“A good book may have the power to change the way we see the world, but a great book actually becomes part of our daily consciousness, pervading our thinking to the point that we take it for granted, and we forget how provocative and challenging its ideas once were--and still are. "The Structure of Scientific Revolutions "is that kind of book.”
Our current medical science paradigm that informs our healthcare system is hopelessly out of date. This is one of the main topics that I write about. When our current design came together, nearly 100 years ago, our understanding was limited by what we could see touch and feel. Oh, we could make slides of heart tissue and look at them under a microscope, but the old science was based on looking at the heart as a whole, the valves, the arteries, and veins, listening to the heartbeat, and feeling the heartbeat and pulse. It was all based on what we could see, touch, and hear. The EKG was developed in the early 1900s, but genetics, epigenetics, and human molecular biology were primitive. The other specialties were no different. That is how a system based or organ systems developed with specialties based on those organ systems. We have a medical science system based of diseases of organs and risk factors for those diseases.
I was a biology major in collage in the late 1960s. I took a course in genetics and our understanding was exceedingly primitive. DNA had only been identified in the 1950s and we were just beginning to learn something about that. The most common cause of death for Americans is heart disease. Our model there was also based on what we could see with the naked eye. Patients who died of a heart attack often had a history of chest pain and blocked arteries. It only made sense that opening the artery would protect patients from heart attack, and that is what our system is focused on to this day. That model is also based on what we can see, touch, and feel. If you examine a heart after death from a heart attack, you will find an artery that is blocked, usually by a clot. New science helps us understand that opening arteries does not prevent heart attack. Diet, exercise, and precision medicine do prevent heart attack and sudden death.
We also observed that chronic diseases like diabetes were “hereditary”. They clustered in families and we thought that was based in changes in the DNA code itself. We thought that the human genome project would solve all of the problems in chronic diseases. It would help us understand them and give us cures. It did not. When the mapping of the entire human genome was completed just 20 years ago, It did not give us the answers to chronic disease. It only gave us more questions. For example, only about 15% of heart disease and cancer is based on heredity—changes in the DNA itself. This leads us to the very new science of epigenetics, the new frontier in medicine. Seventy years ago, most people were slender and there was only one tenth as much diabetes. Our DNA did not change that much in 70 years. Type 2 diabetes is mostly due to family food culture.
It turns out that most chronic diseases are caused by changes in gene expression. Genes that are essential to fetal development become dormant in young, healthy adulthood, only to be reactivated later in life by overeating, abdominal fat, or smoking. All the DNA in your many cells were present in the fertilized egg at the moment of conception. Your development as a human being involved a perfect symphony of gene regulation. Just the right genes were turned on at just the right time, in just the right place, for just the right duration, and in just the right intensity, to make a perfect young healthy adult. One set of genes coordinates kidney formation in the fetus. Later in life—say at about age 50—these genes are reactivated by abdominal fat to cause chronic kidney disease, diabetes, and high blood pressure. Genes that are essential in early like, become less active in healthy young adults, only to be reactivated later in life to make us sick and kill us. Not only that, but these genes cause us to age more rapidly.
These realities should have a massive impact of the way we treat chronic illnesses. The changes in gene expression that cause chonic disease and make us age faster have effects on molecular biology that we can block very precisely. For example, losartan or lisinopril precisely block the gene effects that form a normal kidney in the fetus or cause chronic kidney disease in the adult. That is why these drugs cause kidney birth defects at birth or protect the kidney and every other cell and organ in old age. A system based on risk factors for heart attack and specialists for organ systems no longer fits our understanding of genetics, epigenetics, and molecular biology.
Dr. Milton Packer is one of the world’s leading experts on congestive heart failure and this quote comes from a journal that focuses on diabetes. He is discussing the new diabetes drug Jardiance. Jardiance lowers hospitalizations for congestive heart failure and progression of chronic kidney disease by 30% compared with other approaches the that achieve the same sugar level. The old paradigm says that it is all about the level of the risk factor glucose. That old science cannot explain this 30% difference. Dr. Packer says we need an entirely new model. “However, regardless of how their actions are envisioned, it is now critical for physicians to reconceptualize SGLT2 inhibitors (like Jardiance) as organ-protective agents rather than glucose-lowering drugs. The antihyperglycemic action of these drugs represents a tiny fraction of their broad portfolio of effects, which (when fully exercised) cause an adaptive reprogramming of stressed cells in a manner that promotes homeostasis and survival.” Translation: Jardiance does not produce this benefit by lowering glucose, it produces it by increasing activity of a master genetic metabolic switch called AMPK. It is an epigenetic effect. Here is the critical point. Jardiance provides these benefits whether the patient is diabetic or not. Metformin protects cells and organs in the same way for pennies on the dollar.
My last post was about a man who had terrible side effects from treatment aimed at the risk factor high blood pressure. Two comments asked how could the prior doctor have been so incompetent? I must defend him. Scientific paradigms are taught like fundamentalist religious dogma. “This is the framework within which you must understand medical science and treat patients.” He was merely doing what he had been taught to do. He was operating under the old paradigm and that is the point of the story.
Dr. Thomas Kuhn was a philosopher who wrote a landmark book explaining why changing scientific paradigms is so hard, and make no mistake, if we want better health at lower cost, that is the task we face. He analysed The Structure of Scientific Revolutions. “Kuhn challenged the then prevailing view of progress in science in which scientific progress was viewed as "development-by-accumulation" of accepted facts and theories. Kuhn argued for an episodic model in which periods of conceptual continuity where there is cumulative progress, which Kuhn referred to as periods of "normal science", were interrupted by periods of revolutionary science. The discovery of "anomalies" during revolutions in science leads to new paradigms. New paradigms then ask new questions of old data, move beyond the mere "puzzle-solving" of the previous paradigm, change the rules of the game and the "map" directing new research
In this post, I have been describing the accumulation of anomalies in the prevailing medical scientific paradigm. The anomalies are questions that are unanswerable under the old paradigm. It is time to move to a new medical scientific paradigm that is informed by genetics, epigenetics, molecular biology, and a precision medical approach that protects every cell and organ in the body. We can begin here and now. Join us in developing a system that produces better health at much lower cost.
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