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THE PATH AHEAD

Conflicts of Interest
Joseph Pizzorno, ND, Editor in Chief

n its October 12 issue, the British Medical Journal (BMJ) pub- bed with the pharmaceutical com-

I lished a relevant editorial on conflicts of interest as the term


applies to medical research publications. BMJ is to be con-
gratulated for proposing a very stringent policy, complete with a
panies, we may now become uncon-
sciously less rigorous when evaluat-
ing CAM research—in particular
form for authors to fully disclose potential commercial conflicts research from natural health manufacturers—that proves the
of interest. (And I might add, IMCJ also asks authors for such a efficacy of their products.
form, albeit a less comprehensive one. You can find our Conflict The issue of unfair advantage for Bioclinics Naturals is easy
of Interest form on our website www.imjournal.com by clicking to handle as I can simply recuse myself by handing off to other
on “Submissions.”) editors any studies submitted by the Factors Group and can be
Over the past decade, we repeatedly have seen disquieting sure to not mention them or their products in any future editori-
revelations on research authors having undisclosed financial als. (Interestingly, in early 2009, the Factors Group submitted an
associations with companies whose products they are supposed article that is currently going through peer-review. I will, of course,
to be objectively testing. Even worse is the more recent revelation recuse myself from the acceptance decision.) On a more subtle
involving the Journal of the American Medical Association (JAMA) note, when Bioclinic Naturals advertises in any Innovision Health
among others that some authors, for a fee, simply put their Media publications, my name and image will not be in the ads.
names on research articles written by drug companies. One won- The issue of unfair treatment of competitors is going to be
ders how a researcher can truly claim credit for publishing 500 much more difficult to handle. IMCJ has for many years had an
original research studies over a lifetime, much less over 10 years. editorial priority of strongly encouraging natural health product
The disclosure form is now posted on the website of the manufacturers to conduct direct research on their own products.
International Committee of Medical Journal Editors (www.icmje. We are very concerned that many manufacturers use borrowed
org/coi_disclosure.pdf ) and includes instructions and examples research—ie, they assert that research done by other companies
to help authors provide the needed information. applies equally to their products. The problem with this is that
The bottom line appears to be full disclosure as well as hon- there are so many variables in how, for example, an herbal medi-
est revelation of who actually has done the research. cine is processed that there is real doubt about just how compa-
However, readers of IMCJ may recall my editorial “How Do rable products manufactured by different companies really are.
We Get Better?” (IMCJ. 2008;7.4:8-10) where I cited an article Another problem is that many formulations are put together by
from JAMA that showed a more subtle form of conflict of inter- some very smart people who read the research and determine
est: The more drug research advertising a journal accepts, the less what should work. But really, how do you know that this appar-
likely it is to publish a study on CAM, and, if it does, the study is ently wonderful blood sugar–lowering formula really will do
almost always a negative one. what it says it does without actually trying it on real people? (One
This issue of potential conflict of interest is extremely chal- excellent article we recently ran on borrowed research was
lenging and should apply not only to the authors of journal arti- “Quality Assurance: The Difference Between Quality Control and
cles but also to those editors and peer reviewers associated with Quality Assurance Using an Example of Pomegranate Extract” by
the journal as well. Rick Liva [IMCJ. 2009;8.3:48-50].)
At IMCJ, we have spent a lot of time and editorial resources
My Own Conflict of Interest Disclosure helping to encourage, teach, and guide manufacturers to engage
So, time for my own full disclosure: I have become a consul- in real research. I realize this has not often been visible to you, the
tant to the Factors Group to develop a line of natural health reader, but I think you will agree that this is desirable.
products for healthcare professionals under the Bioclinic Naturals Unfortunately, in spite of all our efforts, most of the research
brand. You may shortly see my name and image with that of my submitted to us needs further refinement before it can be consid-
long-time friend and coauthor, Michael Murray, ND, in advertise- ered as original research. Happily, fellow editor David Riley, MD,
ments for the Bioclinic Naturals. editor in chief of Alternative Therapies in Health and Medicine, one
This relationship, of course, poses a potential conflict of of our sister publications, has made the excellent suggestion that
interest for me as the editor in chief of IMCJ. The obvious con- we add the category of Research Letters to accommodate such
cern is that the journal might give unfair advantage to Bioclinic submissions as another tier of research articles. (These letters will
Naturals in editorials, peer review, or article selection. Or per- be reports on original research that are between 600 and 1500
haps, as editor in chief, I will become biased against competitors. words of original text not published elsewhere.)
A more subtle concern is that, just as so many of us have cri- My intent is to continue to encourage manufacturers to
tiqued conventional medicine journals for being apparently in engage in research, and since IMCJ will welcome such research

8 Integrative Medicine • Vol. 8, No. 6 • Dec 2009/Jan 2010 Pizzorno—The Path Ahead
letters—clearly identified as such—I will actually be accepting Botanical alternatives to hormone replacement therapy are of
more research from supposed competitors. increasing interest to this group of women, and, in fact, peri-
In regard to unfair favoritism to the industry, all I can say is menopausal and postmenopausal women are among the most
that IMCJ has published more than 50 editorials, articles, and frequent users of botanical and dietary supplements. Useful
columns on quality control problems with natural health prod- herbs include black cohosh (Cimicifuga racemosa), chasteberry,
ucts. While I expect to continue to receive the occasional irate vitex (Vitex agnus-castus), dong quai (Angelica sinensis), ginseng
call or letter from a manufacturer, I can say with considerable (Panax ginseng), kava (Piper methysticum), kudzu (Pueraria mirifi-
determination that IMCJ will continue to be a force for improve- ca), maca (Lepidium meyenii), red clover (Trifolium praetense),
ment in the quality, safety, and efficacy of the agents we pre- rhubarb (Rheum rhaponticum), St John’s wort (Hypericum perfora-
scribe for our patients. tum), burdock root (Arctium lappa), licorice root (Glycyrrhiza
I also want to be clear that if my association with the glabra), motherwort (Leonurus cardiaca), wild yam root (Dioscorea
Factors Group is perceived to be a conflict of interest or in any villosa), and pycnogenol.
way taints the integrity and/or professionalism of the journal, I I am always intrigued by clinician/researchers who cre-
will step down as the editor in chief. It is actually a great oppor- atively conceptualize models to help us more deeply understand
tunity to bring this issue to the forefront, and I am proud that our patients. W. John Diamond, MD, writes on the sympathetic
IMCJ can once again be on the leading industry edge and open and parasympathetic nervous systems in “Allostatic Medicine:
up such a discussion. I am utterly committed to continuing to be Bringing Stress, Coping, and Chronic Disease into Focus.” This
an unbiased advocate for both the journal and the advancement article is not light reading. I found his discussion of the central
of good medicine. nervous system as the preeminent regulatory influence on somat-
A last point of consideration: There is also a reality factor for ic physiology useful. He suggests a newly coined anticipatory
all editorial disclosures. The vast majority of medical profession- regulatory concept called allostasis that permits bodily efficiency
als who are associated with journals—including authors, by matching resources to perceived or anticipated need. If this
researchers, and editors—generally do so on a part-time basis. need is not met, stress results. In turn, if the stress reaction is
This leaves time and finances that need to be filled. Liaisons with continuously activated, the allostatic system of stress-associated
commercial interests can be a win:win for both parties, so it is a reactions is also chronically activated, and this prolonged arousal
joining we will likely see continued in this field. leads to a wear and tear on the body, resulting in an inefficient,
So, what do YOU think? Letters to the editor, please. “bad” stress response.
Write IMCJ, 2995 Wilderness Place, Suite 205, Boulder, CO Our interview is with Mary Hardy, MD, and Anne Coscarelli,
80301; e-mail imcjsubmissions@innovisionhm.com; or send a PhD, of the Simms/Mann Center for Integrative Oncology, which
fax to 303.440.7446. is part of the Jonsson Comprehensive Cancer Center at the
Please be assured that if there are letters expressing concern University of California, Los Angeles. My friend Dr Hardy is the
over my involvement with the Bioclinic Naturals brand, these medical director and Dr Coscarelli is the director of the center. The
responses will be blinded before coming to me so I won’t know center was created based on the understanding that patients with
who sent them. We want to keep the conversation as open and cancer have diverse psychosocial needs, and many of those needs
receptive as possible. were not being met in other places. At the clinic, a patient’s needs
are assessed in a variety of areas: psychological, social support,
In This Issue nutrition and dietary supplementation, mind-body techniques for
In this issue, we have a special report on women’s reproduc- stress management, and physical appearance assistance. Based on
tive issues. Bethany Hays, MD, starts us off with another of her this assessment, the clinic offers services such as psychological and
incredibly insightful articles, this time on infertility. She focuses nutrition counseling, guided imagery and mindful meditation
on 4 mitigating factors in infertility: the external environment, the techniques, and a detoxification program.
internal environment, the intracellular environment, and the Sadly, Andrea McCloud, MFA, who has done such a good job
psycho-social-spiritual environment. Ways to address these areas conducting these interviews for us the past several years, is leaving
include cleaning up the patient’s environment with a diet of pri- to start a promising career in screenwriting. We will all miss her.
marily organic vegetables and animal products; normalizing Joel Kreisberg, DC, continues his Green Medicine Tips, this
insulin resistance, obesity, and inflammation with a balanced time considering indoor pollution. Tobacco smoke, mold, pesti-
antiinflammatory diet; and evaluating vitamin deficiency with the cides, chemical cleaners, radon, carbon monoxide, asbestos,
goal to replenish missing vitamins and minerals with a balanced formaldehyde, and lead are the “short” list of the most common
multivitamin, activated B-vitamins, and omega-3 fatty acids. household contaminants. Reading his article, I was reminded of a
Associate Editor Tori Hudson, ND, chimes in with another of patient I saw 30 years ago who became sick every summer but by
her clinically useful articles: “Botanicals for Managing Menopause- late winter was again symptom free. It turns out he worked as a
Related Symptoms—State of the Science.” Approximately two- painter until he got too sick and then would go back to college
thirds of women develop perimenopausal and menopausal until his funds ran out and he had to start painting again. I fol-
symptoms. Vasomotor symptoms are reported as the most com- lowed his toxic metals levels (using hair analysis) for several years
mon, followed by anxiety, mood changes (such as sadness or and found a remarkably consistent biphasic toxicity pattern. He
depression), sleep disruption, body aches, fatigue, and more. became so intrigued by the health effects of toxic exposure that he

Pizzorno—The Path Ahead Integrative Medicine • Vol. 8, No. 6 • Dec 2009/Jan 2010 9
later became a naturopathic doctor!
While John Weeks’s News and Analysis is always interesting,
I found this issue particularly compelling. Reading it gave me a
sense that the environment for our medicine is reaching a point of
transition where we move from constantly knocking on the door,
asking to be heard, to having a real place at the table. This was
particularly evident to me at the Hecht Foundation’s Dr Rogers
Award Ceremony that John mentions. As part of the awards cer-
emony, the foundation hosted an afternoon-long colloquium
where several of us (Jim Gordon, MD; medical acupuncturist Steve
Aung, MD; and CAM researcher Marja J. Verhoef, PhD; and I) who
have been working for so many decades to advance this medicine
discussed the future of CAM with a sold-out crowd of researchers,
clinicians, students, and healthcare administrators from across
Canada. For me, this was one of the most inspiring and encourag-
ing signs of the advancement of CAM I have experienced.
BackTalk by Bill Benda, MD. What can I say? Bill, as usual,
you are our Xantippe: You provoke us to think creatively. My
response, “Can’t we all just practice good medicine and get
beyond the tribalism?” A must read.

Joseph Pizzorno, ND, Editor in Chief


drpizzorno@innovisionhm.com

Errata

In the column by Joel Kreisberg, DC, “Preparing Patients for


Proper Sun Exposure,” published in the Aug/Sep issue (IMCJ.
2009;8.4:52-54), a paragraph on page 52 incorrectly used the
word melatonin vs melanin. It should read: “In addition, as a
person’s own melanin kicks in from repeated sun exposure,
there is less need for environmentally impactful sunblocks when
the person stays out for a longer time.”
Also on page 52, the second bullet point in column 2 misspelled
the word melanocyte in “increases in alpha melanocyte-stimulating
hormone, which limits DNA damage resulting from UV radiation.”
IMCJ apologizes for these errors and any confusion they may
have caused.

10 Integrative Medicine • Vol. 8, No. 6 • Dec 2009/Jan 2010 Pizzorno—The Path Ahead