Medical Flip-flops: Is It "Flip" to Call Them Flops?

I get baffled and bewildered. In my previous post, “The Comatose Cow”, I confess I’m baffled by wounded parrots and comatose cattle. I admit being bewildered by humans whose “stomach pain” is cardiac. And when the only medical history I’m given is, “He bottom falling out,” I own up to being clueless.

My stories took place in a small, distant, resource-poor country. But providing care in the wealthy, developed world can be puzzling, too. Especially when you’re faced with medical flip-flops.

In over 50 years practicing medicine, I’ve run into more medical U-turns than I can count. Enough at times to make my eyes roll, and wonder: is it me who’s flipped? Or has medicine flopped?

Take the cholesterol in your diet, for example. First we told you it was bad for you. Stern warning: Do not eat more than three egg yolks per week! Then we learned that there was “bad” LDL cholesterol (which accumulates in the plaques that narrow our arteries, causing heart disease and strokes), but also “good” HDL cholesterol (which lowers the risk of those nasty things). We told you about saturated fats, triglycerides, omega-3 fatty acids, and complicated calculations about risk-factors for coronary artery disease. If you understood it all, you deserved a university degree in nutrition.

But now, ladies and gentlemen, the cholesterol in your food is basically OK; kindly worry about trans fats, instead.

And don’t worry so much about dairy fat. For we now have the “PURE” (Prospective Urban Rural Epidemiology) study. It turns out that 2 daily servings of whole-fat dairy – milk and yogurt with 3.3% milk fat, and cheese with 31% fat – is associated with a lower risk of heart disease, stroke, and death from cardiovascular disease.¹

There are 6 key foods that, eaten in combination, may help us live longer: fruits, vegetables, legumes, nuts, fish, and whole-fat dairy products.² This healthy PURE diet isn’t overly high in saturated fat. The strength of this new study is its size and diversity: 245,000 people at different economic levels, from 80 countries, in five continents.

And whole milk tastes better than skim, trust me.

Medicine is full of sudden about-faces

Our knowledge can be short-lived even when based on the most rigorous scientific studies, on statistical analysis of randomized controlled trials. Our evidence-based guidelines for treatment need to change when the evidence supporting them changes. One of a doctor’s challenges is keeping up with all these changes.

Consider the flip-flops in hormone replacement therapy, or HRT. It was first touted as wonderful for you, pure and simple. It would not only stop menopausal symptoms, it would keep you feeling young, vibrant and sexy. It would reduce your chances of fractures, and heart disease; maybe even prevent Alzheimer’s dementia. It was prescribed almost routinely. Most women felt much better on HRT, and were grateful. Then came the surprising findings of the Women’s Health Initiative Study in 2002, startling the world with HRT’s dangers. Front-page stories reported the increased risks of heart attack, stroke, and cancer. Like most doctors, I stopped prescribing HRT almost overnight.

Many women were angry at their doctors for having prescribed it, putting them at risk. On the other hand, some patients were upset when their intolerable menopausal symptoms recurred. They begged me to put them back on HRT. Topsy-turvy medicine.

Today, yet another flip-flop. For selected patients, HRT has made a comeback. It’s once again OK. But only sort of. Not for everyone. You’re forgiven if you’re getting confused.

The flip side to flip-flops is the advancement of medicine

The food allergy world has had a shakeup, too. Peanut allergy, sadly, can be fatal. To prevent this from happening, for many years my colleagues and I warned parents not to give peanuts to their children before the age of three.

But clever researchers noticed that Jewish children in Britain were 10 times more likely to have peanut allergies than Jewish children in Israel. It turned out that the Israeli children were actually protected from developing allergy by their early exposure to peanuts. Starting in infancy, they were eating Bamba, a popular peanut-butter snack.

Now we recommend preventing fatal allergy by introducing peanut-containing foods to babies by 6 months. Even earlier in children with eczema who are at high risk of developing peanut allergy.³

We’ve learned. Our former advice, given with the best of intentions, leads to more deaths.

Infallibility

Is there a doctor who has never made a mistake? A lawyer who never erred in law? A painter or carpenter who never goofed?

Popes are supposed to be infallible, at least when they speak about faith or morality, but these days, even popes are held up to scrutiny.

We’ve come a long way from the god-kings of history who couldn’t be questioned – the monarchs of ancient Egypt, and the Roman Empire; of the Aztecs, and Japan.

Today most rulers are no longer permitted to play God. Nor are doctors.

Communicating the rapid changes in medicine isn’t simple. Getting new evidence from high-quality research out into day-to-day medical practice is known as “knowledge translation.” It can be confusing and upsetting.

Yet flip-flops are a sign of medicine’s continuing advancement.

So the next time your doctor does a U-turn, it’s probably for the best. The doctor hasn’t flipped. Medicine hasn’t flopped. Congratulations, you’re on the cutting edge of science. Smile – if you can.

Peter

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1. https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(18)31812-9/fulltext

2. https://academic.oup.com/eurheartj/article/44/28/2560/7192512

3. Feed Your Kids Peanuts, Early and Often, New Guidelines Urge, https://www.nytimes.com/2017/01/05/well/eat/feed-your-kids-peanuts-early-and-often-new-guidelines-urge.html