Tuesday, November 1, 2016

The Benefits of Dark Chocolate, Placebos, and Safe Abortion in Ireland

Dark Chocolate: Compounds in cocoa called flavanols are believed to benefit cardiovascular health; a systematic review and meta-analysis of 19 randomized controlled trials of cocoa consumption was recently published in the Journal of Nutrition. Dr. Simin Liu, professor and director of the Center for Global Cardiometabolic Health at Brown University, who worked with epidemiology graduate student and lead author Xiaochen Lin, found that “cocoa flavanol intake may reduce dyslipidemia (elevated triglycerides), insulin resistance and systemic inflammation, which are all major subclinical risk factors for cardiometabolic diseases."  Flavanols are plant compounds found in many foods, and are especially high in tea, blueberries and cocoa. 
Liu noted some limitations in the trials. All studies were small and of short duration, not all of the biomarkers tracked in these studies changed for the better, and none of the studies were designed to test directly whether cocoa flavanol consumption leads to reduced cases of heart attacks or type 2 diabetes.
But taking into account some of these heterogeneities across studies, the team's meta-analysis summarizing data from 19 trials found potential beneficial effects of flavanol-rich cocoa on cardiometabolic health. There were small-to-modest but statistically significant improvements among those who ate flavanol-rich cocoa product vs. those who did not. "The treatment groups of the trials included in our meta-analysis are primarily dark chocolate -- a few were using cocoa powder-based beverages," Lin said. "Therefore, the findings from the current study apparently shouldn't be generalized to different sorts of chocolate candies or white chocolates, of which the content of sugar/food additives could be substantially higher than that of the dark chocolate."

Placebo Effects Conventional medical wisdom has long held that placebo effects depend on patients' belief they are getting pharmacologically active medication. A paper published in the journal Pain is the first to demonstrate that patients who knowingly took a placebo in conjunction with traditional treatment for lower back pain saw more improvement than those given traditional treatment alone.
"These findings turn our understanding of the placebo effect on its head," said joint senior author Ted Kaptchuk, director of the Program for Placebo Studies and the Therapeutic Encounter at Beth Israel Deaconess Medical Center and an associate professor of medicine at Harvard Medical School. "This new research demonstrates that the placebo effect is not necessarily elicited by patients' conscious expectation that they are getting an active medicine, as long thought. Taking a pill in the context of a patient-clinician relationship -- even if you know it's a placebo -- is a ritual that changes symptoms and probably activates regions of the brain that modulate symptoms."
Kaptchuk, with colleagues at Instituto Superior de Psicologia Aplicada (ISPA) in Lisbon, Portugal, studied 97 patients with chronic lower back pain (which causes more disability than any other medical condition worldwide.) After all participants were screened and examined by a registered nurse practitioner and board certified pain specialist, the researchers gave all patients a 15-minute explanation of the placebo effect. Only then was the group randomized into one of two groups; the treatment-as-usual (TAU) group or the open-label placebo (OLP) group.
The vast majority of participants in both groups (between 85 and 88 percent) were already taking medications -- mostly non-steroidal anti-inflammatories (NSAIDS) -- for their pain. (Patients taking opioid medications were excluded from the trial.) Participants in both the TAU and OLP groups were allowed to continue taking these drugs, but were required not to change dosages or make any other major lifestyle changes, such as starting an exercise plan or new medication, which could impact their pain.  In addition, patients in the OLP group were given a medicine bottle labeled "placebo pills" with directions to take two capsules containing only microcrystalline cellulose and no active medication twice daily. Patients who knowingly took placebos reported 30 percent less pain and 29 percent reduction in disability compared to control group. 'Open-labeling' addresses longtime ethical dilemma, allowing patients to choose placebo treatments with informed consent.
Dear Reader – this study could be interpreted in various ways – that the caring and interest of health-care providers is powerful, or that doing something for pain is better than doing nothing, or that we have strong cultural belief in the taking of a pill.  All of these are probably operative, but I think the caring and attention from a provider is the most powerful.

Safe Abortion in Ireland Women on Waves is a Dutch organization that sends the pills that can safely produce an early abortion to women in countries where abortion is illegal.  The British Journal of Obstetrics and Gynecology recently reviewed and published the results of 5,650 abortions done in Ireland with these medications.  All abortions were done at home.  Women
were diverse with respect to age, pregnancy circumstances, and reasons for seeking abortion. Study findings include:
                Among women completing early medical at-home abortion, 97 percent felt they made the right choice and 98 percent would recommend it to others in a similar situation.
                The only negative experiences commonly reported by women were the mental stress caused by pregnancies they did not want or felt they could not continue, and the stigma, fear, and isolation caused by current restrictive abortion laws.
Women with financial hardship had twice the risk of lacking emotional support from family and friends.
The author of the article stated
“Women in Ireland and Northern Ireland accessing medical abortion through online telemedicine report overwhelmingly positive benefits for health, wellbeing, and autonomy ,This examination and subsequent findings provide a new evidence to inform the policy debate surrounding abortion laws in Ireland and Northern Ireland.”  

Sadja Greenwood, MD, back issues at sadjascolumns.blogspot.com

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