Measles/Vitamin A, Asthma/intravenous magnesium, Joint pain/food allergies

Modern Medicine Neglects the Basics, Part 2

By Alan R. Gaby, MD

In an editorial in the January 2020 issue of the Townsend Letter, I reviewed research showing that as many as 50% of patients with heart failure have iron deficiency; and that iron deficiency, even in the absence of anemia, is a strong and independent predictor of mortality in these patients. I also cited evidence that correction of iron deficiency can improve functional capacity, symptoms, and quality of life, and decrease the number of hospitalizations for worsening heart failure. However, despite the strong evidence of its clinical importance, iron deficiency is not being adequately evaluated or treated in heart failure patients. In a retrospective study of 10,631 patients hospitalized in Philadelphia for heart failure, only 1.5% had adequate laboratory tests for iron status. Moreover, of the patients who were tested and found to be deficient, less than half were given an iron supplement.¹ The editorial concluded that the widespread incompetence regarding this basic aspect of healthcare represents a system failure in modern medicine. As medical care continues to become more complicated and more specialized, we must remember not to forget the basics.

Since the editorial was written, other examples of how modern medicine is overlooking the basics have appeared in the medical literature. One study examined the use of vitamin A in children hospitalized in the United States with measles. Several randomized controlled trials have shown that vitamin A can significantly decrease morbidity and mortality in children with acute measles infection. The American Academy of Pediatrics recommends using vitamin A in severe or hospitalized cases, and the World Health Organization recommends vitamin A for all acute cases. The recommended dosage is 50,000 to 200,000 IU per day (depending on age) for two days. The new study was a retrospective review of 142 children hospitalized for measles in 52 US children’s hospitals that are considered “advanced” and that are said to adhere to “the most demanding standards of pediatric service.” Only 47 of the 142 children (33%) received vitamin A. Of those given vitamin A, 62% received 10,000-IU doses and 13% received 50,000-IU doses. None of the children were given the dosage that is currently recommended for their age.²

Another study examined the use of intravenous magnesium in children aged 2-17 years who were treated for acute asthma in one of seven emergency departments in the United States from 2012 to 2017. Systemic reviews and meta-analyses suggest that intravenous magnesium improves pulmonary function in asthmatic patients and may decrease hospitalizations by as much as 30%. Based on this evidence, guidelines from the National Heart Lung and Blood Institute of the National Institutes of Health recommend intravenous administration of magnesium as adjunctive treatment for asthma in the emergency department. In the new study, intravenous magnesium was administered in only 10.5% of 61,854 emergency department visits for acute asthma. The median time from triage to magnesium treatment was 154 minutes (interquartile range, 84-244 minutes). Of 22,495 children who required hospitalization after emergency department treatment, only 25.7% received intravenous magnesium. Transient hypotension occurred in a small proportion of children receiving magnesium, but the treatment was otherwise well tolerated.³

These examples may reflect the well-known bias in mainstream medicine against nutritional therapies. But they are more than that: they illustrate the fact that modern medicine too often delivers substandard care by failing to embrace safe, effective, low-cost treatment options. These two points are actually related, because being biased against nutritional therapies virtually guarantees that medical care will in many cases be substandard. That is because nutritional therapies are often safer, less expensive, and at least as effective as drug treatments.

As noted above, the practice of medicine continues to become more complicated and more specialized. Many doctors choose to become specialists so that they can be expert in at least one portion of the vast body of medical knowledge (and, of course, they also make more money). Ironically, however, achieving the best outcomes for patients often depends more on the doctor having broad knowledge of the basics than on being an expert in one narrow area. I am reminded of a patient I once saw, an adolescent male who had a five-year history of severe joint pain, as well as asthma, recurrent headaches, and severe abdominal pain. He was under the care of three different specialists for his various problems. None of these specialists had considered hidden food allergy as a cause of the patient’s symptoms. I recommended an elimination diet followed by individual food challenges, which implicated corn as a major symptom-evoking food. On a diet free of all corn products his joint pains, asthma, and headaches resolved rapidly, and his abdominal pain improved by 90%.

Medical schools, residency programs, and specialty organizations should review their curricula to make sure that trainees achieve proficiency in basic aspects of medical care. It will likely remain an uphill battle to convince these programs to embrace elimination diets and certain other nutritional therapies. At the very least, however, trainees should be required to be knowledgeable about those nutritional therapies that have already made their way into official practice guidelines.