilizing disability over five years. A systematic review showed:
As far as efficacy is concerned, the results showed statistically significant evidence in favour of NTZ for all the primary outcomes and for the secondary ones where data was available. NTZ reduced the risk of experiencing at least one new exacerbation at 2 years by about 40% and of experiencing progression at 2 years by about 25% as compared to a control group.
Treatment literally decreases time to wheelchair, in direct contradiction to Dr. Whal’s claims. That doesn’t fit her narrative, however. Her story is that diet is everything. Drake reports:
Soon she realized something that seems patently obvious in retrospect. “All disease begins on a cellular level,” she says. “When cells are starved of building blocks they need—disease begins.”’
Beware of any sentence that begins with “all disease.” Nutrition is but one potential cause of illness, consuming too much or too little of certain nutrients. It is absurd, however, to claim that it is the root cause of most or all disease. Drake continues to quote Wahls:
“We’re not telling patients the truth—that medicines won’t make you well,” Dr. Wahls says. Patients with multiple medical problems who have found themselves standing in the kitchen choking down pill after pill probably have an idea of what she is taking about. “Life is self-correcting chemistry,” says Dr. Wahls. “If we fix the nutrition, this is the real way to address the root cause of most disease.”
Medications serve a variety of functions in medicine, as I discuss above, so this is, again, not consistent with reality. The last sentence begs the question – for most people, even people with chronic illness, is their nutrition broken? Some diseases are dominantly lifestyle diseases, like Type II diabetes. For such diseases the management is also dominantly lifestyle.
But for many diseases there are non-nutritional causes, not matter how far down you dig. There are genetic, toxic, traumatic, degenerative, infectious, neoplastic, and immune mediated diseases without any significant connection to nutrition.
The myth of nutrition gurus, however, is that – if only you were properly fed, you would be a superhuman, immune to all disease, with a flawless immune system and limitless energy. This is fantasy, not reality.
Dr’s Drake and Wahls paint a picture of reality that is at drastic odds with the evidence. It seems clear that their ideology comes first. They downplay the effectiveness of current medical treatment, emphasize the side effects, and elevate nutrition to a magical stature that is not based on a lick of published evidence.
If you could really cure MS with diet alone, it would be easy to demonstrate this in a clinical trial. Drake and Wahls know this, so they have to also endorse (even if just implied) crazy conspiracy theories about Big Pharma, the medical system, and greedy or just pathologically incurious doctors.
They act as if they (and those who agree with them) are the only ones who actually care about their patients and want to help them. It’s an insulting and self-serving narrative that seems designed to sell books, and provide a convenient excuse for the complete lack of evidence to back up their ideology.
In reality, it is a very cynical and uncaring world view. If you truly care about your patients you will want to engage in due diligence, to make sure that your advice is the best you can give, rather than substituting your personal philosophy for careful evidence.
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