Another benefit of organic produce

I have noted elsewhere that conventionally grown vegetables must confer significant health benefits as all studies documenting the decreased cancer rates in those who consumed more than five servings a day were done on folks consuming the typical produce found in a grocery store. In other words, whatever negative effect there might be from consuming small amounts of pesticide residue were more than offset by all the good stuff that's in fruits and veggies. An important component of that "good stuff" are constituents called flavonoids. A recent study now shows that organic produce has twice as much of that good stuff as that which is conventionally grown.

The power of patient expectations

This recent article touts the power of patient expectations in the effectiveness of acupuncture. The author summarizes the study:

In analyzing the patients’ responses, the researchers found: “In our four randomized trials, patients with high expectations were more likely to report better outcomes than patients with lower expectations, both after treatment and four months later. The size of expectation effects is … clearly clinically relevant. This effect was observed both in patients receiving the ‘true’ and the minimal acupuncture.”¹ In fact, for patients with migraines², the number of patients who reported improvement was almost 60 percent and did not differ between those who got ‘true’ acupuncture and those who got “minimal [or sham] acupuncture.”

In examining this interesting phenomenon further, they speculated that perhaps a nurturing environment helps foster this positive attitude: “Intense and frequent provider-patient interaction, touch, needling pain, and an ‘exotic’ framework could make acupuncture a strong ‘ritual’ which is associated with stronger expectation effects than other interventions.”¹

Another possible explanation is that positive expectations can modify pain receptor pathways in the brain. As the researchers noted, “There is clear evidence from research on placebo analgesia showing that, in principle, expectations can modify pain perception in the brain. Several lines of research indicate that expectations associated with the application of placebos activate endogenous opioid systems, however, non-opioid pathways are also likely to play an important role … In summary, expectations of clinical benefit seem in general to be a major mechanism of placebo effects.”¹

The author then concludes:

Clearly, these study findings seem to emphasize that fostering a positive patient attitude toward acupuncture and Oriental medicine can have a pronounced influence on clinical outcomes. If patients understand and appreciate AOM, that alone might contribute to healing as much as the actual acupuncture procedure itself.

I am certainly all in favor of creating a nurturing, positive doctor-patient interaction. However, this should be no reason for cheering among acupuncturists. The combination of environment, expectations, and a non-specific opioid effect in the success of treatment is none other than the placebo effect. This is not to say that such body-mind interventions are not therapeutically desirable. They certainly are. However, there are a couple of thorny issues here. Since acupuncture is a very expensive form of treatment whose effects typically disappear at some point after treatment is discontinued, it is important that it is determined what mechanisms are truly at play so they may be incorporated into mainstream care without significant costs to providers or patients. In addition, a number of court rulings have made it clear that no therapy, no matter how effective, may be employed on a patient if deception is a factor.

If a provider knows that his treatment method is a placebo, but he pretends it is something other than that, he has committed both an ethical and criminal violation. It is called fraud. What this study and others like it suggest is that a method inducing a state of relaxation, suggestion, and non-specific opioid effects can have health benefits. If patients are told that this is what is happening to them when they see an acupuncturist instead of being handed some mystical mumbo-jumbo, that then obviates the issue of fraud. However, insurers should still only be expected to pay for such a therapy if there are no cheaper and equally effective alternatives. In fact, it is likely that guided relaxation, yoga, and meditation can yield similar results. Such therapies are not only cheap to administer, but patients can learn to do them on their own, resulting in long-lasting benefits. One of the reasons that acupuncture effects are short-lived is that they are passive on the patient's part. The patient will benefit more from an active approach to wellness. Acupuncturists, of course, have a vested interest in telling their patients otherwise, so caveat emptor.

Acupuncture effective for hypertension?

A new study is being touted as demonstrating that acupuncture is effective for hypertension. However, looking closely at the study reveals the following:

• It was not a truly "randomized, double-blind study" as the authors claim.
• There was an element of the placebo effect at play that could have skewed the results.
• The patients did not have significant hypertension to begin with.
• The results disappeared after treatment was discontinued.

While the treatment group did better than the sham group, the doctors administering the treatment would have known they were giving what they believed to be true acupuncture, thus introducing a bias that has been shown to impact patients in countless other studies. If a doctor knows he is using the therapy he believes to work, there are subtle clues he will unconsciously provide to his patients. This is not double-blind and has a high risk of placebo effects. The results, while statistically significant, were not clinically significant. As the author writes:

For example, before treatment, the mean 24-hour systolic/diastolic reading was 131/81 for the active group and 129/80 for the sham group. By the end of the six weeks of treatment, the active group mean systolic/diastolic was 125/78 and the sham group was 130/80. The active group daytime systolic/diastolic scores before and during treatment were 136/84 and 128/80, respectively. The daytime sham group scores were 133/82 and 134/82, respectively. The nighttime scores for the active group, before and during treatment were 120/73 and 117/72. The sham group's nighttime scores were 120/73 before treatment and 120/74 during treatment. Blood pressure changes during peak bicycle stress-testing were also measured, but the changes were not significant.

I say this is clinically insignificant because according to the American Heart Association:

Your blood pressure can change from minute to minute, with changes in posture, exercise or sleeping, but it should normally be less than 120/80 mm Hg for an adult. Blood pressure that stays between 120–139/80–89 is considered prehypertension and above this level (140/90 mm Hg or higher) is considered high (hypertension).

In other words, the patients in both groups had only borderline prehypertension to begin with and neither group had normal blood pressure at the end of the study. It should be noted that the main risk of prehypertension is the later development of true hypertension. It does not pose an imminent risk if MI or stroke. Also, since exercise stress did not result in significant differences between the groups, the true risk is probably negligible as exercise stress is often a precipitating factor for an MI. The study also does not appear to control for other variables that may have influenced BP such as stress, diet, etc. Changes such as the one shown is this study are within the range of effects often seen with slight changes in diet, exercise, or stress levels. Acupuncture is an expensive therapy. While it is not noted in the article, acupuncture is China typically performed daily or every other day, meaning six weeks of treatment yielding only temporary effects would cost an American over $1000 and in most cases would not be covered by insurance. Other more cost-effective approaches such as yoga, meditation, diet and exercise would likely be just as beneficial and much cheaper.