The “Heart Healthy” scam

27. July 2008 William Davis (1)
Like many scams, this one follows a predictable formula.

It is a formula widely practiced among food manufacturers, ever since food products began to jockey for position based on nutritional composition and purported health benefits.

First, identify a component of food, such as wheat fiber or oat bran, that confers a health benefit. Then, validate the healthy effect in clinical studies. Wheat fiber, for instance, promotes bowel regularity and reduces the likelihood of colon cancer. Oat bran reduces blood cholesterol levels.

Second, commercialize food products that contain the purported healthy ingredient. Wheat bran becomes Shredded Wheat, Fiber One, and Raisin Bran cereals and an endless choice of “healthy” breads. Oat bran becomes Honey Bunches of Oats, Quaker’s Instant Oatmeal, and granola bars. Even if many unhealthy components are added, as long as the original healthy product is included, the manufacturer continues to lay claim to healthy effects.

Third, as long as the original healthy ingredient remains, get an agency like the American Heart Association to provide an endorsement: “American Heart Association Tested and Approved.”

The last step is the easiest: just pay for it, provided the product meets a set of requirements, no matter how lax.

You will find the American Heart Association certification on Quaker Instant Oatmeal Crunch Apples and Cinnamon. Each serving contains 39 grams carbohydrate, 16 grams sugar (approximately 4 teaspoons), and 2.5 grams fat of which 0.5 grams are saturated. Ingredients include sugar, corn syrup, flaked corn, and partially hydrogenated cottonseed oil. Curiously, of the 4 grams of fiber per serving, only 1 gram is the soluble variety, the sort that reduces cholesterol blood levels. (This relatively trivial quantity of soluble fiber is unlikely to impact significantly on cholesterol levels, since a minimum 3 grams of soluble fiber is the quantity required, as demonstrated in a number of clinical studies.) Nonetheless, this sugar product proudly wears the AHA endorsement.

Thus, a simple component of food that provides genuine benefit mushrooms into a cornucopia of new products with added ingredients: sugar, high fructose corn syrup, corn starch, carageenan, raisins, wheat flour, preservatives, hydrogenated oils, etc. What may have begun as a health benefit can quickly deteriorate into something that is patently unhealthy.

There’s a clever variation on this formula. Rather than developing products that include a healthy component, create products that simply lack an unhealthy ingredient, such as saturated or trans fats or sodium.

Thus, a ¾-cup serving of Cocoa Puffs cereal contains 120 calories, no fiber, 14 grams (3 ½ teaspoons) of sugar—but is low in fat and contains no saturated fat. Proudly displayed on the box front is an American Heart Association stamp of approval. It earned this stamp of approval because Cocoa Puffs was low in saturated, trans, and total fat and sodium. Likewise, Cookie Crisp cereal, featuring Chip the Wolf, a cartoon wolf in a red sweater (“The great taste of chocolate chip cookies and milk!”), has 160 calories, 26 grams carbohydrate and 19 grams (4½ teaspoons) of sugar per cup, and 0 grams fiber—but only 1.0 gram fat, none saturated, thus the AHA check mark. (Promise margarine, made with hydrogenated vegetable oil and therefore containing significant quantities of trans fats, was originally on the list, as well, but removed when the trans fat threshold was added to the AHA criteria.)

It is this phenomenon, the sleight of hand of taking a healthy component and tacking on a list of ingredients manageable only by food scientists, or asserting that a product is healthy just because it lacks a specific undesirable ingredient, that is a major factor in the extraordinary and unprecedented boom in obesity in the U.S. Imagine the chemical industry were permitted such latitude: “Our pesticide is deemed safe by the USDA because it contains no PCBs.” Such is the ill-conceived logic of the AHA Heart-Check program the "Heart Healthy" claims.

It’s best we keep in mind the observations of New York University nutritionist and author of the book, Food Politics, Marion Nestle, that “food companies—just like companies that sell cigarettes, pharmaceuticals, or any other commodity—routinely place the needs of stock holders over considerations of public health. Food companies will make and market any product that sells, regardless of its nutritional value or its effect on health. In this regard, food companies hardly differ from cigarette companies. They lobby Congress to eliminate regulations perceived as unfavorable; they press federal regulatory agencies not to enforce such regulations; and when they don’t like regulatory decisions, they file lawsuits. Like cigarette companies, food companies co-opt food and nutrition experts by supporting professional organizations and research, and they expand sales by marketing directly to children, members of minority groups, and people in develop countries—whether or not the products are likely to improve people’s diets.”

Qualms over just how heart-healthy their products are? Doubtful.
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Comments (1) -

  • jimray

    7/28/2008 3:26:00 PM |

    I want to print this out and post it on the wall of my office.  You have made clear what I have been trying to articulate for years. The labels do not always tell the truth. And ultimately it goes back to money. Thank you.

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Video Teleconference with Dr. William Davis

Video Teleconference with Dr. William Davis

2. December 2009 William Davis (0)

Dr. Davis is available for personal
one-on-one video teleconferencing

to discuss your heart health issues.


You can obtain Dr. Davis' expertise on issues important to your health, including:

Lipoprotein assessment

Heart scans and coronary calcium scores

Diet and nutrition

Weight loss

Vitamin D supplementation for optimal health

Proper use of omega-3 fatty acids/fish oil


Each personalized session is 30 minutes long and by appointment only. To arrange for a Video Teleconference, go to our Contact Page and specify Video Teleconference in your e-mail. We will contact you as soon as possible on how to arrange the teleconference.


The cost for each 30-minute session is $375, payable in advance. 30-minute follow-up sessions are $275.

(Track Your Plaque Members: Our Member cost is $300 for a 30-minute session; 30-minute follow-up sessions are $200.)

After the completion of your Video Teleconference session, a summary of the important issues discussed will be sent to you.

The Video Teleconference is not meant to replace the opinion of your doctor, nor diagnose or treat any condition. It is simply meant to provide additional discussion about your health issues that should be discussed further with your healthcare provider. Prescriptions cannot be provided.

Note: For an optimal experience, you will need a computer equipped with a microphone and video camera. (Video camera is optional; you will be able to see Dr. Davis, but he will not be able to see you if you lack a camera.)

We use Skype for video teleconferencing. If you do not have Skype or are unfamiliar with this service, our staff will walk you through the few steps required.
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Fish oil: What's the difference?

Fish oil: What's the difference?

10. December 2010 William Davis (27)
Ultra-purified, pharmaceutical grade, molecularly distilled. Over-the-counter vs. prescription. Gelcap, liquid, emulsion.

There's a mind-boggling variety of choices in fish oil today. A visit to any health food store, or any "big box" store for that matter, will yield at least several, if not dozens, of choices, all with varying and often extravagant claims of purity and potency.

So what's the real story?

Given the analyses conducted over the years, along with my experience with dozens of different preparations, I believe that several conclusions can be reached about fish oil:

Fish oil is free of contamination with mercury, dioxin, PCBs, or furans. To my knowledge, only one fish oil preparation has been found to have a slight excess of PCBs. (This is different from cod liver oil that has been found by one source to have a slight excess of PCBs.)

Oxidative breakdown products differ among the various brands. Consumer Lab (http://www.consumerlab.org/), for instance, has found that several widely available brands of fish oil contained excessive oxidative breakdown products (TOTOX). You can perform you own simple test of oxidative breakdown products: Sniff it. Your fish oil should pass the "sniff test." High quality fish oil should smell non-fishy to lightly fishy. Rancid fish oil with excessive quantities of oxidative breakdown products will smell nasty fishy.

FDA approval does not necessarily mean greater potency, purity, or effectiveness. It just means that somebody assembled the hundreds of millions of dollars to obtain FDA approval, followed by lots of marketing savvy to squash the competition.

This means that there are a number of excellent fish oil products available. My favorites are the liquid fish oils from Pharmax, Nordic Naturals, and Barleans. Capsules from Carlson, PharmaNutrients, and Fisol have also performed consistently. The "big box" capsules from Sam's Club and Costco have also performed well and are wonderfully affordable.
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Comments (27) -

  • Bill Millan

    12/10/2010 3:01:47 PM |

    I have engaged in more discussion about fish oil than any other supplement. Just remember we could care less about the fish oil, what we are after is the EPA+DHA Omega 3 in the oil. The rule of thumb is, "the higher the price, the more Omega 3." You can save money and get the 30% in the Kirkland or Sam's Club brand or spend a lot more money and get the 50% to 70% brands.

  • Bill Millan

    12/10/2010 3:01:47 PM |

    I have engaged in more discussion about fish oil than any other supplement. Just remember we could care less about the fish oil, what we are after is the EPA+DHA Omega 3 in the oil. The rule of thumb is, "the higher the price, the more Omega 3." You can save money and get the 30% in the Kirkland or Sam's Club brand or spend a lot more money and get the 50% to 70% brands.

  • arnoud

    12/10/2010 3:11:11 PM |

    Often I have wondered about the benefits, if any, of krill oil versus regular fish oil.    
    It seems that the Phospholipids in the Krill oil play a role in HDL quality.

    I have not yet found a good paper explaining this, but Neptune Technologies is doing some research on this.  I prefer whole foods, rather than drugs, but the research on this topic looks interesting.

    From their website on a research on concentrated phospholipids form krill oil:
    Neptune Technologies & Bioressources Inc. Reports Completion of Acasti Pharma Comparative Benchmarking Program versus Lovaza®



    Laval, Québec, CANADA – November 25, 2010 – Neptune Technologies & Bioressources Inc. (“Neptune”) (NASDAQ: NEPT - TSX.V: NTB) subsidiary, Acasti Pharma Inc. (“Acasti”), reports the completion of its  preclinical program designed to compare the lipid management effects of Acasti’s drug candidate CaPreâ„¢ versus prescription drug Lovaza®.  Blood lipids were monitored in two animal models in order to assess and compare the efficacy of CaPreâ„¢ and Lovaza® over a 12-week treatment period.

        * A low daily human equivalent dose of 1g CaPreâ„¢ reduced LDL-C (bad cholesterol) levels by 40% and increased HDL-C (good cholesterol) by 180% in a normal rat model (“SD”) while 4gr of Lovaza® did not show any significant effect.
        * An even lower daily human equivalent dose of 0.5g CaPreâ„¢ was shown to be as efficient as 4g of Lovaza® in reducing triglycerides levels by 40-50% in obese rats with severe diabetes and high triglycerides (“ZDF”)


    “These results suggest that a low (0.5g to 1g) daily dosing of CaPreâ„¢ is more effective than 4g Lovaza® in elevating HDL-C and lowering LDL-C and triglycerides.  These effects become even more striking considering that a 1g daily dose of CaPreâ„¢ contains 8.9 times less EPA and 11.1 times less DHA than the recommended 4g daily dose of Lovaza®. It is also important to note that the triglycerides reduction was observed only after 4 weeks and was maintained throughout the study suggesting a significant metabolic impact of CaPreâ„¢,” said Dr. Bruno Battistini, Senior Director, Pharmaceutical R&D of Acasti.

  • Geoffrey Levens

    12/10/2010 4:38:02 PM |

    If one brand showed slight excess of PCB's, does that mean all the rest also contained PCB's only just the right amount?

    What are the benefits to cardiovascular health of taking plant/algae sourced DHA vs fish sourced EPA/DHA?

  • Anonymous

    12/10/2010 4:54:31 PM |

    What do you think of the conclusions in this blog post?
    http://thehealthyskeptic.org/when-it-comes-to-fish-oil-more-is-not-better

    For a "healthy" person are your recommendations the same- as in make sure to get a high quality fish oil?

    I really appreciate you taking the time to write on this blog.  Thank you!
    Char

  • Jack

    12/10/2010 5:00:58 PM |

    or you could just eat natural food sources of omega-3, like wild salmon, tuna, sardines, grass fed butter, eggs from pastured chickens, fermented cod liver oil. then you wont need supplements.

    cheers
    jack k

  • Eric

    12/10/2010 5:20:40 PM |

    What if you can't stand the taste of fish like salmon and sardines or fermented cod liver oil?

    I'm hoping Carlsson's is good, that's what I've been taking for the past few months and I love how it tastes like lemon oil, not fishy at all.

  • Dr. William Davis

    12/10/2010 7:48:29 PM |

    While there is debate on the reduction in cardiovascular events with omega-3 fatty acids, I use them to achieve correction of a number of physiologic parameters:

    1) Reduction of triglycerides
    2) Acceleration of clearance of postprandial lipoproteins, such as chylomicrons, chylomicron remnants, and VLDL
    3) Reduction of lipoprotein(a)

    The data on the likelihood of cardiovascular mortality correlates inversely with RBC omega-3 EPA + DHA; the relationship is quite strong. While we lack prospective trials outside of GISSI Prevenzione on the reduction of cardiovascular death with higher levels, given the overall improved surrogate measures of risk, I believe that the data overall are sufficiently compelling.

  • Anonymous

    12/10/2010 8:49:01 PM |

    Funny, I've been reading up about this lately. I like the fact that if we can - there is the possibility of actualy getting the appropriate amount of EPA+DHA Omega 3's by eating fish. I recently started buying sardines just for this purpose and I'm going to try real hard to incorporate oily fishes. I like it when people help others minimize the amounts of supplements they use.

  • Anonymous

    12/10/2010 10:03:22 PM |

    dr. davis

    i can't smell anything rancid in my distilled fish oil with orange flavour but its so weird its too heavy barely digests and stays as if stuck in the chest. feels horrible.

    not sure what to make of it.

  • Pater_Fortunatos

    12/10/2010 10:07:40 PM |

    There are a few benefits of a plant based diet: avoiding acid load, toxin accumulation in the food chain, and another one, high lipid peroxidation level of the longer chain EFA.
    So I just heard that "Reduction of triglycerides" using fish oil, is an effect of liver damage.

    Just search for this book:
    "Fatty acids in foods and their health implications" - Ching Kuang Chow
    I just quote from the chapter V. MEMBRANE UNSATURATION AND LONGEVITY
    _______________________________
    In summary, the above mentioned studies provide a correlation between the maximum longevity of animals and the degree of unsaturation of membrane fatty acids. That correlation joins the previously stated one between the rate of mitochondrial oxygen radical generation and the maximum
    longevity of animals. In long-lived homeothermic vertebrates, both free-radical production and the
    membrane fatty acid unsaturation are lower, offering an explanation for some of the main causes of
    the low aging rate peculiar to these animals. No studies have been carried out on these aspects in
    relation to dietary fat and, as it will be stated below, this is another notable aspect of fatty acids and
    aging.
    _______________________________

  • John

    12/11/2010 2:35:55 AM |

    Is there an over-the-counter brand of fish oil that closely matches prescription Lovaza?

  • Jack M.

    12/11/2010 3:37:59 AM |

    westonaprice.org has very informative articles on this. Type "cod liver oil" in the search box to find their articles.  There is great info on how the better brands are manufactured.

  • William Trumbower

    12/11/2010 3:24:04 PM |

    A product similar in principal to krill oil is Vectomega.  It is a phospholipid bound salmon oil made from salmon heads.  The heads used to be discarded and this is a resource that doesn't deplete the food of whales etc.  According to the companies data, one tablet is the equivalent of eight standard capsules (probably 2.4gm of EPA+DHA).  It is a little pricey, but you will never burp it and it is very portable when you travel.  I suggest to my patients that if they regularly take much more than 2.5gm, that they get AA/EPA ratio available thru many labs.  yourfuturehealth.com,    LEF.org

  • Geoffrey Levens

    12/11/2010 4:57:33 PM |

    Supposedly DHA converts in the body to EPA pretty easily.  Anyone know any data about taking DHA alone vs with EPA?

  • Vlado

    12/11/2010 5:36:56 PM |

    to come from other side, I have started to read Ray Peat's articles and he is big on the dangers and overhype of non saturated fatty acids , in particular omega 3. It makes sense that humans having developed in hot climate require primarily saturated fat to protect from heat, light and oxygen. There is a reason why fish oils smell and why vegetable oils must be deodorized, it's basically our body telling us that non saturated oils are bad for us. Ray Peat says these oils make our membranes "floppy" and our skin prone to photo dammage by the sun. Basically we need all the saturated fat we can get primarily from coconut oil and butter but polyunsaturated fats should be minimum and certainly no supplement. Read up here
    http://raypeat.com/articles/articles/fishoil.shtml
    http://raypeat.com/articles/articles/membranes.shtml
    http://raypeat.com/articles/articles/unsaturatedfats.shtml

  • Anonymous

    12/11/2010 6:57:14 PM |

    I take at least 900 EPA + 600 DHA fish oil daily. I usually take 1-2 softgels with each meal. I continue to experiment with higher doses, but so far, I can't tell the difference between 5 softgels daily vs 10 softgels daily except 10 softgels means 50 extra calories. Sometimes I actually need extra calories, so I've taken as much as 40 softgels in one day.

  • rhc

    12/12/2010 2:30:31 AM |

    I guess I'm the only one who actually LIKES chewing my fishoil capsules. To me they are like a treat! This has the added advantage of knowing for sure if they are rancid. I've been getting Sundown Naturals for over a year - never had a bad one yet. The taste is very mild and I they never make me burp.

  • Anonymous

    12/12/2010 2:53:27 PM |

    dr. davis i d like to know your take on this

    http://raypeat.com/articles/articles/fishoil.shtml

  • Travis Culp

    12/12/2010 7:27:04 PM |

    I've found that Barlean's cod liver oil is least offensive taste-wise, followed by Spectrum. Both are molecularly distilled. I have trouble finding Barlean's, however.

  • Anonymous

    12/12/2010 9:45:55 PM |

    In declaring EPA and DHA to be safe, the FDA neglected to evaluate their antithyroid, immunosuppressive, lipid peroxidative (Song et al., 2000), light sensitizing, and antimitochondrial effects, their depression of glucose oxidation (Delarue et al., 2003), and their contribution to metastatic cancer (Klieveri, et al., 2000), lipofuscinosis and liver damage, among other problems.

  • Anonymous

    12/13/2010 4:56:56 PM |

    Dr. Davis,

    Should Vitamin D gelcaps have an odor? I've been taking a generic drugstore brand and they always have an unpleasant smell, but I assumed they were supposed to.

    Thanks!

  • Vin

    12/13/2010 7:29:14 PM |

    @arnoud - phospholipid-bound Omega-3 appear to get incorporated into membranes 1.5 to 2X more than triglyceride or ethyl ester Omega-3. But Neptune researchers have not explained why krill oil reduces LDL more than Lovaza.

    @Geoffrey Levens - just about every food product has small amounts of PCBs. Yes, fish oil too. Cod and Shark liver oils typically have much higher levels. More on fish oil and PCBs here.

    Retroconversion of DHA to EPA is not very efficient. Roughly 10% of DHA gets converted to EPA. EPA to DHA far less efficient. Several metabolic factors affect these conversions. Bruce Holub at Univ Guelph has done great work on this. Check out PMID: 9507234 and 9076673.

    @John - Several brands have 700 - 900 mg Omega-3 per pill, like Lovaza.

    A few have 20-30% more Omega-3 than Lovaza:
    Minami Nutrition CardiO3
    OmegaVia
    Ocean Blue Professional
    RenewLife come to mind.

    These all have over 1000 mg Omega-3 per pill.

    Next-gen fish oil (pipeline) drugs like Epanova and AMR101 are mostly EPA - so worth looking into high EPA OTC formulas for a fraction of the price.

  • Kevin

    12/14/2010 12:05:36 AM |

    $2000 per month doesn't seem so bad.  For the three of us, two adults and one 18yr old, we pay $2600 per month.  But my wife had cancer twice:  Hodgkins Lymphoma 24 years ago and breast cancer six years ago.  Before doing anything that might be dangerous, I remind myself of the $1500 deductable.  

    kevin

  • Anonymous

    12/15/2010 8:27:27 AM |

    dr. davis

    i did some research and to answer my own question on fish oil...
    for those without heart disease (like me) 1 gram of fish oil is sufficient and should be taken with 4 grams of saturated fat otherwise fish oil slips through the intestines undigested. 4 grams of saturated fat is used for making the liver start bile production.


    -----------------------------------
    original question

    dr. davis

    i can't smell anything rancid in my distilled fish oil with orange flavour but its so weird its too heavy barely digests and stays as if stuck in the chest. feels horrible.

    not sure what to make of it.

  • Buy Resveratrol

    1/13/2011 9:41:21 AM |

    It is good; however the oil came from the liver. It can contain too much Vitamin A and it could be dangerous if u overdose. I suggest sticking with eating a variety of fish.

  • Anonymous

    2/12/2011 10:33:52 PM |

    ah great info.......i live in the UK and I usually take different supplements, plz cud u tell me what should i look for while buying the fish oil....tnx in advance Smile

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Who is your doctor?

27. July 2008 William Davis (7)

Primary care physicians are the initial entry point for healthcare for the majority of Americans.

Develop pneumonia; go to your family or internal medicine physician (internist) to be prescribed an antibiotic. Need your blood pressure or cholesterol checked? Develop a sore knee or swelling in your leg? Once again, go to your primary care physician.

Image courtesy Dedde'


Primary care physicians are a patient’s guide to a bewildering array of technology and specialists. If you require a specific diagnostic test or consultation with a specialist, your primary care physician will help you navigate through the maze, choosing the path that is best for you. He or she will order a chest x-ray for a cough and fever, provide vaccines to prevent flu or pneumococcal pneumonia, perform an annual physical. If you require hospitalization, your primary care physician will admit you. He or she will order diagnostic tests like MRI’s, ultrasounds, x-rays, and blood testing, usually performed in the hospital or a hospital-owned facility. If you require the services of a gastroenterologist, orthopedist, general surgeon, or neurologist, your primary care physician will refer you to the appropriate specialist.

That’s how it’s supposed to work, at least in principle. In fact, during the first eight decades of the 20th century, it did work that work way for the most part. Your primary care physician acted not just as a provider of healthcare, but as your advocate, someone who knew you and worked to protect your welfare. Your family doctor often knew your parents, maybe even delivered you at birth, and cared for your children. His children often went to the same schools as your children. He and his family lived in the same town and sometimes went to the same church.

That hardly happens any more. It’s more likely you got the name of your primary care physician from a doctor referral service provided by a hospital. Or you picked a name off a list provided by your health insurer. It’s also common to see one doctor, only to see another a year later. Two, three, or more different primary care physicians over a five-year period are common. Doctors come and go, since physician turnover in clinics and practices has been on the increase for years. Insurance companies frequently force policyholders to change doctors, requiring you to choose from a list.

The end result of this shuffling of primary care is increasing impersonality of the relationship. You probably don’t know your primary care physician outside of the 10-minute interaction you had six months ago. She probably never met your mother and will likely not care for your children. Two years from now, she will likely not be your doctor any more, replaced by someone else who obtains the details of your health from a chart. Your chart is more likely to be electronic, with the details of your health history listed in a checklist. There’s little room to detail the idiosyncrasies and quirks of your unique personality or health profile. Throw into this impersonal equation the fact that many doctors have become scared of patients because of potential for lawsuits, often over the most trivial of issues, or because of an error of oversight or misdiagnosis.

This flawed and impersonal system, though emotionally unsatisfying, can still work if each doctor who assumes a patient’s care maintains the ethic of putting health and welfare above all.

But what if your primary care physician is not just an advocate for your welfare, but is a representative of the hospital? What if there are hidden, unspoken financial incentives paid to your doctor to direct you to the hospital for diagnostic testing, hospitalization, and referral to specialists? If a headache becomes a $4800 MRI, or chest pain becomes a $4200 nuclear stress test, then a $14,000 heart catheterization, your primary care physician becomes the purveyor of far greater financial opportunity for the hospital. The entire interaction, founded on the proposition that your doctor actually cares about you, collapses in a heap of financially motivated testing and procedures. It appears to work, and you and your family can still obtain access to healthcare. The problem is that you’re likely to get too much of it.

This message has not been lost on the shrewd administrators at hospitals. Take a look at the ranks of primary care physicians who refer patients to some of your local hospitals. It is typical that a hospital system maintains several hundred primary care physicians on their payroll, all of whom are expected to refer patients to the hospital, cardiologists, and other proceduralists. Why so many?

Most primary care physicians today have signed contracts with a hospital. In other words, they are employees of the hospital. This practice is not unusual: the American Medical Association reported that 4 of 5 primary care physicians are now bound by such employment arrangements across the U.S. In effect, 80% of primary care physicians are legally bound by contract to direct patients to cardiologists who work at hospitals.

On top of contractual obligations, there are financial incentives for the volume of procedures that are generated as a result of referrals. The more procedures generated from an internist’s or family practitioner’s practice, the greater the end-of-year productivity bonus will be, not uncommonly totaling tens of thousands of dollars. Dr. Ted Phillips (not his real name, since he declined to allow me to use it) received a bonus check of $9,437 this year for his “productivity,” defined murkily as the return on specialist referrals. While the bonus may have helped him pay for his son’s college tuition, it clearly was a situation that made him acutely uncomfortable when asked.

Several primary care physicians are also quietly dismissed every year from the ranks of employed physicians for not maintaining a minimum flow of patients into the system.

Another hazardous point of entry: Many patients enter the hospital through the emergency room (ER). A patient in the emergency room is at his or her most vulnerable, seeking help for an urgent complaint and usually willing to accept whatever the ER physician advises. Hospitals know this. That’s why many systems insist that the ER physicians be employees of the hospital, with their practice habits subject to control. A patient goes to the ER with chest pain or breathlessness. The worst thing that can happen from a financial standpoint is for the patient to be evaluated and discharged. For this reason, a growing number of hospitals employ ER physicians, then proceed to legislate practice patterns. Consulting a cardiologist is strongly encouraged, since they generally provide access to the downstream revenue-producing procedures offered in the hospital. That way, what might have been a four hour, $2500 ER visit is converted into a $10,000 to $40,000 hospital stay, even when nothing was wrong in the first place. There are millions of people nationwide who have the hospital bills to prove it after being discharged with a diagnosis of indigestion.

Caveat emptor: Buyer beware.
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Comments (7) -

  • JPB

    7/27/2008 4:45:00 PM |

    Wow!  This is an incredible conflict of interest!!  No wonder I have felt so much pressure to do this and that despite never being sick and having no symptoms.  

    How did medicine get to this point?  The better question is 'How can doctors live with themselves?'  

    We all know that everyone has to earn their living but but this milking of the system and of patients is truly horrible! It is especially insidious when you are dealing with someone you need to trust implicitly and who tells you that you need to do these things because he/she is worried about your health!

  • Jenny

    7/27/2008 5:15:00 PM |

    I thought you might be interested in this article on a physician in Arizona who is remodeling his practice to offer concierge health care.
    http://www.azcentral.com/business/articles/2008/07/23/20080723biz-elitedocs0724-ON.html
    As an advocate of free market solutions, I will be looking for a physician in my area with the same philosophy.  But I don't really expect to find one, as I am in an area dominated both by a State University Health System, and a Private University Health System. My own PCP is in the private University system.  We are asked to sign arbitration agreements with the University in case of  some untoward event (I refused, but I believe many patients believe they must either sign or go untreated, or else do not realize what they have signed.) Now the system has implemented a program that is ostensibly designed to help patients develop preventive health practices.  You are provided a liason person ( a nurse I assume) to check in with once/month by phone,and in that conversation you are asked about your goals and what you're doing to reach them, and given the usual status quo, conventional advice about concerns.  (This person will never even set eyes on you, after all.)   Still, it  doesn't sound bad, even sounds as if they are making genuine if nonsubstantive efforts toward helping people be proactive.  But I would not be surprised if the whole scheme were somehow rigged to the advantage of the University insurance plan, such as being enabling them to see if you are receiving more treatment (such as seeing an acupuncturist or chiropractor) than "they" think is appropriate or taking only the drugs "they" approve, and I also suspect that one day it will no longer be voluntary, and that you will be coerced toward only the practices they approve of.  Why are they offering payments for participation, is my question, and what do they do with the information you give them?  I will be opting out of that too.

    As far as free market solutions and the concierge model go, many will argue that it is too expensive and will only provide care for an elite.  The Arizona physician will charge a flat fee of $1500/year, and that will entitle his patients to direct access to him by phone or email, and at least 30 minutes of his time per visit.  His practice will have to be smaller than in the past in order for him to give more to each patient, but he will be able to actually practice medicine rather than be a cog in a corporate machine. Surely there are free market models that can be devised for the average person as well.  To object that the cost of modern health care is prohibitive may be simplistic.  Why is it prohibitive?   Can it be because the market does not function freely under the triple chokehold of insurance, drug company and government collectivism?    If patients and physicians were able to devise alternatives to the present environment of health care and PARTICULARLY if true, effective preventive practices (and many are already available at nominal cost but not promoted) became the norm, costs could plummet.  Hail to the pioneers such as Dr. Davis and the TYP members, and to the Arizona Concierge physician, who are striking out for new territory.  We will all benefit tremendously.

  • Bad_CRC

    7/27/2008 7:27:00 PM |

    Dr. Davis,

    Your fellow cardiologist Rich Fogoros also addressed this breakdown of the role of doctor as advocate, but he argues just the opposite: that PCPs today are essentially employees of the health insurance companies, tasked with controlling costs by minimizing tests, procedures, specialist referrals, etc., like claims adjusters.  His version certainly seems to be more true where I live.  I can't speak to the extent to which my PCP is under pressure to stay within a quota (however informal) for monthly rheumatologist referrals, CT scans, etc., or the degree such pressure taints his patient interactions, but I do know that he works in a clinic owned by the same (insurance) company to whom my employer and I pay my premiums, and that the same company also owns the local hospitals.  Clearly the profit-maximizing thing in such case is to maximize (healthy) policyholders and minimize claims (treatment).  There's no profit in gratuitous caths and bypasses when the hospital is the insurance company.  Fogoros claims that this sort of vertical integration became the rule when the HMOs bought up all the community hospitals and clinics in the late '90s.  A friend of mine (under my same plan) suffered a nasty GI tract problem and had to beg and fight her PCP, over 2-3 months of almost constant vomiting and other fun, for a referral to a gastroenterologist, who did finally diagnose and cure her.  The PCP was clearly in over his head, yet kept futilely giving her the same garden-variety pills (antiemetics, PPIs, etc.) and at one point told her, "Look, I can't just send everybody to the GI to have him say, 'Take the Purple Pill!'"  So Fogoros' "covert rationing" seems to go on in my town.  Can you reconcile that with what you're saying?

  • Anonymous

    7/27/2008 9:59:00 PM |

    All my adult life I've been told by doctors I have "borderline hypertension" (about 140/90). None, however, ever even suggested that I take an anti-hypertensive. Now I have atherosclerosis and can but wonder what might have been. Let mine be a cautionary tale.

  • Anne

    7/27/2008 11:34:00 PM |

    Not all insurance plans require a person to go through the PCP for referral to a specialist. I have seen patients who are seeing multiple specialists where it seems no one is in charge of the overall picture. These people may be given duplicate tests and incompatable medications. Doctors don't always communicate with each other. Shouldn't there be one chart that follows the patient from doctor to doctor?

    When I was seeing a university PCP I found it difficult to get tests such as vitamin D, B12 and A1C.
    Anne

  • Michael

    7/30/2008 11:13:00 AM |

    Practicing primary care in the US in the current environment is incredibly challenging, but still very rewarding. As an employed family physician in Massachusetts, I am pulled in many competing directions: the hospital encourages referrals and admissions into the system the patient's insurance company discourages some referrals and limits access to certain medications and expensive tests.  There is more paperwork and bureacracy than ever.  Patients are more informed now, and often come in with information, some of which literally may be based on one person's opinion from a website or blog.  There are often many issues to try to sort through in one visit, a visit which is often limited by time pressure that exist as doctors try to see more and more patients.

    Despite this, I still feel it is a privilege to be chosen as someone's family doctor.  I tell my patients that I will try to treat them like my family and give them the same advice I would give my mother or my daughter.  I see my role as their guide, and I try to lay out the different options, and then tell them which one I would personally choose, but that it is ultimately their body, and they get to make the decisions.

    What it comes down to for me is that medicine is still about the interaction between the doctor and the patient, and if a patient is unhappy with that interaction, then they have the right to try to find a new doctor where they will feel cared for.

    I had to also respond to Jenny's post about concierge medicine.  It is definitely an attractive option for some patients and physicians.  I once read it explained like this: "Imagine you're a plumber, and someone says I will pay you more money to do fewer plumbing jobs, so you can spend more time on each job, and really focus on doing the highest quality work you can, really get back to what it was that drew you to being a plumber."  Who wouldn't want that?  My problem is that it is not extrapolable.  If a primary care concierge physician only has 300 patients, there is going to be a huge shortage of primary care doctors in this country.  My training in both medical school and residency was oriented around taking care of all the patients that needed help, not just the few hundred that could afford an annual fee of several thousand dollars a year.

    There is a group of doctors who have come together in Seattle to practice medicine in a very intriguing model.  It is called Qliance (www.qliance.com).  It has some similarities to a concierge practice, but is much more affordable.  They don't take insurance, there are direct monthly costs that are charged to the patient which covers unlimited visits.  Additional tests are paid for by the patient.  This model financially aligns the patient and physician, and the usually-hidden costs of medicine are out in the open.  One physician who works there described it as very refreshing to feel that you are really working for the patient.  It won't be the answer for everyone, but it may be the answer for many.

  • Anonymous

    3/1/2009 5:06:00 AM |

    Anne posted that some patients are seeing multiple specialists without having a primary care doctor.  

    That's my predicament, and I wish it weren't so.  As an 57 year old woman with multiple annoying health problems including diabetes, hypertension, and some difficult-to-treat chronic pain (chronic daily migraine, neck problems), I can't find a PCP who will stick with me: They are apparently so unnerved by the list of maladies that I must deal with that they decide I must be crazy, not ill, and stop working on my behalf.  

    I just hate trying to be my own PCP!  I'm terrible at it!  The idea of having a PCP who would help me manage all this stuff is a dream!  And I haven't had a physical in over a decade because I can't keep a PCP.  And although my specialists kindly try to fill that gap in my treatment, I know that not having a PCP is dangerous.

    However even with my excellent insurance and ability to pay and living in an area with an unusually high number of doctors/capita, apparently I fall into a category of patient that PCP's just can't deal with.

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Fish oil and the perverse logic of hospitals

Fish oil and the perverse logic of hospitals

4. January 2007 William Davis (6)
Hospitals are now starting to carry prescription fish oil, known as Omacor, on their formularies. It's used by some thoracic surgeons after bypass surgery, since fish oil has been shown to reduce the likelihood of atrial fibrillation (a common rhythm after heart surgery).

Why now? The data confirming the benefits of fish oil on atrial fibrillation has been available for several years.

It's now available in hospitals because it's FDA-approved. In other words, when fish oil was just a supplement, it was not available in most hospitals. Whenever I've tried to get fish oil for my patients while in hospital, you'd think I was trying to smuggle Osama Bin Laden into the place. The resistance was incredible.

Now that FDA-approved Omacor is available, costing $130 dollars per month for two capsules, $195 for the three capsule per day dose for after surgery, all of a sudden it becomes available. Why would this irrational state of affairs occur in hospitals?

Several reasons, most of which revolve around the great suspicion my colleagues have towards nutritional supplements. In addition, there's the litigation risk: If something has been approved by the FDA, their stamp of endorsement provides some layer of legal protection.

However, I regard those as pretty weak reasons. I am, indeed, grateful that fish oil is gaining a wider audience. But I think it's absurd that it requires a prescription to get it in many hospitals. Imagine, as the drug companies would love, vitamin C became a prescription agent. Instead of $3, it would cost far more. Does that make it better, safer, more effective?

Of course, no drug sales representative is promoting the nutritional supplement fish oil to physicians nor to hospitals. I now see people adding the extraordinary expense of prescription fish oil to their presription bills.

In my view, it's unnecessary, irrational, and driven more by politics and greed than actual need. Take a look at the website for Omacor (www.omacorrx.com). Among the claims:

"OMACOR is the only omega-3 that, along with diet, has been proven and approved to dramatically reduce very high triglycerides..."

This is a bald lie. Dozens of studies have used nutritional supplement fish oil and shown spectacular triglyceride-reducing effects.

Their argument against fish oil supplements:

"Dietary supplements are not FDA-approved for the treatment of any specific disease or medical condition. Get the Facts: nonprescription, dietary supplement omega-3 is not a substitute for prescription OMACOR."

Does that make any sense to you? Should you buy a GM car because only GM makes genuine GM cars? This is the silly logic being offered by these people to justify their ridiculous pricing.

How about: "The unique manufacturing process for OMACOR helps to eliminate worries about mercury and other pollution from the environment."

Funny...mercury in fish tends to be sequestered in the meat, not the oil. Independent reports by both Consumer Reports and Consumer Lab found no mercury, nor PCB's, in nutritional supplement fish oil. But just suggesting a difference without proving it may be enough to scare some people.

Just because something is used by a hospital does not make it better. The adoption of fish oil is hospitals is a good thing. Too bad it has to add to already bloated health care costs to enrich some drug manufacturer.
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Comments (6) -

  • Cindy

    1/4/2007 3:38:00 AM |

    I'm not surprised at all. I've "met" people on forums that are on this, and they rave about how much better it is than non-prescription fish oil.

    Reminds me of years ago, when patients were given (in my area) "Anacin" in the hospital, then would ONLY take it for pain....other brands, or heaven forbid generic just didn't work as well!

    Amazing, huh?

    On the other hand, like you say, at least now they're giving it to patients.

    Now how about Mg? CoQ10? Are they starting to show up too?

  • Soundhunter

    1/4/2007 9:31:00 AM |

    Not sure if you find this interesting or not, but after stumbling on your blog not knowing anything about Pectus Excavatum, I went googlin' and got a bit depressed, as it's not as benign a malformation as I was led to believe.

    But I found this site http://www.ctds.info/pectus_excavatum.html which suggests that Vit D deficiency/rickets causes the malformation in many cases, and also that celiac disease might cause rickets in some due to malabsorbtion of vitamins/minerals etc.  I thought it was interesting as you've been posting about wheat and vitamin D and heart health, while perhaps they are also necessary for chest wall health.  I take heparin and low dose aspirin while pregnant to prevent fetal demise due to antiphospholipid antibody syndome (aware of that? causes blood clots), but I'm wondering if it somehow inhibited Vit D absorbtion in me when pregnant, couldn't have been a normal deficiency I was gardening in the sun during the entire pregnancy and I don't use sun block. I assume some of your patients are on blood thinners as I was? I know it effects calcium.

    As for fish oils, Udo's blends are supposed to be incredible, several moms I know use it on themselves for exhaustion and over all health, and many moms swear that fish oils have helped their toddlers with speech delays.

    Let me know if you'd rather I didn't yammer at your blog, I've linked to it from my little blog because I find your blog fascinating.

    Happy 2007

  • Soundhunter

    1/4/2007 10:08:00 AM |

    As for hospitals, well, there's a reason homebirthers and women into birth politics are as passionately anti-hospital as they are, many bad medical practises continue in the litigation crazed society of the USA medical system, from what I read. Forward thinking countries like Germany and Sweden incorporate natural remedies and holistic medicine right in with the mainstream medical system...great role models for us north americans, but impossible in a litigation-mad culture. But, the pharmaceutical companies are to blame too, though that discussion requires tin oil hats.

  • Dr. Davis

    1/4/2007 4:45:00 PM |

    Coenzyme Q10, no. Magnesium, yes. In fact, magnesium is pretty routinely checked and replaced via intravenous supplementation to avoid diarrhea. However, magnesium levels are checked because of heart rhythm disorders, not for general health.

  • Dr. Davis

    1/4/2007 4:46:00 PM |

    I know of no interaction between blood thinners and vitamin D. However, you're absolutely right on the increased likelihood of vitamin D deficiency in the presence of bowel diseases like celiac.

  • Cindy

    1/6/2007 5:47:00 PM |

    I use RxList.com to check any and all medications I am prescribed (or friends/family are prescribed).

    This about Omacor on their site:
    The empirical formula of DHA ethyl ester is C24H36O2, and the molecular weight of DHA ethyl ester is 356.55. Omacor®  capsules also contain the following inactive ingredients: 4 mg α-tocopherol (in a carrier of partially hydrogenated vegetable oils including soybean oil), and gelatin, glycerol, and purified water (components of the capsule shell).

    I mentioned in another comment that I am intolerant to soy, so I avoid it whenever possible.....but to put hydrogenated oils in a preparation touted as "pure"????

    I realise it's a very small amount....but from what I've read on trans-fats, the only amount of transfat that is good for us is NONE!!!

    Of course, the AHA also promotes foods that contain transfats in their "No Fad Diet" (see Regina Wilshire's blog post here: http://weightoftheevidence.blogspot.com/2005/07/aha-includes-trans-fats-in-heart.html)

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