Has Evidence Based Medicine Come to a Moment of Crises?

Has Evidence Based Medicine Come to a Moment of Crises?

written by: Ms. Kathy Shattler
by: Ms. Kathy Shattler
Information science Information science

It had to happen sometime . . . health professionals don't agree with the evidence that created guidelines that we are to follow as standards of care. What happened? No one seemed to notice as the American College of Cardiology/American Heart Association released, with the blessings of the National Heart Lung and Blood Institute, the 2013 guide on Cholesterol, the guide to replace ATP III.

Ignored was the fact that guideline ES16 confidently stated that limiting dietary cholesterol did not have sufficient evidence to continue advising individuals to limit it in their food. Unreal – the program was called the National Cholesterol Education Program, but no one bothered to accumulate EVIDENCE that there is a relationship between amount of cholesterol eaten and plaque forming arteriosclerotic cholesterol plaque. So, the so-called new guidelines (ATP IV), or the 2013 release snuck in the statement that there is insufficient evidence to "restrict dietary cholesterol."

In fact, in the cardiovascular section of the Nutritional Care Manual (NCM), it still advises a restriction of dietary cholesterol to less than 200 mg/day. They also continue to recommend a diet distribution of 25-35% fat when the 2013 ACC guideline number ES11 states that a diet restricted in fat to 26-27% of total kcals has the greatest positive effect on lipid reduction. The Academy of Nutrition and Dietetics, who profess to practice by evidence based medicine and publish the Nutrition Care Manual, have been caught not upholding the very standards they ask us RDs to uphold. The NCM manual has not added the revised Asian BMI of 23 to our Assessment Criteria for the cardiology section, they ignored the % dietary fat distribution recommendation and they ignored the updated cholesterol guidelines for about two years before revising.

Cholesterol restriction can deplete our choline, a conditionally essential nutrient, to levels that can precipitate a deficiency. Cholesterol makes up a good share of the brain and the tissue making up our nervous system. That is one reason why blood cholesterol will traditionally go up in pregnancy as the fetus needs the cholesterol for brain and nervous system development.

Then today I opened my mail to find an article by David Templeton on how Scientists Debate the Impact of Removing Risk for Dietary Cholesterol. It took us two years to realize a change had been made? This is called "being on Top of Things". The researchers had ten years while everyone waited for ATP IV (which never came, just the 2013 ACC guidelines), to collect the data needed to make a decision on dietary cholesterol, but I guess no one was interested.

Quite a conundrum isn't it? To have therapies that work, but we shout "Where's the evidence?" and to have no evidence and complain because the lack of evidence changes our intuitive way of treating our patients?

I can see both sides of it as I lean towards integrative medicine. There are many therapies in integrative medicine we don't have "evidence" for but work. So, to be true to ourselves what is it going to be? Pick and choose the evidence to follow and then find out there is no real evidence? Is that being true to a commitment of "evidence based practice"? And, for those organizations professing evidence-based practice, what is the responsibility of that organization in keeping the stakeholders up-dated as to current evidence? What timeline should they set for themselves, two years? Is that reasonable?

We need to stop the talk and walk the walk. Part of that encompasses the overwhelming need for clinicians to learn statistics and how to design statistically significant studies. Oh, and do we need to study nematodes for 20 years (i.e. Resveratrol Supplement, very promising) before we get tough with clinical trials?? All of us need an upgrade our skills designing studies that do not waste our money, do what they are intended to do, have clinicians that know how to interpret methodology and outcome for themselves and to give back "evidence-base" as a statement to be respected, not questioned.

Mid-level Update: New Guidelines Out by the American Association of Endocrinologists- guidelines, among others, on glucose, lipids

Along with this organization, the American Heart Association sets guidelines -glucose, diabetes

Any reason for confusion, I wonder . . .

Kathy Shattler, MS,RDN

written by: Ms. Kathy Shattler

share this