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Why Patient Autonomy Is Critical To Good Health Care


Article Source: Health And Fitness Journal

Many of the patients that I treat have brain injuries. Whether caused by a stroke, car accident, fall, or drug overdose, their rehab course has taught me one thing: nobody likes to be forced to do things against their will. Even the most devastated brains seem to remain dimly aware of their loss of independence and buck against it. Sadly, the hospital environment is designed for staff convenience, not patient autonomy.

In the course of one of my recent days, I witnessed a few patient-staff exchanges that sent me a clear message. First was a young man with a severe brain injury who was admitted from an outside hospital. EMS had placed him in a straight jacket to control his behavior on his trip and by the time I met him, he was in a total panic. Sweating, thrashing, at risk for self harm. He didn’t have the ability to understand fully what was happening but one thing he knew – he was being restrained against his will. The staff rushed to give him a large dose of intramuscular Ativan, but I had a feeling that he would calm down naturally if we got him into a quiet room with dim lights and a mattress with wall padding set up on the floor. As it turned out, the environmental intervention was much more successful than the medicine. Within minutes of being freed to move as he liked, he stopped moving much at all.

Later I was speaking with one of my patients in the shared dining room. An aide arrived with a terry cloth bib to tie around his neck so that he didn’t spill anything during lunch. I saw a flash of anger in my patient’s eyes as he pulled the bib away from his neck with his good arm and placed the towel on his lap instead. I could tell that he found the bib infantalizing, though none of us had thought twice about it before. Here again, a patient did not appreciate having everything determined for him, right down to napkin placement.

Towards the end of the day, I was bidding farewell to a patient whose care would be provided by another attending physician going forward. I was summarizing my view of his progress and expectations for the future, and stopped to ask if he had any questions. What he asked completely flummoxed me. Instead of probing for details about his medical condition and treatment options, he asked, “Will the new doctor be a good listener? Will she pay attention to what I’m saying and be easy to talk to?”

It is unfortunate that healthcare providers and patients are often on very different wavelengths. In Atul Gawande’s recent book, Being Mortal, he argues that nursing homes have often failed to provide healthy environments for patients because they have focused exclusively on safety and meeting basic needs (eating, dressing, bathing, etc.) on their terms. The removal of patient independence unwittingly results in devastating loneliness, helplessness, and depression. It seems to me that hospitals end up doing the same thing to patients – if only for a shorter period of time.

I was moved by Gawande’s book (and I consider it required reading for anyone facing a life-limiting illness or caring for someone who is). It renewed my conviction about the importance of rehabilitation – helping people to become as functionally independent as possible after a devastating injury or disease. Even as we age, we all become less able to do the things we hold dear. Preserving dignity by prolonging independence, and respecting patient autonomy, are often overlooked goals of good health care. It’s time to think about what our actions – even as small as placing a bib around someone’s neck – are doing to our patients’ morale. Maybe it starts with asking the right questions… Or better yet, just watching and listening.

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The Unexpected Implications of Industry Involvement in Trans Fat Research


Article Source: Health And Fitness Journal


By Dr. Mercola

I’ve written many articles about the bias inherent in industry-funded research. As a general rule, when research is funded by the industry, the results are likely to overwhelmingly favor the industry’s preconceived stance.

When unfavorable results emerge, confidentiality agreements typically have been signed that prevent the research from ever seeing the light of day.

However, in a paper that I will summarize in this article, titled: “We Spent a Million Bucks and Then We Had To Do Something: The Unexpected Implications of Industry Involvement in Trans Fat Research,”1 author 

David Schleifer points out that, sometimes, industry research may also be the very thing that compels an industry to make a better, safer product. Such was the case with trans fat, he claims, noting that:

“American food manufacturers long denied that transfats were associated with disease… But in 1990, a high-profile study showed that trans fats increased risk factors for heart disease more than saturated fats did.

Industry funded a US Department of Agriculture study that they hoped wouldexonerate trans fats. But the industry-funded… study also indicated that trans fats increasedrisk factors for heart disease more than saturated fats.

Industry quickly began developing trans fat alternatives. This confirmsthat corporations get involved in science in order to defend their products. But involvement in science can be the very meansby which corporations persuade themselves to change their products.”

Food Industry Interests Can Be Flexible…

Food manufacturers have had to disclose trans fat content since 2006, based on the emerging scientific consensus that trans fat consumption in fact increases your risk of heart disease. At least a dozen US states also restricted the use of trans fat in restaurants.

“Dow AgroSciences estimated a 50 percent decrease in the use of partially hydrogenated oils in North America between 2006 and 2008. From 2002 to 2009, trans fats were replaced in approximately 10,000 American food products,” Schleifer writes.

According to Schleifer, this change of heart came about as a result of the food industry’s own findings, which showed that trans fats are indeed worse than the saturated fats they were designed to replace.

His paper goes on to analyze the development of scientific claims about trans fats, with the goal of showing how industry science can, at times, lead to positive change.

Paradoxically, I show that ‘meddling’ in science is precisely what led corporations to change their positions in the 1990s and replace trans fats in their products in the 2000s,” he says.


I give an account of what might be called hegemonic power by showing that industrial actors indeed tried to discredit potentially damaging findings about trans fats. But in their efforts to discredit those findings, industry ended up funding research that showed trans fats increased the risk of heart disease more than saturated fats did.


Rather than manipulating scientific claims in order to defend their products, industry actors changed their products in light of the scientific claims that they participated in producing.”

Schleifer points out that, in the late ’80s and early ’90s, many consumer advocacy groups actually praised food companies for replacing saturated fats with trans fats, which was widely, albeit wrongly, believed to be healthier.

For example, the activist organization Center for Science in the Public Interest (CSPI) actually notoriously promoted and defended the use of trans fats throughout the ’80s, urging food manufacturers to switch from saturated fat to trans fat. At the time, CSPI “relied on the same government reports that industry actors used when they defended trans fats,” Schleifer says.

Once the tide began to turn away from trans fats, trans fat manufacturers and related trade associations did resist by discrediting and downplaying damaging evidence. Some even engaged in more unsavory tactics involving intimidating scientists who produced the damaging findings.

The reasons for such activities are manifold, but  it usually boils right back down to money. New scientific claims can trigger costly regulations, and can impact sales, of course. 

So clearly, financial incentives are front and center when the food industry meddles with nutritional research. However, conducting research is also one of the ways that corporations “develop, adjust, and redirect their courses of action,” Schleifer insists.

Dr. Kummerow’s Surprise

Schleifer’s article includes a summary of Dr. Fred Kummerow’s lipid research, which is detailed in my previous interview with him (featured above). Dr. Kummerow’s work clearly demonstrated that it’s not cholesterol that causes heart disease; rather it’s the trans fats that are to blame. He was one of the first to make this association, and the first to publish a scientific article on it, in 1957.

Since then, research has repeatedly refuted the correlation between high cholesterol and plaque formation that leads to heart disease. Despite that, the saturated fat/cholesterol myth persisted far longer than seems reasonable, and in my view, industry resistance had an awful lot to do with that.

As a result, tens of thousands of lives have been cut short; the death toll rising with each passing year of inaction… Schleifer, on the other hand, is more forgiving in this regard, noting that:

“Kummerow’s story exemplifies the close connections between academic and industrial science and the sometimes hostile ways in which academics and industry interacted over trans fats…

In an article…[Robert Hastert of the Harshaw Chemical Company]   discussed a contentious presentation by Kummerow at the 1974 AOCS meeting that associated trans fats with disease.

‘Shouting matches between industry- employed oil chemists on the one hand and so-called ivory tower physiologists and nutritionists on the other are definitely nonproductive,’ Hastert wrote.

But Hastert referred to Kummerow’s presentation as an upsetting development ‘from within,’ rhetorically including academics and industrial scientists as part of the same world. The fats and oils industry looks to the health professions for guidance. Tell us, with at least a reasonably united voice, what you want and what you don’t want…While we may appear grumpy at times, especially when we feel we have been blindsided by ivory tower investigators, we are listening.”

Industry Scientists Try to Maintain the Status Quo

While Hastert claims the industry was listening, a number of industry scientists have been accused of limiting research on trans fats and aggressively refuting negative findings as they cropped up. Two mentioned by Schleifer are J. Edward Hunter, employed by Crisco maker Procter and Gamble, and Thomas Applewhite, who worked at Kraft.

“Hunter, Applewhite,and others often argued that the experimental diets in trans fats studies did not accurately represent real American diets,” Schleifer writes. “Mary Enig  published studies that associated trans fats with disease. Hunter, Applewhite, and others strongly criticized her claims….

While still a graduate student, Enig published an epidemiological article correlating trans fat consumption with cancer rates. Note that trans fats are usually associated with heart disease. Enig’s research associating trans fats with cancer is not unique, but it is rare. She has claimed that after her article was published, representatives from the major American edible oils trade association, the Institute of Shortenings and Edible Oils (ISEO), visited her office in person to intimidate her…

More than two decades later, Enig told a Gourmet magazine reporter, “They said they’d been keeping a careful watch to prevent articles like mine from coming out in the literature and didn’t know how this horse had gotten out of the barn”…

A Study Impossible to Ignore…

Under pressure from CSPI and the National Heart Savers Foundation, many food manufacturers began replacing saturated fats with trans fats in the late 1980’s. Then, in 1990, a study that has been retroactively regarded as the beginning of the end for trans fats was published in the New England Journal of Medicine (NEJM)… Schleifer writes:

“High levels of ‘bad’ LDL cholesterol are thought to increase the risk of heart disease. But high levels of ‘good’ high-density lipoprotein (HDL) cholesterol are also thought to protect against heart disease. Some types of saturated fats, such as stearic acid, for example, increase good HDL cholesterol.

[Lead author of the NEJM study] Martijn Katan was interested in whether and how trans fats affected good HDL cholesterol. He said that he did not have sufficient funding to address that question until Unilever hired a chief of nutrition who was willing to fund the research that became the NEJM study.

Katan and his graduate assistant Ronald Mensink fed diets based on monounsaturated, saturated, and trans fats to human subjects for three weeks per diet. Katan said the subjects’ cholesterol measurements ‘came out totally different from what I had expected and predicted.’

Trans fats raised bad LDL cholesterol and also ‘turned out to really lower HDL fairly dramatically.’  Katan’s experiment therefore suggested that trans fats increased the risk of heart disease more than saturated fats did. As per his agreement with Unilever, Katan showed them his results before publication. Like him “they were surprised. But they never tried to maneuver things or influence things… or to cover up.”

American organizations and trade groups, on the other hand, were quick to criticize Katan’s study, arguing that “the types and amounts of trans fats used in the Dutch study were not consistent with those found in the American diets.” However, the dam had been broken, and studies that followed only made the case against trans fats stronger.  A couple of studies that helped shift the position in the US included Walter Willett’s 1993 study that related trans fat consumption directly to heart disease.

According to Willett’s team, consumption of partially hydrogenated vegetable oils causes more than 30,000 deaths per year, courtesy of the trans fats these oils contain. Joseph Judd’s study, commissioned by the US soybean industry and performed by USDA researchers, also played a key role in shifting perception about trans fats. Judd’s team reconfirmed Katan’s findings. This USDA study also appears to have been a key piece of evidence that finally changed CSPI’s stance on trans fat as well.

Industry-Funded USDA Study Shifts Industry Stance in the US

According to Schleifer, the edible oil industry immediately began pondering solutions when Katan’s study came out, should it be proven correct by other studies. Many food manufacturers had traded saturated fat for trans fat in the 80’s, and were now unsure of what to do next.

“How did suppliers, manufacturers, and trade groups persuade themselves that trans fats really were a problem?” Scheifer writes. “A trade association representative told me that she brought food manufacturers, oil suppliers, and trade associations together into a group that she called the Trans Fat Coalition specifically in order to coordinate research that would address Mensink and Katan’s study. She emphasized that collaborating across corporations is a normal part of how industries ‘develop strategies on how to manage an issue.’

Another industry professional said that interfirm collaboration allows companies and trade associations to set industry-wide priori ties and to pool research funds. He explained that research committees meet regularly to talk about shared problems and opportunities, but that they exclude discussion of business in favor of science.

One industry professional who participated in the Trans Fat Coalition explained to me, ‘The industry itself wanted to get to the bottom on what’s going on with trans fat and they spent several millions of dollars through USDA in order to get the best science.’ The Trans Fat Coalition funded an existing USDA nutritional science laboratory to replicate Mensink and Katan’s experiment. This became known as the Judd study, after its lead author.

The industry coalition assisted Judd’s lab with research design and provided experimental materials meant to accurately represent the types and amounts of trans fats found in American diets. As one industry professional said, ‘It was completely the belief of this group that the Mensink and Katan study was not well done… and [Judd] would show that it wasn’t true.’ However, the Judd study in fact confirmed Mensink and Katan’s results.”

‘We Spent a Million Bucks, and Then We Had to Do Something’

The American Journal of Clinical Nutrition published the Judd study in April 1994, which concluded that: “trans fats raise LDL cholesterol to a slightly lesser degree than do saturates, and… may result in minor reductions of HDL cholesterol… The present study, together with that of Mensink and Katan and other recent investigations, indicates that dietary transfatty  acids may adversely affect plasma cholesterol risk factors for heart disease.”

One food industry employee interviewed by Schleifer claims that as soon as they were reasonably convinced about the health risks, they immediately set about to find a suitable replacement. According to Schleifer’s account, the interviewee stated that: “We spent a million bucks and… proved that the science was right, and then we had to do something.”

“Industry actors initiated the USDA Judd study specifically in order to disprove the Mensink and Katan study. This is troubling. But industry actors apparently felt they needed a scientific study, carried out in a nonindustrial laboratory, in order to know whether trans fats were a problem. This indicates the extent to which industry actors believe science matters,” Schleifer writes.

Should Industry Meddle with Science?

Schleifer believes the trans fat case shows two sides of the same coin. First, it confirms that industry indeed “meddles in science in order to defend their products.” But it also demonstrates that sometimes corporations will use negative findings to “persuade themselves that a product needs to be changed.” That’s a good thing. It’s unfortunate it doesn’t happen quicker, and more often, and in more branches of industry.  I personally feel there are a number of industries that have and continue to fight tooth and nail against evidence showing their products to be very harmful. The tobacco- and chemical technology industries are but two examples where you’d be hard-pressed to find any real shifts in position based on their own research.

“This returns us to the question of why industrial actors recalculated their positions on trans fats instead of digging in and resisting,” Schleifer writes. “Trade associations, suppliers, and manufacturers apparently expected to profit or at least to avoid trouble by replacing trans fats. The Unilever chief nutritionist who facilitated the NEJM study commented to the Washington Post about trans fats, ‘Unilever found that if you make yourself vulnerable by not being able to defend your product, you have big problems.’

But firms may be less likely to fight damning scientific findings when they can swap out troublesome aspects of their products and profit by doing so… Food companies may be particularly prone to introduce ‘new and improved’ products as part of their efforts to ‘grow’ their brands. Corporations may change products in order to get ahead of regulators and competitors. They may try to create new desires among consumers, whether for products free of trans fats, fortified with probiotic flora, or flavored with the latest antioxidant ‘superfruit.’

Other industries may be less able to be flexible than the food industry… Social scientists cannot assume that industrial involvement in science skews the truth…Industrial involvement in science can have a variety of consequences.

These include disturbing instances of suppression but they also include changing how firms manufacture their products. Social scientists have to closely follow how scientific claims matter to industrial action. We have to be vigilant in watching not only what corporations do to scientific claims but also what they do on the basis of those claims. All commercial products are manufactured and marketed by economically interested and presumably greedy corporations. But interestedness does not mean that industrial actors will necessarily prefer to keep their products unchanged.”


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Cartoon: How Some Surgeons Behave In The O.R.


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