By KELLY CARROLL

There is a dire need to raise awareness about heart disease in women. It is the number one killer of American women, and key data points reveal a lack of cognizance among doctors and women.

An assessment of primary care physicians published in 2019 revealed that only 22% felt extremely well prepared to evaluate cardiovascular disease risks in female patients. A 2019 survey of American women showed that just 44% recognized heart disease as the number one cause of death in women. Ten years earlier, in 2009, the same survey found that 65% of American women recognized heart disease as the leading cause of female death, revealing an alarming decline in awareness. 

Recent evidence suggests that many adults don’t know the important health numbers that can help identify heart disease risk factors, like their blood sugar and cholesterol. A 2024 survey of American adults conducted by The Ohio State University Wexner Medical Center found that only 35% of adults knew their blood pressure and 16% of adults knew their cholesterol levels. In comparison, the study reported that 58% knew their childhood friend’s birthday.

Heart Disease Risk Factors in Women

Women have specific risk factors for heart disease that don’t pertain to men. Nanette Wenger, M.D., a cardiologist and researcher, said in an American Heart Association (AHA) statement, “For most of the last century, heart disease was considered a problem for men, and women were believed to have cardioprotective benefits from female sex hormones such as estrogen. However, emerging evidence shows that there are a substantial number of heart disease risk factors that are specific to women or predominant in women.” Some gender-specific risk factors outlined by the AHA are early onset of menstruation, early menopause, autoimmune disease, anxiety, depression, and pregnancy complications.

Bethany Barone Gibbs, Ph.D., an associate professor at West Virginia University, emphasized in an email that pregnancy is a “critical window” for women’s cardiovascular health. She said, “The cardiovascular and metabolic challenge of pregnancy may unmask risk for conditions like hypertension and diabetes, but it is also possible (though not yet clear) that experiencing an adverse pregnancy outcome may independently contribute to the development of maternal cardiovascular disease.” A history of adverse pregnancy outcomes can be associated with more than two times the risk of cardiovascular disease later in life, she explained. 

Filling in knowledge gaps regarding the connections between pregnancy and long-term cardiovascular health is important to improving outcomes.

One knowledge gap is effective strategies to reduce future cardiovascular disease risk among people who experience adverse pregnancy outcomes. “Though we know these individuals are at much higher risk for poor outcomes, evidence-based approaches that are tailored to the postpartum years (which often includes subsequent pregnancies) are lacking,” Gibbs said. 

Gibbs is working to identify the optimal physical activity, sedentary behavior, and sleep patterns during the postpartum years that may reduce cardiovascular risk. “We are hopeful that we can identify which behaviors are most important for cardiovascular recovery following pregnancy and we can work with these populations to prioritize the most potent interventions to support heart health during the postpartum period,” she said. 

Signs of Heart Disease in Women

Knowing the signs of heart disease in women is an important part of saving lives. Men and women both commonly experience chest pain during a heart attack, but women are more likely than men to have other symptoms unrelated to chest pain. These symptoms include shortness of breath, nausea, vomiting, perspiration, indigestion, atypical fatigue, faintness and pain in the torso, neck, jaw, shoulders and arms.

A February 2020 study reported that women under age 55 display different heart attack symptoms and a wider variety of symptom combinations than men. The study’s lead author, John Brush, Jr., M.D., said in an AHA statement, “As a physician, if you’re looking at a woman, you need to think more expansively. She might not have the prototypical combination of features of chest pain, radiating pain down the arm, shortness of breath and sweating, which are often the examples given in textbooks.” 

It is also common for women to attribute their heart disease symptoms to another ailment, such as the flu, acid reflux or aging. Failure to recognize the symptoms of heart disease can cause women to delay seeking treatment. While chest pain is still the most common symptom of heart disease in both men and women, awareness of other heart disease symptoms can help women get treatment faster.

Heart Disease Prevention

Most heart disease cases are preventable. Wenger said in an AHA statement, “About 80-90% of cardiovascular disease is preventable. Implementing preventative strategies early could have a significant impact on reducing premature cardiovascular disease, stroke and related mortality for women.”

Lifestyle choices like maintaining a healthy diet and prioritizing physical activity can help prevent heart disease. Keeping a healthy weight and steering clear of tobacco products also support cardiovascular health. A person understanding her individual risks of heart disease and factors that may put her at higher risk, such as high blood pressure and diabetes, is also helpful. The AHA has outlined the top 8 factors for cardiovascular health, called Life’s Essential 8. They are: Eat Better, Be More Active, Quit Tobacco, Get Healthy Sleep, Manage Weight, Control Cholesterol, Manage Blood Sugar, and Manage Blood Pressure. 

Efforts to Raise Awareness and Understanding

National efforts are being made to raise awareness of heart disease in women. The AHA hosts the Go Red for Women campaign to fight cardiovascular disease in women. Circulation published the eighth yearly Go Red for Women issue featuring new cardiovascular research in women in 2024. The National Heart, Lung and Blood Institute also hosts a cardiovascular health education program called The Heart Truth. 

While these efforts are underway to improve heart disease outcomes for women, women need more. AHA laid out a constellation of strategies to improve women’s heart health in a May 2022 publication, and several deserve further emphasis here. To make progress, we need more and improved gender-specific cardiovascular disease training for healthcare providers. We need more collaboration between cardiologists, obstetricians-gynecologists, primary care physicians and other healthcare providers to improve the prevention and treatment of cardiovascular disease in women. We need more research on gender-specific cardiovascular disease to fill in knowledge gaps and improve prevention and treatment strategies. 

We also need more awareness. Spreading awareness of the risk factors and symptoms of heart disease in women can help save lives. Campaigns can help spread this message, and men and women sharing this information with other men and women can also help. If we all know the risk factors and symptoms of heart disease in women, all our mothers, sisters, daughters, neighbors and friends will be better off. 

More than 300,000 women in the U.S. died from heart disease in 2021. Let’s make sure that number is much lower in 2031 and beyond. 

Kelly Carroll is a freelance health writer based in Kentucky. More at her site

By ZOYA KHAN

A few weeks back, Matthew met with TestCard (another Brit like him) at TechCrunch Disrupt 2018. Greg, from TestCard, spoke to Matthew about how their device can test multiple different illnesses using urine and a clinical grade camera, which then spits out results (almost) immediately on your smartphone. Currently, the device can be used for detecting pregnancy, glucose, STIs, UTIs, and many more diseases. Their focus is on preventative care for patients, so they are working with insurance companies to use their product as a kit to diagnose problems that are prevalent in UK’s population. Not to mention their slogan is “A bit like Theranos, but our flagship products work.”

Zoya Khan is the Editor-in-Chief of THCB as well as an Associate at SMACK.health, a health-tech advisory services for early-stage startups.

Concern around the Affordable Care Act has reached a fever pitch, as Republican members of the House have succeeded at shutting down the government because the law has not been defunded or delayed. Meanwhile, a handful of states continue their efforts to undermine its implementation, which begins this week. While I by no means want to downplay the urgency of this situation, I would like to offer some reassurance as to the patient’s ultimate prognosis — as long as we remain committed to funding public health prevention efforts.

From 2000 to 2006, I served as minister of health in Mexico, where I spearheaded Seguro Popular, a comprehensive national health insurance program that enrolled more than 52 million previously uninsured persons, achieving universal coverage in less than a decade. In Mexico, as in the United States, introducing such a fundamental reform meant confronting special interests, making pragmatic trade-offs, and facing seemingly insurmountable challenges.

Every health system reform in an advanced nation has gone through such valley-of-death moments. That is the nature of the political process. For a variety of reasons, the United States is coming late to the global movement for expanded health care, the only one of the world’s 25 wealthiest nations lacking some form of universal care as of last year. National reforms inevitably go through great transitions, from vision to legislation, and then from legislation to implementation.

There is always a gap between the ideal vision and the ultimate design — and there are always times of fear that the whole endeavor will collapse under the weight of competing interests. Importantly, there is also no end to the reform process as every nation’s health system continuously evolves.

I believe that the Affordable Care Act will survive this current crisis.

Though securing the law may require further compromise, it is essential to hold fast to the elements that will assure its long-term health, especially funding for public health and prevention. The law’s architects recognized the critical importance of balancing expanded coverage with expanded prevention efforts. That is why they created the Prevention and Public Health Fund as a crucial component of the act. They recognized the paramount importance of prevention not only as a way to improve health but also as a cost-containment strategy.

Unfortunately, a movement is now afoot that would disregard this dual commitment, sacrificing prevention funding not only within the law but also elsewhere in the federal budget in a misguided effort to reduce costs. Already public health funds within the ACA have faced serious cuts, with the $15 billion multi-year commitment in the ACA reduced to $10 billion.

This is just the tip of a dangerous iceberg, as Congress also weighs cuts to the Centers for Disease Control and Prevention, the National Institutes of Health, and state health departments, all of which are critical to illness prevention. In an environment of budget deficits and sequestration, public health prevention efforts funded through the Environmental Protection Agency (for clean air and water), the Food and Drug Administration (to ensure drug safety), and other agencies must also be preserved if the Affordable Care Act is to actually be affordable.

Today people are living longer but are also spending more time living with chronic ailments. Over the course of the 20th century, global life expectancy soared by 30 years, 25 of which stemmed from public health advances such as improved sanitation, environmental advances, vaccine campaigns, and tobacco control.

Today, we are quite literally victims of our own successes, as we confront the burdens of long-term chronic illnesses. People are living with HIV/AIDS, living with diabetes, living with cancer. As the enormous baby boomer cohort ages, this trend will only accelerate.

Prevention may seem expensive, but in the long term it saves money. Consider that a scant 3 percent of current health care spending in the United States is now focused on prevention and public health, while a whopping 75 percent of health care costs are related to preventable conditions. The United States can — and must — do better, especially considering that its per capita health care spending is twice the average of other industrialized nations even as it still ranks a dismal 24th out of 30 for life expectancy.

Compromise is inevitable, but some things should be placed beyond the reach of politics — prevention funding is one of them. Making sure that sick people are getting care is a good thing, both for them and for society, but we must also prioritize upstream public health interventions to stop people from getting ill in the first place. Failure to do so will yield a vast and unnecessary increase in human suffering while also putting the nation on a fast track to insolvency. It will not save money. It will do just the opposite.

Julio Frenk is dean of the Harvard School of Public Health. This piece originally appeared in The Boston Globe.

A patient walked into clinic wearing only a hospital gown, feet bare and EKG wires trailing. Just hours after having surgery, his dementia had prompted him to wander out of the hospital and walk two miles to proudly show off his new surgical scar to a familiar face. Physically unharmed, his heart was easy to fix but his memory was beyond repair.

Though the road to a cure has long seemed insurmountable, dementia advocates have recently found reason to celebrate. Scientists announced this week the development of a new tool that may help identify people who are prone to Alzheimer’s disease, and Bill Gates has made a 100 million dollar pledge to join the fight. These vital research dollars give renewed hope to millions of families who already realize that by the time any kind of dementia is diagnosed, treatment options are incredibly limited.

With no current cure, prevention should be the primary focus but often remains ignored until it’s too late.

Commonly  termed “memory loss,” Alzheimer’s disease is actually a progressive death of nerve cells with associated decline in memory and function.  As more of the brain is affected as Alzheimer’s disease progresses, patients increasingly rely on caregivers, usually devoted family members.  Over 5.5 million Americans suffer from Alzheimer’s disease, costing our nation $259 billion, and leading to immeasurable physical and emotional toll in patients and caregivers alike.

Although Alzheimer’s disease is one of the top 10 causes of death worldwide prevention strategies are almost never addressed with younger age groups or before symptoms begin.

Luckily, we know of some strategies that everyone can use to lower your risk for Alzheimer’s disease. Here’s what you need to know:

1.   Memory loss: know what is normal.  Mild forgetfulness related to normal aging may include losing your glasses once in a while. But memory loss that impacts your daily life is not normal. If you’re not sure, talk with a care provider who can help test your memory.

2.Genetics matter, but it’s not everything. Have you talked to your family about memory loss and Alzheimer’s disease? If you have a family member with Alzheimer’s disease, that may mean you carry the gene that predisposes the individual for Alzheimer’s disease. However, just because you have family history, doesn’t mean that you will automatically develop the disease. Maintaining a healthy lifestyle can prevent these genes from “turning on” or expressing themselves with that negative health outcome.

3.    Lifestyle matters!  A healthy diet and physical activity prevents a host of chronic diseases, and Alzheimer’s disease is included in this.

a.     Eat like a heart patient. For diet, stick with heart-healthy options, including the DASH (Dietary Approaches to Stop Hypertension) or the Mediterranean diet, which both emphasize vegetables, fruits, whole grains, and limits sweets, salty foods, and red meat.  No Alzheimer’s disease diet has been tested or approved yet, but a large trial that combines the DASH and Mediterranean is underway.

b.    Just keep moving.  In particular, do enough activity to get your heart pumping 150 minutes or more per week, which increases blood flow to the brain. This is crucial for preventing Alzheimer’s disease and for preventing diseases that can impact brain health, like heart disease or diabetes.

c.Get a good night’s sleep, most nights. Not getting enough Rapid Eye Movement (REM or the restorative, dream-stage sleep) is related to higher risk of dementia and Alzheimer’s disease.  In particular, poor sleep can cause the formation of tangles in the brain that are characteristic of Alzheimer’s disease.

d.    Train your brain. The jury is still out on brain games, or cognitive training programs. There are commercial programs that aim to improve cognition, but the evidence is mixed for Alzheimer’s disease prevention. What may be more beneficial, especially over long-term, is to engage in enriching activities – learn a new language, practice dance, or play games that are challenging and fun.

e.Smoking is still bad. Actively smoking, especially in midlife, is related to developing Alzheimer’s disease later in life. If you needed another reason to stop smoking, add Alzheimer’s disease risk to the list.

4.     Chronic conditions increase risk. Physical and mental health are directly related to brain health. Certain chronic health conditions, including high blood pressure, heart disease, diabetes, and depression all increase risk for developing Alzheimer’s disease and other dementias. Getting treatment means taking one more step to preserving memory as you age.

Despite other medical advancements, Alzheimer;s̶< and other forms of dementia haven’t seen the major advances in treatment like other diseases in recent years. While researchers work to develop improved treatments, let’s focus on prevention. Regardless of your age, if memory loss is a topic that hasn’t come up in the exam room, it’s time to speak up.

Shannon Halloway is a postdoctoral research fellow at Rush University College of Nursing. Melissa D. Kalensky is an assistant professor at Rush University College of Nursing and a family nurse practitioner. They are both Public Voices Fellows through The OpEd Project.

Or…it’s complicated.

The New York Times today published a story titled, “No, Giving More People Health Insurance Doesn’t Save Money.” A piece of the argument is, as the author Margo Sanger-Katz puts it, “Almost all preventive health care costs more than it saves.”

What do you think? What’s the evidence? Leave aside, for the moment, the “big duh” fact that at least in the long term saving people’s lives in any way will cost more, because we are all going to die of something, and will use a lot of healthcare on the way. Leave aside as well the other “big duh” argument: It may cost money, but that money is worth it to save lives and relieve suffering. Leave that argument aside as well. The question here is: Does getting people more preventive care actually lower healthcare costs for whoever is paying them?

My thoughts? #1: No consultant worth his or her salt trying to help people who are actually running healthcare systems would take such a blanket, simple answer as a steering guide. Many people running healthcare systems across the country are seriously trying to drop real costs, and how you do that through preventive care is a live, complex and difficult conversation all across healthcare.

#2 thought: It depends. It needs analysis. It depends on which preventive tests, screens, and prescriptions you’re talking about, and how it is decided whom to help with them. Sanger-Katz’ article only shows that we cannot assume that every preventive screening or test saves money and/or is worth the money spent. Mammograms, for instance, show no benefit (no extra tumors caught, no lives saved) over breast exams alone (Canadian Breast Cancer Study, n=89,000 over 25 years).

This is true of many preventive items, including the annual checkup — it’s hard to show a true benefit from them. So yes, if you assume that every preventive test, screen, or prescription is worth it, and then you give more people access to those, you’ll end up spending more money. Equally important, the assumption is that you screen everyone, and you do it the most expensive way, like giving older people regular colonoscopies as a test for colon cancer. There are far less expensive ways to pre-screen people for that. This one assumption alone costs an estimated $10 billion per year in the U.S..

The problem is that these assumptions mean giving a lot of medical care, much of it not even effective, to people who are well. There are reasonable ways to narrow the focus of expensive, personal, procedural preventive care and maintenance to the 5% or so who really need it. Find that 5%, give them extra care, and you will save money.

Joe Flower is a healthcare futurist and author. He is a contributing editor with THCB.

“Where in the Affordable Care Act (ACA) does it mandate that every health insurance policy must include a free annual checkup?”

I posed this question to Al Lewis and Vik Khanna in the comments of their recent post entitled: The High Cost of Free Checkups, where they argue against the Affordable Care Act (ACA) provision that requires “free checkups for everyone.” They cite a recent New York Times Op-ed authored by ACA co-architect, Dr. Ezekiel Emanuel, that essentially debunks the link between annual checkups and overall health outcomes.  For Lewis and Khanna the solution is simple, we need to “remove the ACA provision that makes annual checkups automatically immune from deductibles and copays.” But for me there’s an enormous problem with their argument: The ACA doesn’t actually have any such provision.

After raising the issue in the comments section of the post, Mr. Lewis responded informing me that: “It’s definitely there” and “You’ll have to find it on your own, though — I unfortunately have to get back to my day job.” What Mr. Lewis doesn’t consider with his quick dismissal, is that I have already looked.  I’ve combed through the law and other policy guidance, rules and regs; searching for any mention of this required annual wellness exam, physical, visit, or any other linguistic derivative.  It doesn’t exist.

It turns out that while the law does require that an annual wellness visit be covered (sec. 4103. “Medicare coverage of annual wellness visit providing a personalized prevention plan”), this requirement is specific to Medicare beneficiaries and does not apply to individual or group plans. Beyond this particular section you won’t find any mention of a requirement within the ACA.

So what gives?  Lewis and Khanna aren’t the only ones who’ve mentioned this “free” Obamacare benefit. Even when researching this piece I had to engage in a lengthy discussion with a friend who is a healthcare policy advisor, unexpectedly defending my position. This claim has to be coming from somewhere, surely people smarter than me have gotten it right?

I suspect the confusion stems from the fact that the ACA makes preventive services free for virtually everyone.  But that’s not the same thing as saying everyone is entitled to a free annual checkup.  When you read sec. 2713. “Coverage of preventive health services” of the ACA, it basically says that in the Individual and Group markets, at a minimum, insurers must provide coverage (meaning they must pay 100% of the cost) for certain preventive benefits and services.  It goes on to state that those services are defined as “evidence-based items or services that have in effect a rating of ‘A’ or ‘B’ in the current recommendations of the United States Preventive Services Task Force;”

In other words, outside of a few mandated preventive services (such as visits for women and children only), the law leaves it up to this independent task force to determine what preventive services should be covered for free.  Several of these services aren’t available every year and in the aggregate, they don’t necessarily comprise all the services typically included in the annual wellness exam. As Dr. Emanuel points out in his Op-ed, the lack of evidence that annual checkups lead to healthier outcomes is the main reason that same task force “does NOT have a recommendation on routine annual health checkups.”

Propelled by a derisive political debate primarily concerned with the promotion or denigration of this new healthcare law, somewhere along the way we’ve gotten it twisted. And while I wouldn’t normally care, navigating the truths of the industry is complex enough.  It get’s that much more difficult when those truths are littered with negligent misinformation.

So, I’d like to take this opportunity to once again ask Mr. Lewis or Mr. Khanna: “Where in the ACA does it require insurance companies to provide a free annual checkup for everyone?” As a longtime reader of this blog I’ve always appreciated the provocative content, discussions, and thought leadership inspired herein; but I’ve never actually written anything.  In this case, I just felt strongly about correcting the record, because understanding the ACA doesn’t have to be your day job to care about the veracity of what you write.

Christian Gleason is a healthcare marketplace analyst with GetInsured.com

A predictable irony of the never-ending Affordable Care Act (ACA) debate is that the one provision that the Republicans should be attacking — free “checkups” for everyone — is one of the few provisions they aren’t attacking. Why should they attack them? Simple — checkups, on balance, are worthless. Why provide a 100 percent subsidy for a worthless good? Where is the GOP when you need it?

How worthless are checkups? Dr. Ezekiel Emanuel — one of the architects of the ACA and its “free” checkup centerpiece — recently recommended not getting them. As if “free” is not cheap enough, the ACA also pushes ubiquitous corporate wellness programs, which often pay employees to get checkups — or fine them if they don’t. This policy establishes a de facto negative price for millions of workers, making checkups the only worthless service on earth that one could get paid to utilize.

Those economics of a “negative price” trump Dr. Emanuel’s advice, and have made preventive care the fastest-growing component of employer health spending. Though hard statistics on checkups themselves are elusive, Dr. Emanuel estimates about 45-millon adult checkups are conducted each year, the equivalent of roughly 8 percent of America’s PCPs doing nothing but checkups, a curious use of their time when experts say the country could soon face a shortage of PCPs.

Shortage or not, subsidies and incentives might make economic sense if checkups improved health. However, when generally healthy adults go to the doctor for no reason, just the opposite is true: the Journal of the American Medical Association (JAMA) supports Dr. Emanuel assertion that annual checkups for asymptomatic adults are at best worthless, saying that additional checkups are “not associated with lower rates of mortality” but “may be associated with more diagnoses and more drug treatment.”

At worst, checkups are counterproductive. The British Medical Journal adds to JAMA’s conclusion that “important harms [of checkups] were not reported.” Overtreatment following overdiagnosis is the most common harm: Canada’s former prime minister spent six weeks in the hospital due to complications of a biopsy investigating two spots on his lung that, like most apparent abnormalities, proved completely harmless. No wonder Slate concluded: “If you’re not sick, don’t go to the doctor.” (One could also make the argument that the people who most need to have checkups are disproportionately the ones least likely to get them no matter what the economics.)

None of these findings discourage workplace wellness vendors, who — empowered by ACA provisions encouraging financial incentives for all preventive care — want physicians to order “biometric screens” during these checkups, or spend time discussing the screens performed at the employee’s worksite. As with the visits themselves, most of this screening has no value, and literally no one in health care other than wellness vendors and consultants who make their money off the practice defends annual screening. By contrast, there is no blood-based test that the United States Preventive Services Task Force (USPSTF) recommends be done annually on healthy people.

So checkups driven by an overzealous corporate screening agenda, for patients who participate largely due to the incentives or penalties, exacerbate the worthlessness of the entire endeavor by crowding out the most useful part of any patient-provider interaction, relationship-building, in favor of signing off on a screening report card allowing employees to get their money.

The solution to this orgy of overscreening and overdoctoring is remarkably simple: remove the ACA provision that makes annual checkups automatically immune from deductibles and copays; if they are going to be free at all, it should only be every few years. The proposal could still allow employers to override this provision — and even to attach money (incentives and penalties) to checkups — if they are willing to summarize the above-cited clinical findings for their employees.

If the only way they can continue the subsidy is by summarizing the literature, corporate human resources departments would predictably and immediately curtail this expensive corporate medical campaign. That would free up PCP time to work with patients who actually need medical care, while reducing counterproductive and costly healthcare utilization by those who do not.

Note: Just to show the bipartisanship of this proposal, this posting was written in collaboration with my Surviving Workplace Wellness co-author , Vik Khanna, who could never be confused with a Democrat.

Al Lewis is not related to Michael Lewis, although he is frequently mistaken for him on the street.  He is, however, together with his writing partner Vik Khanna, the author of Surviving Workplace Wellness the best selling guide to staying healthy in the Wellness era. 

Meaningful Use and Pay for Performance – two of the most talked about programs in healthcare IT over the past several years. They are both based on the premise that if you want to drive behavior change among providers and improve quality of care, you need to offer financial rewards to get results.

But what about the consumer? We have now entered a new era in healthcare where the consumer is rightfully front and center – AHIP is even calling 2014 the “Year of the Consumer.” Payers, and other population health managers, who until recently viewed consumers as claims, now want to “engage,” “motivate” and “delight” them.

The challenge, however, is that we are giving consumers more responsibility, but not making them accountable for the quality of care they provide for themselves.

Two weeks ago, Vik wrote a column for the The Health Care Blog on the now infamous meat-and-cheese study done by a team of researchers led by folks from USC. You can read the column, and the hilarious comments, here. I sent the column to one of the researchers, using the messaging available at LinkedIn. Here is that researcher’s response in its entirety:

I feel no need to get into a debate with someone who doesn’t understand basic statistics, how research is conducted, and has written a statement that is blatantly wrong. It does worry me that you are propagating yourself as an “expert” when you can’t seem to critically evaluate or understand a study. I know that this study is not perfect, hardly any are, especially in epidemiology, but the points you bring up in your blog are completely misconstrued and show very poor understanding of research methodology.

If you had actually read and understood the paper you would see that we controlled for waist circumstance [sic] and BMI. Also, this isn’t some random population of fat, low educated, American smokers, it is a nationally representative sample–unfortunately this is what the American population looks like. Finally, the idea that you think our supplemental tables house the real results illustrates your lack of understanding about statistics or how mortality models are run.

That being said, if you come up with a legitimate critique, I would be happy to engage in a friendly debate. When you attack something, I would suggest you make sure you understand it first, otherwise it is hard to legitimize anything else you say. I find it ironic that most of the push back from this paper has been from the general public who don’t have experience doing these types of studies, while for the most part, the scientific community (at least from people at R1 universities) has been fairly receptive.

We are glad to offer this legitimate critique, beginning with what we find in the very first sentence of the Results discussion that is not in the paper itself, but in the supplementary materials: “Using Cox Proportional Hazard Models, we found no association between protein consumption and either all-cause, CVD, or cancer mortality (Table S2).” Table S1 makes the point even more clearly: all-cause mortality in the low protein group was 42.9%. All-cause mortality in the high protein group was 42.9%, meaning that there is ZERO impact on overall mortality from protein variation at the extremes.

We may not be “experts” on biostatistics and epidemiology, but we do read pretty well, and we know the difference between controlling or adjusting the data and making correlations. Put simply, controlling the data for potential confounding variables eliminates them from consideration as causative agents for the effects seen in the analysis. Thus, controlling or adjusting the data is not even remotely the same as what I charged in my THCB column.

The researcher’s riposte that the study population is representative of the US population is preposterous on its face. While demographers don’t estimate the US population’s mean age, they do track its median age, which is just over 37. Thus, it is inconceivable that the population’s mean age is anywhere near 65 because people older than that die with alarming frequency. The US population is 63% white only, 13% black, 5% Asian, and nearly 17% Hispanic or Latino. Education is a little more complex, but broadly speaking there is no way that the average educational attainment in the US is less than high school. Amongst people over 16, 28% have ONLY a high school education and 17.6% have not completed high school. This means that the remaining 55% of the population has more than a high school education.

We do appreciate all the hard work that went into trying to adjust the data for every conceivable confounding variable. But even that yeoman effort appears to have been for naught because this population of older Americans has an all-cause mortality rate that is more than double the death rate for all people in the US over age 64each year. If nothing else, that establishes quite well that data from this portion of the NHANES sample is in no way, shape or form generalizable to the broader population.

We found the conflation of human data and mouse data to be a bizarre juxtaposition. In our combined 60 years of reading the literature neither of us can think of a single large-scale epidemiology study in which researchers sought to buttress their data (which in this case needed all the help it could get) with findings from a study of mice genetically engineered to be slugs.

As many people no doubt know, cancer has been cured many times in mice, but continues to plague humans. This scientific flotsam belongs with the nut study and Ancel Keys’ ludicrous and manipulative demonization of dietary fat, which somehow became gospel and helped to make us the fattest nation on earth.

Finally, there is this: in typical journal fashion, there is an anemic disclosure at the end of the article that Valter Longo “has equity interest in L-Nutra, a company that develops medical food. The other authors declare that they have no conflicts of interest.” If that’s true, what are L-Nutra “team members” Sebastian Brandhorst and Priya Balasubramanian doing on the paper without making disclosure of their affiliation with the same company?

Did they help to secure funding? Do they have a (sweat) equity stake? Are they paid in any way? Are they working for free on hopes of a big commercial payoff down the road? Where was the adult supervision of this work and the disclosures?

Vik Khanna is THCB’s Editor-At-Large for Wellness. He is also author of THCB’s next e-book, Your Personal Affordable Care Act: Making Yourself Scarce in the Dysfunctional US Healthcare System. Along with Al Lewis, he is co-author of THCB’s inaugural e-book, Surviving Workplace Wellness With Your Dignity, Finances and Major Organs Intact.

Alan Cassels is an expert advisor with EvidenceNetwork.ca, a pharmaceutical policy researcher, and the Author of Seeking Sickness: Medical Screening and the Misguided Hunt for Disease.

On Tuesday of this week (4/29/14), I was on the Katie Couric Show to discuss Integrative Medicine.

Somewhat ironically, I returned from Manhattan that same day to a waiting email from a colleague, forwarding me a rather excoriating critique of integrative medicine on The Health Care Blog, and asking me for my opinion.

The juxtaposition, it turns out, was something other than happenstance. The Cleveland Clinic has recently introduced the use of herbal medicines as an option for its patients, generating considerable media attention.

Some of it, as in the case of the Katie Couric Show, is of the kinder, gentler variety. Some, like The Health Care Blog — is rather less so. Which is the right response?

One might argue, from the perspective of evidence based medicine, that harsh treatment is warranted for everything operating under the banner of “alternative” medicine, or any of the nomenclature alternative to “alternative” — such as complementary, holistic, traditional, or integrative.

One might argue, conversely, for a warm embrace from the perspective of patient-centered care, in which patient preference is a primary driver.

I tend to argue both ways, and land in the middle. I’ll elaborate.

First, I am a card-carrying member (well, I would be if they issued cards) of the evidence-based medicine club. I am a conventionally trained Internist, and run a federally funded clinical research laboratory. I have taught biostatistics, evidence-based medicine, and clinical epidemiology to Yale medical students over a span of nearly a decade. I have authored a textbook on evidence-based medicine.

But on the other hand, I practice Integrative Medicine, and have done so for nearly 15 years. And I represent Yale on the steering committee of the Consortium of Academic Health Centers for Integrative Medicine.

Odd as it may seem, I consider these platforms entirely compatible. I did not go into Integrative Medicine because I believe “natural” is reliably better or safer than “scientific.” I respect the often considerable prowess of modern medical technology and pharmaceuticals.

And, frankly, I have never much cared whether a therapy derived from a tree leaf, or a test tube. I have cared about whether it was safe, and whether it was effective.

As an Internist taking care of patients for many years, one thing was painfully clear: I could not make everyone better. And while this deficiency might have been my personal shortcoming, it was much more than that. Modern medicine couldn’t make everyone better.

We tended to fall down particularly when it came to treating chronic pain, or chronic fatigue. We tended to stumble rather badly over any condition with “syndrome” in the title (as opposed to a “disease,” a “syndrome” is a description of symptoms generally lacking a clear explanation).

Integrative Medicine — a fusion of conventional and “alternative” treatments — provided patients access to a wider array of options. So, for instance, if medication was ineffective for anxiety or produced intolerable side effects, options such as meditation, biofeedback, or yoga might be explored.

If analgesics or anti-inflammatories failed to alleviate joint pain or produced side effects, such options as acupuncture or massage could be explored.

The array of potential options extends, of course, to herbal remedies and nutriceuticals as well — the apparent focus at the Cleveland Clinic. And, more controversially, it potentially extends to modalities that conventionally trained clinicians find implausible, such as homeopathy or energy therapies. I won’t get too deep into such weeds today, but have done so before.

Here are a few key considerations from my perspective.

1. Evidence is not a reliable differentiator of conventional and alternative medicine. By the standards that now prevail, more than 50 percent of conventional medical practice is not truly “evidence based.” Some years ago, colleagues and I were charged in a CDC grant to chart the evidence related to complementary and alternative medicine.

We would up inventing a technique called “evidence mapping,” since adopted by the World Health Organization and applied to an international traumatic brain injury program. Our finding was that in the realm of alternative medicine, some practices are rather well studied, some are understudied and some unstudied. Much like conventional medicine, in other words.

2. To the extent that evidence does differentiate conventional and alternative medicine, it’s often because — in the pursuit of evidence — cart and horse routinely swap positions and money cracks the whip. If the horse pulled the cart, then what gets studied would be what is needed, and what looks promising. But in our world, what gets studied often begins with what can be patented. It now costs nearly a $billion to bring a new FDA approved drug to market.

The only rationale for spending that much is the likelihood making back much more — and that only occurs when the product in question is exclusive and propriety, i.e., patented. There is a classic demonstration of the power of this influence.

More than a decade ago, a study of about 50 people followed for about three months was used to “prove” that coenzyme Q 10 was ineffective for treating congestive heart failure. At about the same time, a study of nearly two thousand people followed for years proved that the proprietary drug, carvedilol, was effective. The difference at the time was not really evidence — it was money.

A great deal more money was spent on the carvedilol trial — because no one can patent coenzyme Q 10.

More than a decade later, we now have evidence that coenzyme Q 10, when added to standard therapy for heart failure, can reduce mortality by as much as 50 percent. That is a stunning effect for something that has been “alternative” medicine all this time, and was declared useless by the conventional medical establishment.

Unless we are willing to practice money-based medicine, or patent-based medicine, we are obligated to recognize that the playing field for generating evidence is not level. It is tilted steeply in favor of patent holders.

3. Evidence is not black or white. It comes in shades of gray. Clinical decisions are easy if a treatment is known to be dangerous and ineffective, or known to be safe and uniquely effective. But what if a given patient has tried all the remedies best supported by randomized clinical trials, but has “stubbornly” refused to behave as the textbooks advise and failed to get better?

Or what if a patient just can’t tolerate the treatments with the most underlying evidence? One option is to tell such a patient: See ya! But I think that is an abdication of the oaths we physicians took. When the going gets tough, we are most obligated to take our patients by the hand, not wave goodbye.

To address this very scenario, colleagues and I have developed and published a construct that examines therapeutic options across five domains: safety; efficacy; quality of evidence; therapeutic alternatives; and patient preference. If a patient is otherwise running out of options and is in need, trying something that is likely to be safe and possibly effective — makes sense.

If there is something that is likely to be safer and more effective, then that should be used first.

But by recognizing and prioritizing the obligation to blend responsible use of evidence with responsiveness to the needs of patients that often go on when the results of large randomized, clinical trials have run out — we can wind up, inadvertently even, in the realm of Integrative Medicine.

That’s how I got here.

The needs of my patients led and I followed. And yes, the wider array of treatment options I can offer working side by side with my naturopathic colleagues absolutely does mean I have been able to help patients I otherwise could not.

Integrative Medicine should not involve a choice between responsible use of evidence and responsiveness to the needs of all patients. It should combine the two. We should do the best we can with the evidence we have, but recognize that high quality evidence may start to dwindle before our patient’s symptoms start to resolve.

We should resolve to confront this challenge with our patients, not leave them to fend for themselves.

The belief that treatments are intrinsically better just because they are “natural” is fatuous and misguided. Smallpox, botulinum toxin and rattlesnake venom are natural. Nature is not benevolent.

But the belief that conventional medicine is reliably evidence-based is equally fatuous. Much of what we do is simply tradition. And much of the evidence we get is more about money than other imperatives. Often in the world of alternative medicine, the problem is not evidence of absent effects — but a relative absence of evidence, in turn engendered by an absence of patents and financial incentives.

The history of coenzyme Q10 is a precautionary tale if ever there was one.

Integrative Medicine is not an invitation to supplant evidence with wishful thinking. It is an invitation to a wider array of treatment options, and the prospect of effectively addressing patient need more of the time. Realizing such potential benefits — at the Cleveland Clinic, or anywhere else — requires both open mindedness and careful skepticism.

It calls for a holistic view of the full array of therapeutic options, and the recognition that both conventional and alternative medicine are home to baby and bathwater. Differentiating can be hard — and we and our patients should be confronting that challenge together.

David Katz, MD, MPH, FACPM, FACP, is the founding (1998) director of Yale University’s Prevention Research Center, and author of  recently published book, Disease-Proof. This piece first appeared at The Huffington Post.