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“And one more thing” about Steve Jobs’ battle with cancer

I’ve written quite a bit about Steve Jobs in the wake of his death nearly four weeks ago. The reason, of course, is that the course of his cancer was of intense interest after it became public knowledge that he had cancer. In particular, what I most considered to be worth discussing was whether the nine month delay between Jobs’ diagnosis and his undergoing surgery for his pancreatic insulinoma might have been what did him in. I’ve made my position very clear on the issue, namely that, although Jobs certainly did himself no favors in delaying his surgery, it’s impossible to know whether and by how much he might have decreased his chances of surviving his cancer through his flirtation with woo. However much his medical reality distortion field might have mirrored his tech reality distortion field, my best guess was that Jobs probably only modestly decreased his chances of survival, if that. I also pointed out that, if more information came in that necessitated it I’d certainly reconsider my conclusions.

The other issue that’s irritated me is that the quackery apologists and quacks have been coming out of the woodwork, each claiming that if only Steve Jobs had subjected himself to this woo or taken this supplement, he’d still be alive today. Nicholas Gonzalez was first out of the gate with that particularly nasty, unfalsifiable form of fake sadness, but he wasn’t the only one. Recently Bill Sardi claimed that there are all sorts of “natural therapies” that could have helped Jobs, while Dr. Robert Wascher, MD, a surgical oncologist from California (who really should know better but apparently does not) claims that tumeric spice could have prevented or cured Steve Jobs’ cancer, although in all fairness he also pointed out that radical surgery is currently the only cure. Unfortunately, he also used the failure of chemotherapy to cure this kind of cancer as an excuse to call for being more “open-minded” to alternative therapies. Even Andrew Weil, apparently stung by the speculation that Jobs’ delay in surgery to pursue quackery might have contributed to his death, to tout how great he thinks integrative cancer care is.

Last week, Amazon.com finally delivered my copy of Walter Isaacson’s biography of Steve Jobs. I haven’t had a chance to read the whole thing yet, but, because of the intense interest in Jobs’ medical history, not to mention a desire on my part to see (1) if there were any new information there that would allow me to assess how accurate my previous commentary was and (2) information that would allow me to fill in the gaps in the story from the intense media coverage. So I couldn’t help myself. I skipped ahead to the chapters on his illness, of which there are three, entitled Round One, Round Two, and Round Three. Round One covers the initial diagnosis. Round Two deals with the recurrence of Jobs’ cancer and his liver transplant. Finally, Round Three deals with the final recurrence of Jobs’ cancer, his decline, and death.

Before I start, a warning: I’m going to discuss these issues in a fair amount of detail. If you want “medical spoilers,” don’t read any further. On the other hand, one spoiler I will mention is that there was surprisingly little here that wasn’t reported before; the only difference is that there is more detail. However, the details are informative.
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Posted in: Cancer, Nutrition, Science and the Media

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Steve Jobs’ medical reality distortion field

As I pointed out in my previous post about Steve Jobs, I’m a bit of an Apple fan boy. A housemate of mine got the very first Mac way back in 1984, and ever since I bought my first computer that was mine and mine alone back in 1991 (a Mac LC), I’ve used nothing but Macintosh computers, except when compelled to use Windows machines by work—and even then under protest. Indeed, as I searched for jobs at various times in my life, I asked myself whether I could accept a job at an institution that didn’t permit me to have a Mac in my office, such as the V.A. Fortunately, I never had to make that choice. All of this explains why I paid a lot of attention to Steve Jobs and also why his death saddened me and, relevant to this blog, the clinical history of the cancer that killed him fascinates me.

It’s often been said that there was a sort of “reality distortion field” around Steve Jobs. It was a part joking, part derogatory, part admiring term applied to Jobs’ talent for persuasion in which, through a combination of personal charisma, bravado, hyperbole, marketing, and persistence, Jobs was able to persuade almost anyone, even developers and engineers, of almost anything. In particular, it referred to his ability to convince so many people that each new Apple product was the greatest thing ever, even when that product had obvious flaws. Unfortunately, as more news comes out about how Steve Jobs initially dealt with his diagnosis of a neuroendocrine tumor of the pancreas (specifically, an insulinoma) back in 2003 and 2004, it’s become apparent that Jobs had his own medical reality distortion field, at least in the beginning right after his diagnosis of a rare form of pancreatic cancer, that allowed him to come to think that he might be able to reverse his cancer with diet plus various “alternative” modalities.

In the immediate aftermath of Steve Jobs’ death, I summarized the facts about Jobs’ case that were known at the time. In particular, I took issue with the claims of a skeptic that “alternative medicine killed Steve Jobs.” At the time, I pointed out that, although it was very clear that Steve Jobs did himself no favors by delaying his initial surgery for nine months after his initial diagnosis, we do not have sufficient information to know what his clinical situation was and therefore how much, if at all, he decreased his odds of survival by not undergoing surgery expeditiously. To recap: Did Steve Jobs harm himself by trying diet and alternative medicine first? Quite possibly. Did alternative medicine kill him? As I’ve argued before, that’s impossible to say, and any skeptic who dogmatically makes such an argument has taken what we known beyond what can be supported. Regular readers know that when I see a story that looks as though “alternative medicine” directly contributed to the death of someone, I usually pull no punches, but in this case I had a hard time being so definitive because the unknowns are too many, with all due respect to Ramzi Amri, a Research Associate at Harvard Medical School who in my opinion also went too far. I did, however, point out that I’m always open to changing my opinion if new evidence comes in. Jobs was always incredibly secretive about his medical condition, so much so that it didn’t even come out in the press until after it had happened that he had undergone a liver transplant in 2008 for metastatic insulinoma in his liver, just as his cancer diagnosis in 2003 remained secret for 9 months, not being revealed until he sent an e-mail to Apple employees announcing that he had undergone surgery.

It turns out that, with the imminent release of a major biography of Steve Jobs, more information is finally trickling out about his medical history. For instance, Jobs’ biographer Walter Isaacson is going to appear on 60 Minutes this Sunday, and apparently he is going to say this:
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Posted in: Cancer, Nutrition, Science and the Media

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Vitamins and Mortality

The discovery of various vitamins – essential micronutrients that cause disease when deficient – was one of the great advances of modern scientific medicine. This knowledge also led to several highly successful public health campaigns, such as vitamin-D supplementation to prevent rickets.

Today vitamins have a deserved reputation for being an important part of overall health. However, their reputation has gone beyond the science and taken on almost mythical proportions. Perhaps it is due to aggressive marketing from the supplement industry, perhaps recent generations have grown up being told by their parents thousands of times how important it is to take their vitamins, or eat vitamin-rich food. Culture also plays a role – Popeye eating spinach to make himself super strong is an example this pervasive message.

Regardless of the cause, the general feeling is that vitamins are all good – they are not only important for health, they promote health. Many people take vitamin supplements on the idea that more is better, or for nutritional “insurance” to make sure they are getting enough of every vitamin.

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Posted in: Nutrition

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Steve Jobs’ cancer and pushing the limits of science-based medicine

Editor’s note: There is an update to this post.

An Apple fanboy contemplates computers and mortality

I’m a bit of an Apple fanboy and admit it freely. My history with Apple products goes way back to the early 1980s, when one of my housemates at college had an Apple IIe, which I would sometimes use for writing, gaming, and various other applications. Indeed, I remember one of the first “bloody” battle games for the IIe. It was called The Bilestoad and involved either taking on the computer or another opponent with battle axes in combat that basically involved hacking each other’s limbs off, complete with chunky, low-resolution blood and gore. (You youngsters out there will be highly amused at the gameplay here.) Of course, it’s amazing that nothing’s changed when it comes to computer games except the quality of graphics. Be that as it may, this same roommate was one of the first students to get a hold of the new Macintosh when it was released in early 1984. I really liked it right from the start but only got to play with it occasionally for a few months. After using a Macintosh SE to do a research project during my last year of medical school, I have used the Macintosh platform more or less exclusively, and the first computer I purchased with my own money was a Mac LC back in 1990 or 1991. Today, I have multiple Apple products, including my MacBook Air, my iPhone, and my old school iPod Classic, among others. Oddly enough, I do not have an iPad, but that’s probably only a matter of time, awaiting software that lets me do actual work on it.

All of this is my typical long-winded way of explaining why I was immensely saddened when I learned of Steve Jobs’ death last week. Ever since speculation started to swirl about his health back 2004 and then again in 2008, capped off by the revelation that he had undergone a liver transplant for a rare form of pancreatic cancer in 2009, I feared the worst. Last week, the end finally came. However, there is much to learn relevant to the themes of this blog in examining the strange and unusual case of Steve Jobs. Now, after his death five days ago, which coincidentally came a mere day after the launch of iCloud and the iPhone 4S, it occurs to me that it would be worthwhile to try to synthesize what we know about Jobs’ battle with cancer and then to discuss the use (and misuse) of his story. Of course, this is a difficult thing to do because Jobs was notoriously secretive and I can only rely on what has been published in the media, some of which is conflicting and all of which lacks sufficient detail to come to any definite conclusions, but I will try, hoping that the upcoming release of his biography by Walter Isaacson in couple of weeks might answer some of the questions I still have remaining, given that Isaacson followed Jobs through his battle with cancer and was given unprecedented access to Jobs and those close to him.

In the meantime, I speculate. I hope my speculations are sufficiently educated as not to be shown to be completely wrong, but they are speculations nonetheless.
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Posted in: Cancer, Medical Ethics, Nutrition, Science and the Media, Surgical Procedures

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Artificial Sweeteners: Is Aspartame Safe?

Note: This was originally published as a “SkepDoc” column in Skeptic magazine under the title “Aspartame: Safe Sweetener or Perilous Poison?” and is reprinted here with the kind permission of Michael Shermer. There are other artificial sweeteners not specifically addressed here, but as far as I know there are no convincing health concerns about any of them, just this same kind of hype and fearmongering based on animal studies and speculation with no validation from human clinical studies.


Aspartame is a low calorie sugar substitute marketed under brand names like Equal and Nutrasweet. It is a combination of two amino acids: L-aspartic acid and L-phenylalanine. It is available as individual packets for adding to foods and it is a component of many diet soft drinks and other reduced-calorie foods. Depending on who you listen to, it is either a safe aid to weight loss and diabetes control or it is evil incarnate, a deadly poison that is devastating the health of consumers.

A reader sent me an ad from his local newspaper that recommended using stevia instead of aspartame and made these startling claims about aspartame:

  1. It is derived from the excrement of genetically modified E. coli bacteria
  2. Upon ingestion, it breaks down into aspartic acid, phenylalanine, methanol, formaldehyde, and formic acid.
  3. It accounts for over 75% of the adverse reactions to food additives reported to the FDA each year including seizures, migraines, dizzinesss, nausea, muscle spasms, weight gain, depression, fatigue, irritability, heart palpitations, breathing difficulties, anxiety, tinnitus, schizophrenia and death.

Let’s look at those claims one by one.
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Posted in: Herbs & Supplements, Nutrition

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TIME Magazine, Dr. Oz, What to Eat, and Supplements

Here on SBM we have frequently had cause to criticize the media for poor science reporting and for spreading misinformation. Among many other individual offenders, we have criticized Dr. Oz for promoting alternative medicine on his TV show and gullibly promoting guests who pretend to talk to the dead and pretend to heal people with carnival sideshow tricks. We tend to be negative and critical because somebody has to do it, but it’s not pleasant.  For once, I have some good things to say.

The September 12 issue of TIME magazine was a Special Nutrition Issue. The cover featured pictures of food and the title “What to Eat Now: Uncovering the Myths about Food by Dr. Oz.” It devotes 7 pages to an article by him entitled “The Oz Diet: No more myths. No more fads. What you should eat — and why.” This is followed by a 5 page article by John Cloud “Nutrition in a Pill? I took 3000 supplements over five months. Here’s what happened.” Both articles have a rational, science-based perspective without any intrusions of woo-woo. (more…)

Posted in: Nutrition, Science and the Media

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The Scam Scam

In 1994 Congress (pushed by Senators Harkin and Hatch) passed DSHEA (the Dietary Supplement Health and Education Act). As regular readers of SBM know, we are not generally happy about this law, which essentially deregulated the supplement industry. Under DSHEA supplements, a category which specifically was defined to include herbals, are regulated more like food than like medicinals.

Since then the flood-gates opened, and there has been open competition in the marketplace for supplement products. This has not resulted, I would argue, in better products – only in slicker and more deceptive claims. What research we have into popular herbals and supplements shows that they are generally worthless (except for targeted vitamin supplementation, which was already part of science-based medicine, and remains so).

A company can essentially put a random combination of plants and vitamins into a pill or liquid and then make whatever health claims they wish for their product, as long as they stay within the “structure-function” guidelines. This means they cannot claim to cure or treat a specific disease, but this has proven to be an insignificant limitation on marketing supplements.

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Posted in: Herbs & Supplements, Nutrition, Politics and Regulation

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SOS DD

What does it take to become a doctor?  Endurance and perseverance help. It is a long haul from college to practice.  But the skill that is most beneficial is the ability to consume prodigious amounts of information, remember it, and recall it as needed.  Although I often relied on ‘B’ to get me through some of the exams.

Thinking, specifically critical thinking, is not high on the list of abilities that are needed to become or be a doctor. Day to day, doctors need to think clinically, not critically.  Clinical thinking consists of synthesizing the history, the physical and the diagnostic studies and deciding upon a diagnosis and a treatment plan.  It is not as simple as you might think.  When medical students start their clinical rotations and you read their notes, you realize they have what amounts to an advanced degree at Google U.  They know a huge amount of information, but have no idea how the information interrelates and how to  apply the that information to a specific clinical scenario.  With time and experience, and it takes at least a decade, students become clinicians and master how think clinically, but rarely the need to think critically.

The volume of data combined with time constraints ensures that we need to rely on the medical hierarchy to help manage the information overload required to apply science and evidence based therapy.  There is just to much data for one tiny brain to consume. Other doctors rely on me for the diagnosis and treatment of odd infections.  In turn, I  rely on the published knowledge and experience of my colleagues who have devoted a career to one aspect of infectious diseases.  There is little time for most doctors to read all the medical literature carefully, and usually little need.  We have people and institutions  we use as surrogates.

Not only is critical thinking usually not required to be a good physician, but medical practice can conspire to give physicians a false sense of their own abilities.  Really.  Some doctors have an inflated sense of self worth.  Who would have thought it?  Spend time with some doctors and listen to them pontificate on politics or economics with the same (false) assurance that have in their true field of expertise, and you will run screaming from the room. (more…)

Posted in: Energy Medicine, Medical Academia, Nutrition, Science and Medicine

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Blatant pro-alternative medicine propaganda in The Atlantic

Some of my fellow Science-Based Medicine (SBM) bloggers and I have been wondering lately what’s up with The Atlantic. It used to be one of my favorite magazines, so much so that I subscribed to it for roughly 25 years (and before that I used to read my mother’s copy). In general I enjoyed its mix of politics, culture, science, and other topics. Unfortunately, my opinion changed back in the fall of 2009, when, on the rising crest of the H1N1 pandemic, The Atlantic published what can only be described as an terrible bit of journalism lionizing the “brave maverick doctor” Tom Jefferson of the Cochrane Collaboration. The article, written by Shannon Brownlee and Jeanne Lenzer, argued, in essence, that vaccinating against H1N1 at the time was a horrendous waste of time and effort because the vaccine didn’t work. So bad was the cherry picking of data and framing of the issue as a narrative that consisted primarily of the classic lazy journalistic device of a “lone maverick” against the entire medical establishment that it earned the lovely sarcasm of our very own Mark Crislip, who wrote a complete annotated rebuttal, while I referred to the methodology presented in the article as “methodolatry.” Even public health epidemiologist Revere (who is, alas, no longer blogging but in his day provided a very balanced, science-based perspective on vaccination for influenza, complete with its shortcomings) was most definitely not pleased.

I let my subscription to The Atlantic lapse and have not to this day renewed it.

Be that as it may, last year The Atlantic published an article that wasn’t nearly as bad as the H1N1 piece but was nonetheless pretty darned annoying to us at SBM. Entitled Lies, Damned Lies, and Medical Science, by David Freedman, it was an article lionizing John Ioannidis (whom I, too, greatly admire) while largely missing the point of his work, turning it into an argument for why we shouldn’t believe most medical science. Now, Freedman’s back again, this time with a much, much, much worse story in The Atlantic in the July/August 2011 issue under the heading “Ideas” and entitled The Triumph of New Age Medicine, complete with a picture of a doctor in a lab coat in the lotus position. It appears to be the logical follow up to Freedman’s article about Ioannidis in that Freedman apparently seems to think that, if we can’t trust medical science, then there’s no reason why we shouldn’t embrace medical pseudoscience.

Basically, the whole idea behind the article appears to be that, even if most of alternative medicine is quackery (which it is, by the way, as we’ve documented ad nauseam on this very blog), it’s making patients better because of placebo effects and because its practitioners take the time to talk to patients and doctors do not. In other words, Freedman’s thesis appears to be a massive “What’s the harm?” argument coupled with a false dichotomy; that is, if real doctors don’t have the time to listen to patients and provide the human touch, then let’s let the quacks do it. Tacked on to that bad idea is a massive argumentum ad populum portraying alternative medicine as the wave of the future, in contrast to what Freedman calls the “failure” of conventional medicine.

Let’s dig in, shall we? I’ll start with the article itself, after which I’ll examine a few of the responses. I’ll also note that our very own Steve Novella, who was interviewed for Freedman’s article, has written a response to Freedman’s article that is very much worth reading as well.

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Posted in: Acupuncture, Medical Academia, Medical Ethics, Nutrition, Science and the Media

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Autism and Prenatal Vitamins

Science has found no evidence that vaccines cause autism; but the true cause(s) of autism have not yet been determined. So far the available evidence has pointed towards a largely genetic cause with possible interaction with environmental factors. A new study supports that interpretation. It also supports previous evidence that autism is triggered prior to birth, rather than at the time of vaccinations.

Schmidt et al. published a study in Epidemiology on May 23, 2011, entitled “Prenatal Vitamins, One-carbon Metabolism Gene Variants, and Risk for Autism.” It was a population-based case control study of 566 subjects comparing a group of autistic children to a matched control group of children with normal development. They looked at maternal intake of prenatal vitamins in the 3 months before conception and the first month of pregnancy, and they looked for genotypes associated with autism. They found that mothers who didn’t take prenatal vitamins were at greater risk of having an autistic child, and certain genetic markers markedly increased the risk. There was a dose/response relationship: the more prenatal vitamins a woman took, the less likely she would have an autistic child. There was no association with other types of multivitamins, and no association with prenatal vitamin intake during months 2-9 of pregnancy. (more…)

Posted in: Neuroscience/Mental Health, Nutrition

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