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Follow a natural health philosophy? Vaccination may have more in common with it than you think

October 19, 2021 6.11pm AEDT

Author

1. Jon Wardle Professor of Public Health, Southern Cross University

Disclosure statement

Jon Wardle received funding from the National Health and Medical Research Council for part of this work. He is Maurice Blackmore Chair of Naturopathic Medicine and Foundation Director of the National Centre for Naturopathic Medicine, which was established with a gift from the Blackmore Foundation. He is also co-convenor of the complementary medicine special interest group of the Public Health Association of Australia.

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The natural or “alternative” health community is often held up as being vaccine hesitant.

Yet, the relationship between the natural health community and vaccination is complex.

Stories such as the Adelaide naturopath recently disciplined for using a newspaper column to spread vaccine misinformation may make headlines.

But other stories like the director of Australia’s largest natural medicine society or even Nimbin’s herbal medicine columnist publicly advocating for COVID vaccination are more representative.

Get your news from people who know what they’re talking about.

Although the link between natural health beliefs and vaccine hesitancy gets a lot of public attention, there’s actually little evidence on the topic.

I led a 2016 review which found opposition to vaccination was a minority opinion among natural health practitioners and users. Opposition was more likely related to an individual’s personal beliefs than a default philosophical position associated with natural medicine.

Some have suggested natural health practitioners could even help support vaccination activities. This isn’t as far-fetched as it sounds. There are growing communities of natural medicine practitioners highlighting the alignment between vaccination and natural approaches to health.

One thing people often overlook is the adaptive immune response caused by vaccination is natural. Vaccination prepares the body’s immune system in the same way “natural” exposure to infection does. It just does it in a safer, controlled way with a much lower dose.

Given there’s no underlying reason why natural health and vaccination cannot coexist, why does this perception exist, and why does it persist?

Opposition to vaccines wasn’t always a given

One main reason for historical opposition to vaccination in natural health communities wasn’t due to the vaccine. It was because they rejected “germ theory” itself – the concept that unseen external pathogens like bacteria and viruses led to disease.

Early naturopathic pioneer Henry Lindlahr rejected vaccination in the early 1900s because “germs, bacteria and parasites are products of disease rather than its cause”. He argued “germs themselves cannot create disease – if they could, humanity would soon be extinct”. Also in the early 1900s, chiropractic founder Daniel Palmer rejected the notion there was any cause of disease beyond misalignment of the spine.

It’s important to view this historic opposition in context, given germ theory had only become mainstream in conventional medicine in the recent decades before these statements. Views of these natural health professions have similarly evolved.

Natural health communities sometimes raised “toxins” in vaccines as a concern. It’s important to remember, however, that vaccines up until the mid-1900s weren’t like the vaccines of today. First generation smallpox vaccines, for example, were crudely produced from calf lymph in a process considered cruel by animal rights groups, which were often closely linked with natural health movements.

Also, the natural health community didn’t reserve judgement for vaccines and pharmaceutical medicines. Natural health adherents saw other “drug systems”, such as herbal medicine and homeopathy, as equally invasive and unnatural. Although few would see these therapies as incompatible with natural health today, their adoption by naturopathic practitioners caused significant tensions in the budding “drugless” profession.

Just as vaccine hesitancy can be a proxy for deeper concerns about medicine and the state, conflict between the natural health community and medicine also came to influence vaccine views.

Opposition wasn’t always a given. One of Australia’s earliest Australian naturopathic journals blamed medicine for stealing vaccination from natural healers without credit.

Towards the second half of the 20th century, anti-vaccination statements increasingly began to target those vaccinating (usually medical doctors) as much as the vaccine. Eventually the oppositional stance of “alternative” health subsumed parts of the natural health community.

Due to their marginalisation by the medical community, parts of the natural health community started taking on positions that were more about opposing conventional medical practice than about aligning with natural health philosophies.

These underlying factors are similar to why so many people opposing COVID vaccines as unnatural put their faith in equally unnatural alternatives such as ivermectin today.

What are the natural alternatives to vaccination?

To put it bluntly, there aren’t any.

Homeopathic remedies are marketed by some practitioners as alternatives for childhood vaccinations. The most commonly promoted are those claiming to protect against infectious diseases such as malaria and even COVID. A 2011 survey found nearly one-quarter of Australians thought these “homeopathic vaccines” were an effective replacement for conventional vaccinations. Some have even unknowingly received homeopathic vaccinations thinking they’re conventional vaccinations.

Linking homeopathy and vaccination isn’t surprising. Both emerged during the same period in the 1790s and both focused on infectious diseases (vaccination for prevention of smallpox, homeopathy to address symptoms of malaria).

Homeopathy’s founder Samuel Hahnemann viewed vaccination not only as effective and powerful, but also as an extension of and validation of his own theories.

It might not surprise you homeopathic vaccination alternatives aren’t supported by the scientific community. But it may surprise you to know they’re not supported by the homeopathic community, either.

According to homeopaths, this is because the mechanism of action of “homeopathic vaccination” is wholly incompatible with homeopathic theory.

Homeopathic vaccines are neither homeopathic nor are they vaccines.

What about just increasing immunity ‘naturally’?

Some natural health practitioners have claimed their therapies can offer similar immunity as vaccines. However, these views are usually fringe and roundly rejected by their natural health practice and research peers.

What’s more, boosting for a bigger immune response isn’t necessarily better. Boost the wrong parts in favour of others, and a hyperactive immune system can make things worse in the short term, as well as the long term. Autoimmune disease (where an overactive immune system starts attacking the body) is thought to be one of the causes of “long COVID”.

In natural health we talk about the therapeutic hierarchy. This recommends using low level interventions which encourage self-healing processes to avoid more intrusive and invasive therapies where possible.

Vaccines – once properly tested and assessed for safety and efficacy – clearly fit this bill. They’re a minimal dose, preventive intervention that support and develop the body’s own healing resources to fight disease.

And they offer the opportunity to avoid the alternative of aggressive treatment and management of infection and associated symptoms later on.

Ultimately vaccination, like the use of natural therapies, is a matter of personal choice. But as someone passionate about both natural health and public health, it’s one I would highly recommend people take up.

If you’re hesitating to get vaccinated because you’re concerned it may not align with your preferences for a natural approach to health, there’s no need to be. Vaccines may have more in common with natural health approaches than differences.

Review Adv Exp Med Biol

• . 2020;1242:89-120. doi: 10.1007/978-3-030-38474-6_6.

Hormone Therapy in Menopause

John Paciuc  ¹ Affiliations

• PMID: 32406030
• DOI: 10.1007/978-3-030-38474-6_6

Abstract

As longevity expands, women are spending a third of their existence in menopause and beyond. The vast majority suffer from symptoms that negatively impact their quality of life. Systemic vasomotor symptoms (VMS) are the classic cluster affecting 80% of peri- and post-menopausal women. Once thought to be relatively brief, they sometimes persist more than 10 years. Compelling, yet enigmatic, is the recent finding that women with bothersome and long VMS compared with age-matched peers often have worst underlying preclinical markers of cardiovascular disease (CVD).Local vulvovaginal and urinary symptoms, now termed genitourinary syndrome of menopause (GSM), are seen in 50% of postmenopausal women, and it negatively impacts quality of life. Estrogen remains the most effective treatment for both VMS and GSM, for osteoporosis prevention, and for symptom relief as well as chronic disease prevention in women who experience premature menopause whether from primary ovarian insufficiency (POI) or iatrogenic etiologies. For women who have contraindications to estrogen therapy or who personally object, a panoply of nonhormonal modalities can be offered to treat both systemic and local menopausal symptoms. A historical review of estrogen studies reveals why its persona has vacillated from hero to villain (after the WHI) and back to hero. The “timing hypothesis” and its underlying mechanism shed light on the pleiotropic nature of estrogen. Finally reviewed is the compelling argument from notable thought-leaders that estrogen, in those without contraindications, should be considered for primary prevention of cardiovascular disease as well as the prevention of chronic disease.

What Scientists Are Learning About Estrogen and Exercise

Oestrogen is a hormone that just keeps well-being to women. Here is another study adding to the benefits of this remarkable hormone to women. Note: Menopausal women do not have any oestrogen, so do not share in these benefits. See the books” The good news about Oestrogen”by dr Uzzi Reiss, and “Öestrogen Matters “by Dr Avrum Bluming.

A study in mice raises intriguing questions about the ways that hormones influence the brain and motivate the body to move.

This article appeared in the New York Times recently.

By Gretchen ReynoldsOct. 20, 2021

Estrogen may change brain activity in ways that could affect how physically active we are, according to a remarkable new study in mice that looked at DNA, hormones and brain cells. Using advanced technology to pinpoint and reprogram specific genes and neurons in living animals, the study found that surges of estrogen jump-started processes in the mouse brain that prompted the animals — even males — to become more active.

The study, which was published recently in Nature, involved mice. While humans share many of the same relevant hormones, genes and neurons, we are not mice and cannot yet say whether our brains and physiological systems work the same way. But the findings may open intriguing avenues of inquiry into why women so often become inactive after menopause, when estrogen fades. The results also underscore how the brain and internal biological processes work together to play an unexpected and substantial role in whether the body gets up and moves or remains mostly still.

Moving and mating

For close to a century, since a famous 1924 study involving rats, scientists have known that female mammals tend to be most physically active just before they ovulate, when they are also most sexually receptive. This behavior makes evolutionary sense, since female animals presumably need to be on the hunt then for a mate. In the intervening decades, researchers began to speculate that estrogen must play a driving role in this behavior, with subsequent studies indicating that female lab animals’ daily skitterings typically would surge and wane in tandem with their estrogen levels.

But how could estrogen, which primarily controls ovulation and other aspects of reproduction, influence physical activity? That physiological puzzle recently drew the attention of Holly Ingraham, the Herzstein Endowed Professor of Physiology at the University of California, San Francisco, who has a longstanding research interest in women’s physiology and metabolism. She and her collaborators wondered if estrogen might somehow shape genetic activity in the brain, which would then activate brain cells in ways that could set in motion, well, motion itself.

To investigate that possibility, the scientists first gathered a crowd of healthy adult female mice and chemically blocked estrogen uptake in some of them, while tracking how much all of the animals moved. Almost immediately, the animals without estrogen became noticeably more sedentary than the other females, confirming that estrogen somehow affects physical activity.

Finding the movement cells

Next, the researchers examined the activity of a number of genes in the animals’ brains, noting that one, in particular, enthusiastically pumped out extra proteins when the animals’ brains were bathed in estrogen but became almost quiet when estrogen was absent. This gene, melanocortin-4, or Mc4r, previously had been linked in people to food intake and regulation of body weight. But the scientists now guessed it might also be the bridge between estrogen and the impulse to be physically active, an idea they substantiated by using high-tech genetic mapping techniques refined by one of the study’s authors, Jessica Tollkuhn, an assistant professor at Cold Spring Harbor Laboratory School of Biological Sciences in Cold Spring Harbor, N.Y.

These techniques showed, in real time, estrogen binding to Mc4r genes in certain neurons, especially those in a part of the mouse brain involved in energy expenditure. These brain cells also shared connections with other neurons elsewhere in the brain that control the speed at which animals move. Taken together, this experiment showed estrogen firing up a particular gene that turns on certain brain cells that then should be expected to nudge an animal to move.Sign up for the Well newsletter, for Times subscribers only.  Essential news on health, fitness and nutrition, from Tara Parker-Pope. Get it in your inbox.

But the scientists had not yet seen these genes and neurons in action, so, as a final aspect of the study, they used a sophisticated technique known as chemogenetics to directly galvanize the relevant neurons in female mice that had been bred to produce no estrogen. Once physically sluggish, these mice now explored, stood, played and ran far more than they had before.

Similarly, when the scientists used a form of the gene-editing technology CRISPR to gin up activity of the Mc4r gene in female animals’ brains, the mice became almost twice as active as before, a physical surge that persisted for weeks. Even male mice moved more when their Mc4r gene activity was dialed up by CRISPR, although not as much as the peripatetic females.

These results highlight the “complexity of physical activity behavior,” Dr. Ingraham said, and how the willingness to spontaneously move — or not — for any animal likely involves an intricate interplay between genetics, endocrinology and neurology, along with conscious deliberation.

The study also raises the intriguing possibility that the “timing of exercise, to have its most beneficial impact for women, might be fine-tuned by considering the changing hormonal milieu,” including the hormonal changes of menopause, said Dr. Tamas Horvath, a professor of neuroscience and obstetrics, gynecology and reproductive sciences at the Yale School of Medicine and chairman of the school’s department of comparative medicine.

“Of course, all these observations in mice need to be confirmed to operate in us, humans,” said Dr. Horvath, who was not involved in the current research. “However, the fact that this mechanism is found in an ancient part of the brain suggests that it will be applicable for most mammals, including humans.”

‘Knowledge is power’

Dr. Ingraham agreed. “We assume this circuit is working in humans, too,” she said and, if so, the new study and any subsequent, related research could help to explain, in part, why inactivity is so common in women after menopause and also offer some potential strategies for overcoming the pull toward lassitude. Increasing estrogen levels in older women, for instance, might, in theory, encourage more movement, though estrogen replacement therapy remains a complicated subject because of heightened cancer risks and other health concerns.

The study does hint, however, that it could, eventually, be possible to bypass estrogen and recreate its effects with new therapies that would directly target the Mc4r gene or the relevant neurons in people’s brains and mimic the effects of estrogen without the hormone itself. Any such medical advances are years in the future, Dr. Ingraham said.

Already, though, by delving into “the interrelationship between hormones and physical activity in females, this study has significant implications for human research studying the menstrual cycle and hormonal contraceptives and also menopause,” said Paul Ansdel, a lecturer in exercise physiology at Northumbria University in England, who was not involved with the study but has extensively studied menstruation and physical performance. “We know the importance of exercising in later life for promoting and maintaining health,” he continued, “so the challenge for us now is to understand the best ways to stay active throughout the major hormonal transition that is menopause.”

“Knowledge is power,” Dr. Ingraham concluded. She noted that because so many of us are living longer now, better understanding of why — and whether — we choose to move can help make those years healthier. For example, knowing that biology might angle us toward the couch if we are women and aging, we could use fitness trackers or training diaries to help us compare our activities from year to year. Or, just honestly assess whether we are as active now as we would like to be, whatever our age (or gender). The brain is a complex organ and our motivations for exercise varied and deep, but we always have the option “to decide to be active,” Dr. Ingraham said, to make the choice to get up and move.

I have become very busy over the past few months and so appointments have been hard to get. I will be taking some time off over Christmas and the New Year, so advise anyone wanting to see me to plan well ahead. I have extended my hours to help as many of my patients as I can, but there is a limit. I apologize to anyone having trouble getting an appointment, but there is not much more I can do.

Can cocoa consumption help us age better?

Newswise: Nutrition|September 22, 2021

Whether consuming cocoa, known to be packed with powerful antioxidants that protect our cells from damage, helps us age better, is a question scientists want to definitively answer.

They are looking for answers in the blood of 600 individuals age 60 and older who participated in the largest trial ever to assess the impact of a cocoa supplement as well as a common multivitamin, on reducing the risk of heart disease, stroke, cancer and other health outcomes, says Dr. Yanbin Dong, geneticist and cardiologist at the Georgia Prevention Institute at the Medical College of Georgia.

The COSMOS Trial (COcoa Supplement and Multivitamin Outcomes Study), led by investigators at Brigham and Women’s Hospital and the Fred Hutchinson Cancer Research Center, gathered data from 21,444 men and women looking at the impact of a cocoa extract supplement and/or multivitamins on common health problems, most of which increase with age.

Dong just received a $3 million grant (1RO1HL157665-01) from the National Institutes of Health to perform detailed analysis of inflammatory factors and genetic changes associated with aging to see if cocoa consumption reduces those factors.

Cocoa products have become a “widely consumed food” with still growing demand and increasing interest in their anti-aging potential, Dong says.

“People think the consumption of chocolate is good for you,” says Dong, adding that worldwide enthusiasm for the sweet treat has outpaced the scientific evidence of its benefit in humans.

Chocolate is widely considered beneficial because it has a high content of flavanols, antioxidants known to produce a powerful anti-inflammatory response. In fact, flavanols are the major ingredient, particularly in dark chocolate and cocoa is a purer form of chocolate, says Dong.

Industry experts note that flavanols are often destroyed in normal cocoa and chocolate processing. So, while chocolate may contain some cocoa flavanols, chocolate is not a reliable source of these compounds, and it does not have the right nutritional qualities to be consumed as a health food.Industry experts note that flavanols are often destroyed in normal cocoa and chocolate processing. So, while chocolate may contain some cocoa flavanols, chocolate is not a reliable source of these compounds, and it does not have the right nutritional qualities to be consumed as a health food.

There is no question flavanols are good for you, the questions are how much and in what way they are good for you, he says.

While there has been evidence in cell cultures, animal models and even some relatively small human studies of the anti-inflammatory might of cocoa, there had not been large scale randomized controlled trials, scientific studies in which a large number of participants are randomly assigned into different study arms that include some participants getting a placebo and/or different treatment, often whatever is considered the current treatment standard.

Dong notes that there also is not solid evidence that multivitamins, the most commonly used supplement, which is widely associated with benefits like reduced cancer risk, are of benefit either.

While he doesn’t dispute the biological plausibility that both chocolate and multivitamins should have some health benefit, he says solid scientific evidence should be behind what we choose to put in our bodies with the goal of improving our health.

“We are going to prove or dispute it,” he says, and the size and duration of the COSMOS Trial is enabling him to do both.

Dong and his colleagues will be looking specifically at aging, including so called “inflammaging,” and epigenetic aging, both considered good indicators of our biological age. Rather than just looking at the year you were born, biological age also takes into account key factors that impact your function and health, like genetics and lifestyle. He also has more standard aging measures on these individuals, like blood pressure and cognitive function tests.

Inflammation is a major factor in aging and common conditions such as heart attack, stroke, Alzheimer’s and cancer, and “inflammaging” has been characterized as chronic, low grade inflammation that likely increases the risk of these inflammation-related conditions.

Epigenetic changes, like DNA methylation, which can be good or bad and can result from environmental exposures, including the foods we eat, are changes to the physical structure of DNA which impact gene expression and ultimately what our genes do, including deactivating them. Epigenetic changes are now considered a powerful predictor for life- and healthspan, as well as susceptibility to disease and death, Dong says.

Dong will be analyzing levels of key pro- and anti-inflammatory factors at baseline, and year one and two of the COSMOS Trial in the blood of those taking the cocoa supplement, a multivitamin, both or neither. He’ll also be doing sophisticated, extensive genetic analysis looking for gene changes that correlate with aging, and using “epigenetic clocks” that can calculate biological age based on the amount of DNA methylation.

His work will have the added benefit of better defining any benefit of multivitamins, a top supplement used by many onlybecause they think it is good for them.

Inflammaging can be objectively assessed by measures like blood levels of C-reactive protein, a sort of biomarker of inflammation, which is made by the liver and can increase dramatically with inflammation. Dong likens C-reactive protein levels, which physicians regularly measure, to a Geiger counter for the immune response. He’ll also be assessing levels of tumor necrosis factor alpha, which as the name implies, is an inflammatory cytokine that attacks cancer and other invaders, but can be problematic at elevated levels. He’ll also be measuring levels of anti-inflammatory markers like interleukin-10, or IL 10, then exploring interaction between inflammaging and epigenetic aging, like whether the genes regulating IL-10 expression also increase DNA methylation and whether when blood pressure decreases, it reduces inflammation or changes methylation first.

The investigators central hypothesis is that cocoa supplementation reduces epigenetic aging and inflammaging, consequently reducing the risk of cardiovascular disease, the nation’s number one killer which tends to increase in incidence at age 65 and older. If they find inflammaging and cardiovascular disease indicators are reduced, they want to know if it’s reductions in epigenetic changes driving the improvements.

Particularly dark chocolate is regularly touted for its health benefits as a natural and good source of antioxidants as well as iron, copper and other things good for your heart and health. Eating chocolate has been reported to lower cholesterol, blood pressure, cognitive decline and boost the immune response to invaders like the coronavirus, Dong says.

Food and beverage items like grapes and red wine, tomatoes, onions, berries and peaches also are considered good sources of flavanols.

Surveys indicate the majority of American adults use a dietary supplement, with female use higher than male use and overall usage increasing with age, according to the Centers for Disease Control and Prevention. Multivitamins are a favorite supplement.

Dong’s collaborators on the new studies include COSMOS principal investigators Dr. JoAnn E. Manson and Dr. Howard D. Sesso from Brigham and Women’s Hospital and Harvard University.

Don’t wear earphones all day – your ears need to breathe

October 8, 2021 3.02pm AEDT

Authors

1. Charlotte Phelps PhD Student, Bond University
2. Christian Moro Associate Professor of Science & Medicine, Bond University

Disclosure statement

The authors do not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and have disclosed no relevant affiliations beyond their academic appointment.

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We believe in the free flow of information

Republish our articles for free, online or in print, under Creative Commons licence.

Wireless earphone sales are booming, with Apple alone selling an estimated 100 million sets of AirPods in 2020. Being untethered from our phones or devices means we are likely to wear earphones for longer periods.

As a result, you might notice your ears feeling more sticky or waxy. Is this common? And what happens to our ears when we wear earphones?

Although wireless earphones are fairly new to the market, there is a large amount of research investigating the long-term use of hearing aids, which in many cases, have a similar mechanism. From this research, it appears prolonged use of in-ear devices can cause problems with earwax.

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Read more: Are your kids using headphones more during the pandemic? Here’s how to protect their ears

Get news curated by experts, not algorithms.

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What does earwax do?

The production of earwax (also known as cerumen) is a normal process in humans and many other mammals. There should always be a thin coating of wax near the opening of the ear canal.

This wax is a waterproof and protective secretion. This acts to moisten the skin of the external ear canal and works as a protective mechanism to prevent infection, providing a barrier for insects, bacteria, and water. Wet earwax is brown and sticky, whereas the dry type is more of a white colour.

In fact, earwax is such a great barrier, in the 1800s there were reports of it being used as an effective balm for chapped lips!

Earwax is a naturally occurring substance produced in the external portion of the ear canal. It is created by the secretions of oil glands and sweat glands released by the hair follicles, which then traps dust, bacteria, fungi, hairs and dead skin cells to form the wax.

The external ear canal can be thought of as an escalator system, with the wax always moving towards the outside, preventing the ears from becoming filled with dead skin cells.

This migration of earwax is also aided by natural jaw movements. Once the earwax reaches the end of the ear, it simply falls out.

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Read more: Curious Kids: how do scabs form?

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How earphones might affect this system

The ear is self-cleaning and best performs its function without interruption. However, anything that blocks the normal progression of earwax moving outside can cause issues.

Normal use of in-ear devices don’t often cause a problem. But prolonged earphone use, such as if you leave them in all day, could:

• compress the earwax, making it less fluid and harder for the body to naturally expel
• compact the earwax to the extent the body induces inflammation. This results in white blood cells migrating to the area, increasing the number of cells in the blockage
• impact air flow and stop wet earwax drying out. When earwax retains its stickiness for prolonged periods of time, it encourages build-up
• trap sweat and moisture in the ears, making them more prone to bacterial and fungal infections
• create a barrier to the earwax’s natural expulsion, which ends up stimulating the secretory glands and increasing earwax production
• reduce overall ear hygeine, if the pads of the earbuds are not cleaned properly, or contaminated with bacteria or infectious agents
• damage your hearing if the volume is set too high.

If the build-up accumulates, excessive earwax can cause hearing problems, along with other symptoms such as pain, dizziness, tinnitus, itching, and vertigo.

If you need to listen for a prolonged period of time, using over-ear headphones may help a little. These offer a small amount of extra airflow compared to the in-ear earphones and earbuds. However, this is not as good as leaving the ears open to the outside air, and an accumulation of earwax can still occur.

As they sit outside the ear canal, over-ear headphones are also less likely to cause any earwax compaction, or introduce bacteria or pathogens to the ear canal.

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Read more: Health Check: is it bad to regularly sleep wearing earplugs?

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Nothing smaller than your elbow

In most cases, the best way to control earwax is to leave it alone. It is not recommended to use cotton buds frequently, as this can force earwax back into the ear canal. The longstanding advice is not to put anything smaller than your elbow in your ear – in other words, don’t put anything in there!

Some traditional methods, such as olive oil drops or ear candles, may also have adverse effects and are not helpful.

If your have ear wax or related hearing concerns, your family doctor will have a range of treatment options to assist, and can also direct you to the correct health service if it requires longer-term management.

Initially, they will look into your ear with a special instrument (otoscope) and see the extent of any blockage or dysfunction.

In the meantime, the ear has a wonderful process of self-cleaning, and we should do our best to let this occur naturally. In most cases earphones are fine, but it might still be helpful to stay aware of how long you spend wearing them. Finally, be sure to always keep the volume at safe levels.

Eur J Cancer.. 2018 Feb;90:34-62. doi: 10.1016/j.ejca.2017.11.002. Epub 2017 Dec 20.

Mammography screening: A major issue in medicine

Philippe Autier  ¹ , Mathieu Boniol  ² Affiliations

• PMID: 29272783
• DOI: 10.1016/j.ejca.2017.11.002

Abstract

Breast cancer mortality is declining in most high-income countries. The role of mammography screening in these declines is much debated. Screening impacts cancer mortality through decreasing the incidence of number of advanced cancers with poor prognosis, while therapies and patient management impact cancer mortality through decreasing the fatality of cancers. The effectiveness of cancer screening is the ability of a screening method to curb the incidence of advanced cancers in populations. Methods for evaluating cancer screening effectiveness are based on the monitoring of age-adjusted incidence rates of advanced cancers that should decrease after the introduction of screening. Likewise, cancer-specific mortality rates should decline more rapidly in areas with screening than in areas without or with lower levels of screening but where patient management is similar. These two criteria have provided evidence that screening for colorectal and cervical cancer contributes to decreasing the mortality associated with these two cancers. In contrast, screening for neuroblastoma in children was discontinued in the early 2000s because these two criteria were not met. In addition, overdiagnosis – i.e. the detection of non-progressing occult neuroblastoma that would not have been life-threatening during the subject’s lifetime – is a major undesirable consequence of screening.

Accumulating epidemiological data show that in populations where mammography screening has been widespread for a long time, there has been no or only a modest decline in the incidence of advanced cancers, including that of de novo metastatic (stage IV) cancers at diagnosis.

Moreover, breast cancer mortality reductions are similar in areas with early introduction and high penetration of screening and in areas with late introduction and low penetration of screening.

Overdiagnosis is commonplace, representing 20% or more of all breast cancers among women invited to screening and 30-50% of screen-detected cancers. Overdiagnosis leads to overtreatment and inflicts considerable physical, psychological and economic harm on many women. Overdiagnosis has also exerted considerable disruptive effects on the interpretation of clinical outcomes expressed in percentages (instead of rates) or as overall survival (instead of mortality rates or stage-specific survival).

Rates of radical mastectomies have not decreased following the introduction of screening and keep rising in some countries (e.g. the United States of America (USA)). Hence, the epidemiological picture of mammography screening closely resembles that of screening for neuroblastoma. Reappraisals of Swedish mammography trials demonstrate that the design and statistical analysis of these trials were different from those of all trials on screening for cancers other than breast cancer. We found compelling indications that these trials overestimated reductions in breast cancer mortality associated with screening, in part because of the statistical analyses themselves, in part because of improved therapies and underreporting of breast cancer as the underlying cause of death in screening groups. In this regard, Swedish trials should publish the stage-specific breast cancer mortality rates for the screening and control groups separately. Results of the Greater New York Health Insurance Plan trial are biased because of the underreporting of breast cancer cases and deaths that occurred in women who did not participate in screening.

After 17 years of follow-up, the United Kingdom (UK) Age Trial showed no benefit from mammography screening starting at age 39-41. Until around 2005, most proponents of breast screening backed the monitoring of changes in advanced cancer incidence and comparative studies on breast cancer mortality for the evaluation of breast screening effectiveness. However, in an attempt to mitigate the contradictions between results of mammography trials and population data, breast-screening proponents have elected to change the criteria for the evaluation of cancer screening effectiveness, giving precedence to incidence-based mortality (IBM) and case-control studies. But practically all IBM studies on mammography screening have a strong ecological component in their design. The two IBM studies done in Norway that meet all methodological requirements do not document significant reductions in breast cancer mortality associated with mammography screening. Because of their propensity to exaggerate the health benefits of screening, case-control studies may demonstrate that mammography screening could reduce the risk of death from diseases other than breast cancer. Numerous statistical model approaches have been conducted for estimating the contributions of screening and of patient management to reductions in breast cancer mortality. Unverified assumptions are needed for running these models. For instance, many models assume that if screening had not occurred, the majority of screen-detected asymptomatic cancers would have progressed to symptomatic advanced cancers.

This assumption is not grounded in evidence because a large proportion of screen-detected breast cancers represent overdiagnosis and hence non-progressing tumours. The accumulation of population data in well-screened populations diminishes the relevance of model approaches. The comparison of the performance of different screening modalities – e.g. mammography, digital mammography, ultrasonography, magnetic resonance imaging (MRI), three-dimensional tomosynthesis (TDT) – concentrates on detection rates, which is the ability of a technique to detect more cancers than other techniques. However, a greater detection rate tells little about the capacity to prevent interval and advanced cancers and could just reflect additional overdiagnosis. Studies based on the incidence of advanced cancers and on the evaluation of overdiagnosis should be conducted before marketing new breast-imaging technologies. Women at high risk of breast cancer (i.e. 30% lifetime risk and more), such as women with BRCA1/2 mutations, require a close breast surveillance. MRI is the preferred imaging method until more radical risk-reduction options are eventually adopted. For women with an intermediate risk of breast cancer (i.e. 10-29% lifetime risk), including women with extremely dense breast at mammography, there is no evidence that more frequent mammography screening or screening with other modalities actually reduces the risk of breast cancer death. A plethora of epidemiological data shows that, since 1985, progress in the management of breast cancer patients has led to marked reductions in stage-specific breast cancer mortality, even for patients with disseminated disease (i.e. stage IV cancer) at diagnosis. In contrast, the epidemiological data point to a marginal contribution of mammography screening in the decline in breast cancer mortality. Moreover, the more effective the treatments, the less favourable are the harm-benefit balance of screening mammography. New, effective methods for breast screening are needed, as well as research on risk-based screening strategies.

A recent Canadian trial reports breast cancer over-diagnosis rates of up to 55 per cent, from routine screening mammograms. (Shutterstock)

Routine mammograms do not save lives: The research is clear

October 2, 2017 10.09am AEDT

Author

1. Anne Kearney Associate Professor of Nursing, Memorial University of Newfoundland

Disclosure statement

Anne Kearney received funding from Government of Newfoundland and Labrador for a current project related to non-nursing duties (not-related). I have held other funding in the past but none that puts me in a conflict of interest.

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Republish our articles for free, online or in print, under Creative Commons licence.

As breast cancer awareness month kicks off, all women should know something: there is no reliable evidence that routine mammograms for healthy women save lives.

There is good evidence that such mammograms can cause harm.

And yet there are 12 breast-screening programs in Canada, each offering routine mammography screening to well women. Most of them offer mammograms to women of 50 to 74 years of age every two to three years. These programs were set up based on evidence produced in the 1970s and 1980s — that detecting breast cancer early through a mammogram would save many lives.

The Canadian Task Force on Preventive Health Care also still recommends that women aged 50 to 74 get regular mammography screening. They are updating their breast-screening recommendations this year; hopefully they’ll reflect the latest evidence.

Join 175,000 people who subscribe to free evidence-based news.

I have been looking at breast-screening evidence for more than 20 years.

I was part of a small group of individuals who started the breast-screening program in Newfoundland and Labrador. My job was professional and public education, including recruitment of women.

Over time there was increasing evidence that mammography screening may not be as beneficial as once thought. As the daughter of a woman with pre-menopausal breast cancer, I was also interested in the evidence on breast self-examination and clinical breast examination in screening.

If you are a woman who is considering having (or continuing to have) routine mammography screening, here is some information you need to know.

1. Screening mammograms do not reduce death from breast cancer

There is no reliable evidence that having a screening mammogram reduces death by breast cancer on a population basis. The Cochrane Collaboration reached this conclusion after taking a good look at the original randomized trials. A recent Canadian trial, considered the best mammography trial, supported this finding for women aged 40 to 59. This is important evidence that needs careful consideration.

2. Routine mammograms over-diagnose cancer

The Cochrane Collaboration also reported on harms associated with mammography screening. The most important of these is over-diagnosis. That is, the diagnosis of breast cancers in healthy women that would never have become clinically detectable without screening or would have caused harm to the woman in any way.

Estimates of over-diagnosis vary from 30 per cent in the Cochrane Collaboration 2013 report to 55 per cent in the 2016 update from the Canadian trial and 54 per cent by the United States National Cancer Institute.

3. Treatment for over-diagnosed cancer is harmful

Women with over-diagnosed breast cancer receive the usual breast cancer treatments including lumpectomy, mastectomy, radiation and hormonal therapy. All treatment for over-diagnosed cancer is harmful. This means that, because of mammography screening, many women are diagnosed with a breast cancer that might never have become apparent, and they undergo unnecessary treatment.

4. False positives and over-diagnosis cause anxiety

Another harm associated with mammography screening is false positive findings — when an abnormality is detected that might be breast cancer but, after further testing including more mammography, is found not to be. Having additional testing causes significant anxiety for some women, including the belief that they are at higher risk for breast cancer.

In addition to the significant anxiety some women feel because of a false positive finding, consider the experience of a woman who is over-diagnosed, receives cancer treatment and lives with a breast cancer diagnosis for the rest of her life — a diagnosis that might never have occurred without mammography screening.

5. Radiation from screening can also kill

Radiation associated with mammography screening, additional mammography for false positives and with radiation treatment for overdiagnosed breast cancer carries significant risk for women.

A study done for the United States Preventive Services Task Force estimated that radiation exposure from screening and diagnostic workup causes 27 breast cancers and 4 deaths for every 100,000 women aged 50 to 69 screened every two years.

6. Screening directs resources away from treatment

There are significant harms associated with mammography screening and no reliable evidence of benefit. It is time to discontinue routine mammograms for all healthy women of a particular age. Resources should be shifted toward surveillance of women at higher risk for breast cancer, diagnostic workup for women with a change in their breast that does not go away and for ensuring that women receive timely treatment for a confirmed invasive breast cancer.

Population-based mammography screening has opportunity costs for the health care system, not to mention the social, financial, interpersonal and emotional costs to women and their families.

7. Public information is not balanced

It’s important that women are told — in plain language — about the potential harms and benefits of mammography screening so they can make an informed decision about being screened or not. I was involved in a recent review of the websites of 12 breast screening programs in Canada. Our results (accepted for publication) show that no program is offering balanced information on their website to support an informed decision.

It’s time to change the conversation in Canada about how to reduce the significant illness and death associated with breast cancer. Population-based mammography screening is not the way. We need to continue to research better early detection methods, including breast self examination and clinical breast examination.

Full text links

• Comparative Study BMC Public Health

• . 2019 Jan 22;19(1):97. doi: 10.1186/s12889-019-6442-9.

Too much medicine? Scientific and ethical issues from a comparison between two conflicting paradigms

Francesco Attena  ¹ Affiliations

• PMID: 30669992
• PMCID: PMC6341674
• DOI: 10.1186/s12889-019-6442-9

Free PMC article

Abstract

Background: The role of medicine in society appears to be focused on two views, which may be summarized as follows: “Doing more means doing better” (paradigm A) and “Doing more does not mean doing better” (paradigm B).

Main body: I compared paradigms A and B both in terms of a single clinical condition and in the general context of a medical system. For a single clinical condition, I analyzed breast cancer screening. There are at least seven interconnected issues that influence the conflict between paradigms A and B in the debate on breast cancer screening: disconnection between research and practice; scarcity of information given to women; how “political correctness” can influence the choice of a health policy; professional interests; doubts about effectiveness; incommensurability between harms and benefits; and the difficulty in making dichotomous decisions with discrete variables. As a general approach to medicine, the main representative of paradigm A is systems medicine. As representatives of paradigm B, I identified the following approaches or movements: choosing wisely; watchful waiting; the Too Much Medicine campaign; slow medicine; complaints against overdiagnosis; and quaternary prevention. I showed that both as a single condition and as a general approach to medicine, the comparison was entirely reducible to a harm-benefit analysis; moreover, in both cases, the two paradigms are in many respects incommensurable. This transfers the debate to the ethical level; consequently, scientists and the public have equal rights and competence to debate on this subject. Moreover, systems medicine has many ethical problems that could limit its spread.

Conclusion: I made some hypotheses about scenarios for the future of medicine. I particularly focused on whether systems medicine would become increasingly accessible and widespread in the population or whether it would be downsized because its promises have not been maintained or ethical problems will become unsustainable.

Below is the full article, for those of you interested in more information. It is a bit esoteric, unless you are an academic. The abstract above will do for most of my readers.

Keywords: Breast cancer screening; Ethics; Harm-benefit assessment; Incommensurability; Paradigm; Systems medicine; Too much medicine.

D E B A T E Open Access
Too much medicine? Scientific and ethical
issues from a comparison between two
conflicting paradigms
Francesco Attena

Background
Current tendencies regarding the role of medicine in so-
ciety and about the extent of interventions for a popula-
tion appear to be focused on two opposite views, or
paradigms. Those paradigms may be summarized as fol-
lows. According to paradigm A (PA), “Doing more
means doing better.”Conversely, according to paradigm
B (PB), “Doing more does not mean doing better.”
In the past, these two views have had their various ad-
vocates. Against the excess of ineffective treatments, the
movement of therapeutic nihilism took place at the end
of the nineteenth century. However, in the early twenti-
eth century, doctors had to choose between Galenic
methods (purges, emetics, and bloodletting) and the
Hippocratic method (wait, observe, console) [1]. Cur-
rently, the highest expression of PA is found in systems
biology and systems medicine [2]. By contrast, PB is
Correspondence: francesco.attena@unicampania.it
Department of Experimental Medicine, School of Medicine, University of
Campania, Via Luciano Armanni 5, 80138 Naples, Italy
© The Author(s). 2019 Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0
International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and
reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to
the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver
(http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.
Attena BMC Public Health (2019) 19:97
https://doi.org/10.1186/s12889-019-6442-9represented by various approaches and movements that
oppose the excesses of modern medicine. The propensity
toward PA or PB is also an attitude of individual health
operators in terms of being more or less interventionist.
The propensity may also be a cultural feature of particu-
lar nations; for example, the United States is a typical
PA country.
Since its origins, modern medicine has become pro-
gressively more invasive into people’s lives and into soci-
ety in general in pursuit of its goal of always seeking to
improve. Beyond the purpose of doing more and doing
something better, the main reasons for such develop-
ments are well known. From the perspective of the citi-
zen, the reasons are as follows: improving the quality of
life; the obsessive search for well-being; unrealistic ex-
pectations about the ability of medicine to solve all
health problems; health anxiety (i.e. the distress, anxiety
or sensation of serious illness, often unfounded, that a
person feels regarding his/her personal health); the
changed doctor-patient relationship from a paternalistic
to an equal one. From the medical viewpoint, these new
attitudes have led to greater medical-legal disputes and
the birth of defensive medicine. Lastly, health industries
foster health consumerism for the purpose of pursuing
profits through increasingly expensive drugs and con-
stant technological innovation. All these modern condi-
tions are closely related and lead (both in the clinic and
in terms of prevention, both diagnostically and thera-
peutically) toward medical interventionism rather than
non-interventionism.
At the individual level, the best-known consequences of
this hyper-interventionism have been overdiagnosis and
overtreatment [3]; at the social level, the consequences
have been the concept of medicalization in the negative
sense and the problem of economic unsustainability of
public health systems. These negative consequences and
the anomalies of Kuhnian language have given rise to PB
following the classic scheme of a paradigm shift [4].
The present study makes a comparison between PA
and PB. It mainly does so in terms of clinical practice
and preventive diagnosis: it adopts this approach be-
cause early diagnosis underscores the main differences
between the two paradigms. Moreover, the two para-
digms are compared with respect to a single clinical con-
dition and with the general medical system. Maintaining
Kuhnian terminology, I apply the concept of incommensur-
ability in both situations. Incommensurability is deeper and
better suited to the needs of the present discussion than
other more generic concepts, such as incomparability, dis-
similarity, and divergence. I are aware that the rigid oppos-
ition between these two points of view is somewhat
artificial, the reality is more nuanced than the two para-
digms indicate. Therefore, this simplification allow us to
formulate a more linear and comprehensible reasoning.
Incommensurability
Incommensurability has different meanings. In mathem-
atics, it signifies that items cannot be precisely measured
and compared using some common scale of unit of
values. However, in the present study, I use the term in
a way similar to the Kuhnian sense. In that sense, scien-
tific theories are incommensurable if scientists cannot
discuss them using a shared nomenclature that allows
direct comparison of theories to determine which is
more valid or useful. The reason for that lack of com-
parison is that the theories belong to two different scien-
tific paradigms [4].
In this study and following the above definition, I use the
term “incommensurability”in two ways: with respect to a
single disease and with respect to the entire medical system.
A) Incommensurability of harm-benefit assessment.
This occurs when the harms and benefits for a particular
disease affect different domains of health status [5],
which generates a conflict between PA and PB. Of
course, I are aware that there are many conditions in
which the harms and benefits can be compared through
a common denominator (for example, mortality,
quality-adjusted life-years); however, I believe that the
incommensurability of harms and benefits is an underes-
timated topic, and so I addressed the following
condition.
B) Incommensurability between paradigms. In the first
instance, I assumed that PA and PB ignore each other:
they do not have a common language and do not try to
work together to find a shared solution. Ultimately, a
comparison between PA and PB is entirely reducible to a
(meta-) assessment between the harms and benefits.
I begin my analysis with an examination of a single
disease: I present, as an example, the debate about breast
cancer screening. I then investigate PA and PB in the
general context of medical systems.
Incommensurability of harm-benefit assessment
Debate about breast cancer screening
Breast cancer screening is a good example of a conflict
between two different approaches to screening: PA fa-
vors performing it; PB does not. Moreover, breast cancer
screening is particularly interesting because it is a
much-debated topic. There are at least seven intercon-
nected issues that influence the conflict between PA and
PB: disconnection between research and practice; scar-
city of information given to women; how “political cor-
rectness”can influence the choice of a health policy;
professional interests; doubts about effectiveness; incom-
mensurability between harms and benefits; and the diffi-
culty in making dichotomous decisions with continuous
variables.
The first four items are not strictly scientific issues
with respect to PA. Unlike with the many doubts
Attena BMC Public Health (2019) 19:97 Page 2 of 8highlighted by scientific debate, the benefits and effect-
iveness of screening are still overestimated in clinical
practice [6–8]. For many health operators, the difficulties
include updating procedures (disconnection between re-
search and practice); at the population level, the infor-
mation to women is still partly biased toward screening
(scarcity of information given to women) [9, 10]. In
many countries (and in my experience, it is certainly the
case in Italy), it is not possible to speak against screen-
ing; according to [11], even some scientists have sacri-
ficed sound scientific principles to arrive at politically
acceptable results. Finally, many health operators can
distort the judgment about the utility of screening owing
to their particular interests in the field (e.g., as radiolo-
gists, surgeons, breast specialists) [12].
From a scientific perspective (the final three items in
the above list) the debate about breast cancer screening
is intense and engaged on two levels. The first level con-
cerns effectiveness: beside the great amount of studies
which have summarized the effectiveness of breast can-
cer screening [13–17], other studies have strongly ques-
tioned the ability of screening to reduce mortality [18–
22]. If the effectiveness is accepted, the second level of
discussion concerns the harm-benefit ratio: on the one
hand, prevention of breast cancer mortality, and on the
other hand, diagnostic anticipation, false positives, false
positives after biopsy, and overdiagnosis [23–27].
The Canadian Task Force calculated that in the
age-group of 40–49 years for each death from breast can-
cer prevented, it is necessary to screen 2108 women for
11 years, with 690 false positives and 75 false positives
after biopsy. For the age-range of 50–69 years, the figures
are 721 women, 204 false positives, and 26 false positives
after biopsy [28]. Overdiagnosis is a recent, controversial
issue owing to the difficulties involves in calculation [29].
The Independent UK Panel on Breast Cancer Screening
calculated that for each death from breast cancer pre-
vented, there are three overdiagnoses [13]. A more recent
study investigated age-specific overdiagnosis for ductal
carcinoma in situ and invasive breast cancer; it obtained a
wide range of results: less than 1% among 40-year-old
women with a screen detected cancer, up to 30% at age
80 years for ductal carcinoma in situ [30].
The US Preventive Service Task Force (USPSTF) recom-
mends biennial screening mammography for women aged
50–74 years as a B recommendation. The task force makes
that recommendation using a rather convoluted statement:
“The USPSTF recommends the service. There is high cer-
tainty that the net benefit is moderate or there is moderate
certainty that the net benefit is moderate to substantial”[16].
Incommensurability and undecidability
It is necessary to determine what these data tell us about
the harm-benefit ratio. From a scientific viewpoint, the
data are not very enlightening owing to the difficult in
assessing that ratio. From an ethical perspective, an in-
soluble dilemma results. The dilemma arises mainly be-
cause in this example, harms and benefits are
incommensurable. First, they belong to substantially dif-
ferent domains [5], i.e., preventing death versus various
harms. Second, regarding the difficulty in making di-
chotomous decisions on continuous variables, that
means (simplifying the argument), how many overdiag-
noses (or, e.g., false positives) are acceptable for each
prevented death.
Borrowing the language of mathematics and comput-
ability theory, undecidability derives from incommensur-
ability, i.e., the impossibility of constructing a rule that
leads to a correct yes-or-no answer. Thus, given the
same initial conditions of scientific data, the final choice
in conducting or not conducting screening is an ethical,
not a scientific, issue. Scientists and the public have
equal rights and competence to express an opinion on
this subject. Indeed, the most recent and increasingly
shared solution to the problem has been to release the
final decision (and the dilemma!) to women [28]. How-
ever, new problems arise from this new approach since
women’s preference collides with uncertainty about the
benefits and harms; moreover, the transfer of responsi-
bility is a forcing of the informed choice and can cause
trouble to women [31]. The Population-based Research
Optimizing Screening through Personalized Regimens
initiative has been promoted by the US National Cancer
Institute: it is based both on patient preferences and on
optimizing the personalized benefit-harm ratio associ-
ated with screening [32, 33].
Regarding the main topic of my discussion, many sci-
entists seem to ignore this dilemma. Scientists disposed
to PA support the intervention; those disposed to PB
discourage it.
Incommensurability between paradigms
PA: Systems medicine the main representative
Systems medicine is an application in the medical field
of systems biology [34], which developed at the begin-
ning of this century [35]. Systems medicine is also
termed P4 systems medicine (P4SM) because it claims
to be Predictive, Preventive, Personalized, and Participa-
tory. Predictive and Preventive are strictly interrelated
items, as reported by [36]: “Moreover, P4 medicine will
in the future be able to predict the potential future
emergence of disease-perturbed networks in patients
and then design ‘preventive drugs’that will block the
emergence of these disease-perturbed networks and
their cognate diseases.”P4SM is Personalized: it con-
siders each person as a unique individual and not as a
statistical average. Therefore, each person is treated in a
personalized way based on the big data collected during
Attena BMC Public Health (2019) 19:97 Page 3 of 8continuous monitoring. This intervention requires active
participation and a positive contribution from the popu-
lation; in this way, P4SM is able to provide actionable in-
formation, which it can use to improve health.
To achieve the P4 goals, P4SM has to integrate data
from conventional sources (including paper patient re-
cords, clinical and pathological parameters, and molecu-
lar and genetic data) and new sources (originating from
statistical, mathematical, and computational tools). The
procedure requires teams that combine expertise from
different disciplines as well as continuous spatial and
temporal monitoring of every individual. That will allow
the extrapolation, analysis, and relating of a huge
amount of heterogeneous, structured, and unstructured
data (big data) to determine the links between different
phenomena and predict future ones.
To obtain a prediction regarding the status and behav-
ior of a medically monitored person, it is necessary to
proceed according to the following steps [2]. First, it is
necessary to identify the system variables whose meas-
urement and observation can be used to answer a par-
ticular question. Second, the interaction among those
variables has to be characterized at the molecular, cellu-
lar, and whole-body level. Third, the consequences of
such interaction have to be determined using a process
whereby a complex system (the human body) may be
assessed through reduced representation.
The consensus related to this new approach to medi-
cine and its dissemination are highlighted by a number
of international institutions working in the field. Exam-
ples include the Institute for Systems Biology in Seattle,
United States [37], the European Institute for Systems
Biology and Medicine [38], and the Suzhou Institute of
Systems Medicine, China [39].
P4SM is the only international organized movement
for the PA model. However, at the international level, PB
is represented by numerous approaches, movements,
and campaigns, often connected with one another. The
PB approaches include the following: choosing wisely,
watchful waiting, the Too Much Medicine campaign,
slow medicine, complaints against overdiagnosis, and
quaternary prevention. I hope that my list is fully com-
prehensive, and I present below a short summary of each
one.
PB: Approaches and movements
Choosing wisely
Choosing wisely is probably the most widespread and
structured movement featuring PB. Its mission is to pro-
mote dialogue between clinicians and patients by helping
patients choose care that is as follows: supported by evi-
dence; not duplicative of other tests or procedures
already received; free from harm; truly necessary [40].
The core idea is to reduce overutilization of
inappropriate and essentially harmful tests, treatment,
and procedures. This movement is known for having
launched in 2012 a campaign that invites all medical
specialty societies to develop a list of five tests and
procedures that physicians and patients should ques-
tion [41].
Watchful waiting
Watchful waiting is not an organized movement: it is an
approach to health problems. It is an alternative to more
aggressive treatment, whereby time is permitted to pass
before applying a medical intervention or therapy, and it
makes use of patient involvement [42]. Prostate cancer
has received considerable attention in this regard [43].
This approach is also promoted by the National Cancer
Institute, which in its Dictionary of Cancer Terms de-
scribe the concept of watchful waiting as follows:
“Closely watching a patient’s condition but not giving
treatment unless symptoms appear or change. Watchful
waiting is sometimes used in conditions that progress
slowly. It is also used when the risks of treatment are
greater than the possible benefits”[44].
Too much medicine campaign
At the end of the past century, a long debate began with
The BMJ on the theme of “too much medicine?”[45].
The campaign later became formalized and has a dedi-
cated Web site [46], which specifies the following: “The
BMJ’s Too Much Medicine initiative aims to highlight
the threat to human health posed by overdiagnosis and
the waste of resources on unnecessary care. We are part
of a movement of doctors, researchers, patients, and pol-
icymakers who want to describe, raise awareness of, and
find solutions to the problem of too much medicine.”
Slow medicine
The organized movement of slow medicine began in
Italy in May 2011. The background to the movement is
respect for nature and the environment, a sense of just-
ice, and an aversion to waste and consumerism [47].
These ideas are shared with those of another movement,
Slow Food, with whom Slow medicine undertakes con-
tact and collaboration. In the declaration of the slow
medicine movement, seven “poisons”of fast medicine
are described. Collaboration of slow medicine with
choosing wisely came about with the creation of Choos-
ing Wisely Italy [48].
Complaints against overdiagnosis
Overdiagnosis and overtreatment are the most insidious
consequences of overuse of medical interventions [49].
Therefore, all the studies and authors that denounce it
completely belong to PB. Here, the topics are not new;
however, they have gained international resonance in
Attena BMC Public Health (2019) 19:97 Page 4 of 8recent years as mathematical models have been used to
calculate the magnitude of overdiagnosis and overtreat-
ment. Pathirana et al. [50] identified five drivers of overdi-
agnosis: culture; health systems; industry; professionals;
and patients/public.
Quaternary prevention
This approach to medicine has been formalized in the
concept of “quaternary prevention,”and it has particu-
larly developed in the field of general practice [51]. In-
deed the concept of quaternary prevention appears in
the WONCA International Dictionary for General/Fam-
ily Practice, where it is defined as “Action taken to iden-
tify patient at risk of overmedicalization, to protect him
from new medical invasion, and to suggest to him inter-
ventions, which are ethically acceptable”[52].
I now present a comparison between PA and PB. First,
I analyze their sensitivity and specificity; then, I assess
their reduction to a harm-benefit ratio.
Sensitivity and specificity of the two paradigms
As systems medicine, PA pursues the goal of monitoring
(in a continuous spatial and temporal modality) all indi-
viduals. Therefore, owing to this putative ability to pre-
dict and prevent each future disease, PA has a very high
sensitivity: theoretically, almost 100% for any clinical
condition. However, the specificity and positive predict-
ive value are supposedly low, depending on such factors
as the disease, its prevalence, and the threshold used. By
contrast, PB acts with restraint and when there is cer-
tainty of a favorable balance in terms of harms and ben-
efits. Thus, for each disease, PB has a high specificity
and high positive predictive value: only a small part of
the population will be diagnosed and treated, i.e., indi-
viduals who are more probably ill or for whom interven-
tions are more appropriate. Obviously, this approach has
low sensitivity, which entails the risk of losing sick
people. A well-known ancient ethical dilemma, applied
to single clinical problems (as I saw previously with
breast cancer screening), here applies to the whole
population: to include all sick people at the cost of treat-
ing many both overdiagnosed and healthy individuals
(overdiagnosis, overtreatment), or not to include all sick
people (underdiagnosis, undertreatment) with the advan-
tage of not treating healthy individuals.
Reduction of comparison between PA and PB in harm-
benefit assessment
Translating these considerations to the field of
harm-benefit assessment, PA and PB have different ap-
proaches. In brief, PA entails high sensitivity, more bene-
fits, and more harms; PB entails high specificity, fewer
harms, and fewer benefits. Let us imagine ideal condi-
tions under which both PA and PB offer the better
performance. PA attempts to obtain maximum benefits
for the population at the cost of increasing the damage
somewhat (more benefits and a few more harms). PB
tries to achieve minimum harms for the population at
the cost of decreasing the benefits somewhat (fewer
harms and slightly reduced benefits). This is the kind of
incommensurability that I intend to address in compar-
ing PA and PB: it is the impossibility of making a correct
decision starting from these ideal conditions (undecid-
ability). In my opinion, these are the core issues that
arise from such a comparison. Therefore, the questions
“Which is better?”and “Who is right?”are much too
simplistic, or even nonsensical.
Epistemological and ethical issues for PA
Thus, far I have focused on a comparison mainly of
health aspects. If I broaden the horizon, PA, unlike PB,
has epistemological contradictions and ethical troubles;
PB involves potential harm for the population.
From an epistemological perspective, P4SM aims to
achieve a shift in medicine from a reductionist approach
to a holistic one: its tools take into account the complex-
ity of the human body [53]. The main contradiction with
this stance is that the complexity (in which the whole is
greater than the sum of its parts) and holism are epis-
temologically incompatible with the type of predictivity
claimed by P4SM. Thus, its flaunted predictive capacity
could be an illusion. Moreover, I perceive the predictivity
of P4SM as a return to the strictly deterministic ap-
proach to nature and to the human being. That is, if I
consider each person a microcosm, it recalls the old dec-
laration of Laplace’s demon [54]: if a demon knows the
precise location and momentum of every atom in the
universe, their future values for any given time are
entailed. In terms of P4SM, this amounts to the follow-
ing: if big data knows the precise location and momen-
tum of every biological parameter for each individual,
that person’s future values for any given time are
entailed. In conclusion, I believe that P4SM is not a
paradigm change, as suggested in [55]; it is an extreme
form of the current PA and that Vogt et al. [56] define
as a “technoscientific holism.”
From an ethical viewpoint, several criticisms have been
made. Health anxiety [57] and cyberchondria [58], the
modern versions of old hypochondria, have appeared
and are a consequence of the current trend of medicine
becoming increasingly invasive. The boomerang effect is
that people are not feeling healthier but are constantly
anxious about their health. These conditions could in-
crease with the spread of systems medicine: it could be-
come widely invasive of human life, and it has
implications of social and cultural iatrogenesis up to the
medicalization of health and life itself [56].
Attena BMC Public Health (2019) 19:97 Page 5 of 8Other AA. underline the risks to individuals in the cir-
culation of uncovered negative or potentially discrimin-
atory health-related findings [59]. Mittelstadt and Floridi
[60] consider big data particularly challenging from an
ethical perspective owing to the sensitivity of health data
and the fiduciary nature of health care; they identify 11
ethical risks connected to the spread of big data.
Further difficulties arise from the compatibility of pre-
dictive decisions derived from big data with the princi-
ples of clinical practice and evidence-based medicine.
This is because systems medicine is a top-down model,
providing clinicians with a computer algorithm; it is not
based on clinical evidence and research [61].
Despite these limits, the words of the advocates of sys-
tems medicine are attractive and astonishing because they
promise to free humanity from the burden of disease:
“Regular check-ups will allow the physician to longitudin-
ally follow each patient and detect any perturbation that
might lead to disease long before the onset of disease
symptoms. In this manner, an individual’s wellness can be
preserved without the disease state ever occurring”[62].
Conclusions
What lessons can be drawn from analyzing PA and PB
if—beyond their intentions—neither PA nor PB can keep
their promise of better health? What do we want from
the medicine of the future: greater benefits but greater
harm, or fewer harms and fewer benefits? Different sce-
narios are possible.
Shift to PA
Owing to the ineluctable evolution of science and medi-
cine, PA, as systems medicine, could become increas-
ingly accessible and widespread in the population. Some
or many countries will include systems medicine in their
national health services; accordingly, many people or the
whole population under such health services will be
treated in that way. Therefore, PA could steadily become
the dominant paradigm and PB could become marginal
or disappear.
Shift to PB
Over time, the promises of systems medicine are not
maintained; that is because ethical problems arise, risks
and harms are recognized, and the power of big data
prediction is not realized. Furthermore, if such promises
were partially or totally realized, the management of all
that information would still be difficult, and the costs
would become unsustainable. Together with the down-
sizing of PA, the concepts of overdiagnosis and over-
treatment would become established and spread to the
population. Thus, demand for PB would become domin-
ant, and medicine would be practiced in a more con-
tained, sober, and sustainable manner. PA could
disappear or maintain a niche of activities for a few
health obsessives, who voluntarily wish to undergo con-
tinuous monitoring. This development would be favored
by a change in the world capitalist structure, with a
downsizing of the dominant neoliberalism that is the
cultural ground on which P4SM develops.
Simultaneous presence of PA and PB
If the debate between the two paradigms is intrinsically
undecidable because it is impossible to construct ad-
equate decision making, then the debate could never
end. Therefore, this scenario constitutes the persistence
over time of the equal presence in epistemology and
health policies of these two visions of medicine. PB
could gain more support, continuing to counteract the
excesses of PA and declaring the risks of too much
medicine. PA could be available, free or at a cost, for
people who wish to undergo it.
Harm-benefit assessment between PA and PB
The choice between PA and PB refers essentially to a
harm-benefit ratio. Thus, in the future it will perhaps be
possible to overcome the incommensurability between
them using the same big data as PA and performing a
kind of meta-analysis harm-benefit analysis comparing
PA and PB for all health problems and for all the popu-
lation: ex ante, that could be achieved using sophisti-
cated mathematical models; ex post, the analysis could
compare populations submitted to P4SM with those not
submitted to it. Moreover, it is also likely that in any sce-
nario, the role of patients will become increasingly
decisive.
In conclusion, the future attitude of medicine and
health systems will depend not only on the ability to
demonstrate the best health outcomes but also on a
complex intertwining of political, economic, social, and
cultural factors.
Abbreviations
P4SM: P4 systems medicine; PA: Paradigm A; PB: Paradigm B
Acknowledgements
None.
Funding
None.
Availability of data and materials
Not applicable.
Authors’contributions
The author read and approved the final manuscript.
Ethics approval and consent to participate
Not applicable.
Consent for publication
Not applicable.
Attena BMC Public Health (2019) 19:97 Page 6 of 8Competing interests
The author declares that he has no competing interests.
Publisher’s Note Springer Nature remains neutral with regard to jurisdictional claims in
published maps and institutional affiliations.
Received: 7 September 2018 Accepted: 14 January 2019
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I am reading this book at present, and recommend it to my patients. I am generally disillusioned by some in the medical profession, and advise my patients to be very vigilant in hospitals, and frequently seek second opinions when doubtful about a course of action. Recently, I was admitted to hospital for abdominal pain – it was recommended to have a laparotomy to fix my bowel obstruction. I disagreed with the specialist, felt he was wrong, signed myself out of hospital (against his dire warnings of what would happen to me) and was back to normal that evening. I was back at work the next morning. Whatever it was, it fixed itself. With my medical knowledge, I was able to do this. Most of you would have ended up with an unnecessary operation. Of course, this is a generalization, and usually it would be best to take the doctors advice. However, a bit of caution never goes astray.

Two world-leading doctors reveal the true state of modern medicine and how doctors are letting their patients down.

In Hippocrasy, rheumatologist and epidemiologist Rachelle Buchbinder and orthopaedic surgeon Ian Harris argue that the benefits of medical treatments are often wildly overstated and the harms understated. That overtreatment and overdiagnosis are rife. And the medical system is not fit for purpose: designed to deliver health care not health.

This powerful exposé reveals the tests, drugs and treatments that provide little or no benefit for patients and the inherent problem of a medical system based on treating rather than preventing illness. The book also provides tips to empower patients – do I really need this treatment? What are the risks? Are there simpler, safer options? What happens if I do nothing? Plus solutions to help restructure how medicine is delivered to help doctors live up to their Hippocratic Oath.

‘One of the hardest things for a doctor to do … is nothing. This superb book explains how in medicine and surgery less is often not just more, it’s closer to the oath we’re all supposed to practise by.’ ― Norman Swan, award-winning producer and broadcaster of the Health Report and Coronacast

‘This eye-opening and enthralling book on the medical and moral hazards which beset the health profession is a must-read for patients and practitioners alike. From ‘tooth-fairy science’ to medical disasters to the inflated business world of medicine, Hippocrasy is a profoundly thought-provoking and compelling work that challenges our perception of the practice of modern medicine.’ ― Kate McClymont AM, award-winning investigative journalist for the Sydney Morning Herald/The Age

‘Doctors are educated to do good. Yet, as the commercial imperatives of the medical industrial complex tighten their grip, doctors are becoming more and more worried that they are inflicting harm rather than creating benefit. This book is for them and, perhaps even more importantly, for their patients. The road to hell is paved with good intentions: read Hippocrasy and turn back.’ ― Iona Heath CBE, former President, The Royal College of General Practitioners

‘This brilliant book offers clear and compelling evidence that we’re all at risk from too much medicine. Using the best of science, these two respected doctors blow the whistle on harmful healthcare. Buchbinder and Harris reveal how overdiagnosis, overtreatment and the medicalisation of normal life are major threats to human health. But this brilliant book also brings hope that we can wind back the harm and waste of unnecessary tests and treatments, and focus more on the great benefits medicine has to offer.’ ― Ray Moynihan, author of Too Much Medicine? and Selling Sickness, Assistant Professor, Bond University

‘About half of us in advantaged countries are now patients or ‘providers’, or both, and a third of clinical interventions are futile at best. Seeking health is daunting and we could benefit from a guide. Rachelle Buchbinder and Ian Harris have provided such with this volume.’ ― Nortin M Hadler, author of The Last Well Person, The Citizen Patient and Worried Sick, Emeritus Professor of Medicine and Microbiology/Immunology, University of North Carolina

‘Throughout medical history, doctors have routinely ignored the fundamental Hippocratic injunction: ‘First, do no harm’. Most of their treatments produced lots of harms, with little or no benefit. This wonderful book punctures the hyped claims of modern medicine, showing that it is not nearly as scientific, safe, effective, and honest as it should be. Reading Hippocrasy is essential for doctors (to help make them become more cautious); but even more essential for patients (to help them become more self-protective).’ ― Allen Frances, author of Saving Normal, Professor and Chairman Emeritus of the Department of Psychiatry and Behavioral Sciences, Duke University School of Medicine

‘A timely book from two leading doctors. They present evidence that despite medicine’s lip-service to evidence-based medicine, many unnecessary, wasteful and harmful investigations and treatments abound. Increasingly, the healthy are re-defined as having ‘predisease’ and drawn into questionable investigations and monitoring programmes. The book’s core message is that medicine’s hubris and a creeping scientism has come to overshadow the doctor’s commitment to care for and comfort their patients and, above all, do no harm. It is time to step back from the brink and revisit the founding principles and core values of our profession.’ ― Trish Greenhalgh OBE, Professor of Primary Care Research, University of Oxford

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Is salt good for you after all? The evidence says no

October 6, 2021 11.39am AEDT

Author

1. Clare Collins Laureate Professor in Nutrition and Dietetics, University of Newcastle

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Clare Collins is affiliated with the Priority Research Centre for Physical Activity and Nutrition, the University of Newcastle, NSW. She has received research grants from NHMRC, ARC, MRFF, Hunter Medical Research Institute, Diabetes Australia, Heart Foundation, Bill and Melinda Gates Foundation, nib foundation, Rijk Zwaan Australia, WA Dept. Health, Meat and Livestock Australia, and Greater Charitable Foundation. She has consulted to SHINE Australia, Novo Nordisk, Quality Bakers, the Sax Institute and the ABC. She was a team member conducting systematic reviews to inform the Australian Dietary Guidelines update and the Heart Foundation evidence reviews on meat and dietary patterns.

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Salt is the most common form of sodium and is added to food during manufacturing, home cooking or at the table to enhance the taste or to extend the shelf life.

Most people have heard the advice to cut down on salt. That’s because high sodium intakes are associated with high blood pressure, a major risk factor for cardiovascular disease, heart attacks and strokes.

So the recent headline “Food myths busted: dairy, salt and steak may be good for you after all” was bound to grab-attention.

In the research article this headline is based on, the authors examined whether advice to substantially lower sodium intakes was supported by robust evidence.

The article’s premise is that current advice to limit sodium consumption to 2.3 grams a day is unachievable for most people in the long term. And it claims there isn’t good quality evidence to show lower salt intakes reduce the risk of heart attacks and strokes.

The authors suggest that current global sodium intakes, which range from 3-5 grams per day, are associated with the lowest risks for a heart attack, stroke or dying prematurely. And that heart attacks and strokes increase only when sodium intakes are higher or lower than this.

But there are a number of controversies about these claims, and the existing advice to limit salt consumption remains. Lets take a closer a look at some of the issues associated with these claims, as well as important research the authors missed.

Most of us could afford to cut down on salt

One teaspoon of salt weighs around 5 grams and contains 2 grams of sodium.

Australians consume about 3.6 grams of sodium per day, equivalent to 9.2 grams (about 2 teaspoons) of table salt.

This is higher than the suggested dietary target of 2 grams of sodium (5 grams of salt) per day and the adequate intake range of 460-920 milligrams (1.3-2.6 grams of salt) a day.

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Read more: Health Check: how much salt is OK to eat?

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Sodium intakes in Australia are similar to the rest of the world. Data from 66 countries, accounting for three-quarters of the world’s adult population, reported the average sodium consumption is 3.95 grams per day and ranges from 2.2 to 5.5 grams per day.

Yes, it’s possible to cut down on salt

Changing individual behaviour long term is challenging. But it’s possible.

A 2017 systematic review of dietary salt-reduction interventions found individual dietary counselling could reduce a person’s salt consumption by about 2 grams a day (equivalent to 780mg of sodium), over time periods up to five years.

Population-wide strategies that include reformulating manufactured food with lower levels of salt, improved labelling and mass media education were even more effective in some regions, reducing average salt intakes by around 4 grams a day in Finland and Japan.

The authors of the latest paper highlight a lack of studies in the population showing they’ve achieved dietary sodium intakes of less that 2.3 grams per day.

But this fails to acknowledge the challenges in conducting such a study to test that, or the importance of reducing your sodium intake relative to what you usually consume.

Cutting salt lowers your risk of heart disease

A recently published randomised trial across 600 villages in rural China shows cutting salt intakes can reduce a person’s risk of cardiovascular disease, heart attack and stroke.

The study included more than 20,000 people with high blood pressure who either had a history of stroke or were aged over 60 years. One group was randomly assigned to use a salt substitute to reduce their sodium intake. The second group continued to use regular salt. Both groups were followed up over five years.

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Read more: There is no great salt debate: we should be consuming less

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The intervention led to a reduction in sodium excreted in the urine (indicating complicance) and a reduction in blood pressure.

The rate of any major cardiovascular event, including heart attack, was 13% lower among those in the salt-substitute group compared to the regular salt group. The rate of strokes was 14% lower.

This trial demonstrates the benefit of reducing dietary sodium intakes, irrespective of a specific daily target.

Is it risky to have too little salt?

Humans need sodium to maintain essential bodily processes such as fluid volume and cell stability. Sodium levels are balanced though a sensitive system of hormones, chemical processes and nerves to ensure that sodium in excess of needs is excreted in the urine.

There is conflicting evidence about heart health when you have very low sodium intakes. Some researchers have suggested there is a J-shaped relationship, where both low and very high intakes increase the risk of poor outcomes (the end of a “J” shape), while the lowest risk is across a broad mid-point of salt intake (the curve in the “J”).

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Read more: Salt: how to cut back without losing that delicious flavour

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The J-shaped curve in some studies on salt and blood pressure can be explained by issues such as measurement error, random variation, other differences (in age, sex, smoking status or socioeconomic status), existing dietary patterns or other health problems, interactions between a major sodium reduction, and the body’s physiological pathways that regulate blood pressure.

Or it could be explained by reverse causation, where the people recruited into the study report low sodium intakes because they have already been advised to follow a low salt diet before enrolling in the trial.

While we wait for more research to explaining discrepancies related to a J-shape curve, the evidence overwhelmingly finds lower sodium intakes, compared to higher intakes, lead to important reductions in blood pressure.