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205 thoughts on “News flash! Doctors aren’t all compliant pharma drones!

  1. nybgrus says:

    You know why it pisses me off? Because I make mistakes. But I don’t lie. Call me out for being wrong on a topic, demonstrate my evidence is wrong, and I’ll thank you for it. But don’t call me a liar. Give it a few days to recover my password for Thx and we’ll see how you do when you eat your words.

    Until then, you can piss off with your smug elitist asshole attitude.

  2. I whole-heartedly agree. Even a-hole me has written that I think nybgrus is very intelligent. However, I absolutely don’t buy the MCAT story. I don’t think an American on planet earth would pass up Harvard Med, or any other prestigious medical school, to be a FMG.

  3. Harriet Hall says:

    Since SkepticalHealth keeps insisting: I have verified nybgrus’s MCAT score. It is 38. He was not lying. An abject apology is in order.

  4. Ok, then nybgrus, what’s your black mark? Criminal record? Drug arrest? Kicked out of university for cheating? Because no person, in their right mind, would voluntarily go to a foreign medical school. You can’t justify that it any way as something you voluntarily chose to do, in lieu of getting an education at an American school, especially considering you dream about obtaining a critical care fellowship.

  5. mousethatroared says:

    nybrgus – clearly we are going to need to see your birth certificate ;)

  6. Harriet Hall says:

    SkepticalHealth,

    You are out of line.

    I have no idea what my MCAT scores were; I don’t even have any memory of being told my scores (1966 was a long time ago!). But I do remember the SAT. By analogy, you might accuse me of lying if I told you my SAT scores (800 and 776) and high school GPA (4.0, one of only 3 students with a perfect 4.0 out of nearly 800 in my class. You could say no one with those scores would have voluntarily gone to a mediocre public university when they were qualified to get into a prestigious Ivy League school. I happen to have had excellent personal and financial reasons for not even applying to any other school than the U. of Washington.

    You can’t imagine why Nybgrus would have chosen as he did, but that might just mean that your imagination is inadequate.
    You owe him an apology for falsely accusing him of lying. Is it so hard to admit you were wrong?
    Instead of apologizing, you have stayed in attack mode and suggested he had a black mark like a criminal record.Now you owe him another apology for that.

    It would have been so much nicer if you had started out by saying “With a high MCAT score like that, why did you choose an Australian school?” If you had asked nicely instead of attacking, you might have learned something beyond your poor ability to imagine.

  7. In no way do I feel that I’m out of line. First of all, nobody asked nybgrus what his supposed MCAT score is. He volunteered that information, and he volunteered that information in a manner that implied he just winged the test and happened to get a great score on it. That’s one statement in a constant stream of narcisism from a medical student who obviously has some glaring, possibly career-stunting, blemishes in their record.

    Second, just because Harriet says its so, doesn’t mean its so. I Googled “MCAT 38″ and found a dozen pictures of people screen capping their respectable MCAT scores. I have no idea what he supposedly sent you, but unless it’s his score, with his name showing, his photo ID with his name showing, and some sort of proof that “nybgrus” is whatever the real name is showing, then it’s absolutely meaningless.

    But beyond that, I’m actually willing to believe he had a good score – I don’t doubt that he could do well. But it forces one to ask, why would he go to a foreign medical school? And that’s the question that I have not seen answered. There’s no good answer for it. Nobody on earth with a good record would goto a foreign school. You attempted to brag about your own accomplishments, but nobody really cares about a high school GPA, or even a college GPA. And you mentioned state vs. Ivy League – you’re right, there’s a comparison. However, either of them is infinitely more credible than a foreign medical grad. If I was looking for a partner or anything of the sort, I’d consider Podunk University of Idaho over anybody from Australia or any other foreign country. Furthermore, I’d bet good money than 9/10 residency program directors rank American grads ahead of foreign grads.

    So yeah, Harriet, you can make whatever ridiculous post you want defending nybgrus, I don’t care, but it doesn’t change the fact that nobody with a clean record would pick a crappy foreign school, along with all the stigma that comes along with it, over an American Ivy League school. …. Seriously: what’s the justification? It certainly isn’t money. What, it was too cold up North? Be realistic. You don’t have an argument.

  8. And, while obviously random internet user nybgrus doesn’t owe anybody an explanation of why he ended being forced into a crappy foreign medical school program, he at least could admit that it’s a fact that he has glaring issues that are forcing him to pursue substandard education that will blemish his record instead of pretending like he picked this foreign program on purpose, when infinitely better programs exist stateside.

  9. Yeah, that’s what I thought about that completely ridiculous post you just made in the iron supplement thread. I can’t believe a MD is so out of touch with CVD!

  10. weing says:

    “he ended being forced into a crappy foreign medical school program”

    I see several assumptions here. Could it be he chose to go to a better school? What makes you think that other countries have substandard programs? You think the USA has the best programs in the world? Maybe it did at one time. Look around. Don’t you ever get the sneaky suspicion that we are a has been country? They even have a center for CAM at Harvard. BTW, I studied in Poland. Had a scholarship and finished school with zero debt. Of course, there are those who think they are superior because they studied here. But thinking doesn’t make it so. And I see that smug superiority less and less.

  11. Quill says:

    I’ve been reading this blog for a while and enjoy the range of comments and writing styles. nybgrus’s posts have consistently been among the most well-written, thoughtful and intelligent. While I always find out what medical school any of my doctors went to, I’m more interested in their residency (and fellowships, if any.) But above both is their commitment to the practice of medicine which in my opinion is at its foundation the willingness to be a good student, to always learn, to always have the open mind of science that allows a person to evaluate evidence and choose the best courses of treatment. As Dr. Hall noted and I agree, nybgrus’s future as a doctor seems quite bright and I think this is largely because he seems to be an excellent student.

    And for what it’s worth, I hear that Australia is not only a very civilized place with electric lights, running water and fine beers on tap but also home to more than one excellent medical school that has bravely removed leeches from the laboratories and where the teachers even wash their hands. ;-)

  12. gears says:

    I, too, want to come to the defense of nybgrus. Quill said essentially what I was going to, that I don’t think it matters where you went to school so long as you have a commitment to learning and critical thinking, and from lurking here for a while it’s quite clear to me that nybgrus is a decent, thoughtful person. That is what is important to me.

    Furthermore, one of the points I hear repeatedly on this blog, by the editors and other contributors, is that medical schools (in the US, no less) do not equip their students with the critical thinking skills that allow them to easily dismiss pseudoscience and quackery. I was under the impression this was part of the push for formalizing “science-based medicine” and recognizing the place of prior probability in investigating therapies, because most people trained under evidence based medicine hesitate to say that homeopathy is the rank quackery that it is, for lack of insufficient clinical trials (and chiropractic and acupuncture and…). It seems to me that medical schools here in the US aren’t perfect, either.

    Anyhow, I got your back, nybgrus. I’m glad you’re happy with school in Australia and best of luck to you. I don’t know why SkepticalHealth insists on being outright mean (SH: why’d you have to go and spoil our nerd-bro moment like that, man?). Just forget him.

    Responding to things that happened a long time ago:

    @HarrietHall:
    I did study for the MCAT, and I think most people applying these days do study to a greater or lesser degree. I thought I was on the less insane end of the spectrum studying for a month and a half on my own and then taking practice tests like nybgrus, as opposed to the people who spend $2k on practice courses. People go a little crazy about it nowadays.

    @Robb:
    I guess the discussion is over for the most part, but I at least wanted to say that I don’t think it is that “ideological” or overly reductive to expect that, in the most likely case, there is one useful compound to be isolated from an herb. Biological activity is, for the most part, mediated by receptor interaction and the specific character of that interaction (right?). So I think it is reasonable to expect that one compound is going to have a receptor interaction that most effectively elicits the activity you want to produce, so you can leave everything else behind. And like nybgrus said, and what I think is most important to stress, that “everything else” is just as likely toxic as helpful. Even you cited an example where a supercritical CO2 extraction was required to exclude toxic compounds from an herb.

    Also, the fact that you say we can’t compare Celebrex with artichoke leaf because Celebrex is a “novel compound” implies that you wholeheartedly accept the naturalistic fallacy, which is just not true. This has been debunked so thoroughly I won’t get into it, but come on, strychnine comes from an herb. And even though artichokes have been in our food supply for ages, it’s all about dose. Nutmeg has been in our food supply for ages, too, but if you eat a pile of that you hallucinate for like three days.

    I didn’t realize I was going to set off such a firestorm with the MCAT comment. Sorry about that…

  13. Oh, there’s no doubt that people can get a good education at foreign medical schools, but there is not a single advantage had by going to them, especially for someone who supposedly made a nice MCAT score. Even more so for a MCAT score that would get someone into an American Ivy League school. I can’t think of a single person who would rather a degree from Australia, Poland, or the Caribbean instead of Harvard Med. Even a program director would see this: “Would I rather tell people I matched Harvard grads, or foreign medical grads?” In America, there is indeed a stigma among people who went to foreign medical schools. It may be undeserved, but the stigma exists nonetheless. Furthermore, it makes the applicant less competitive for residency. The first question a program director is going to ask in an interview is “Why did you go to a foreign school?” He better have a good answer. I apologize if these facts are unsettling.

    1. Harriet Hall says:

      “there’s no doubt that people can get a good education at foreign medical schools, but there is not a single advantage had by going to them, especially for someone who supposedly made a nice MCAT score.”

      While I accept this reasoning in general, I don’t think you can rule out any possible advantage. There might be factors that haven’t occurred to you or that would be personally compelling for a particular individual. I can think of a few possibilities: free room and board with a relative who lives near that foreign school, for instance.
      I only applied to the one medical school I could afford to go to (because I could live at home). My pre-med advisor told me that with my GPA I would be guaranteed to be accepted if I were male, but as a female there was a strong possibility I wouldn’t be accepted and I should be prepared with a backup plan, like going into microbiology. I told her my backup plan would be to go to a medical school in Mexico that accepted all comers and was the next cheapest option. (My Spanish is fluent).

      Why not give Nybgrus the benefit of the doubt and assume that someone as intelligent as he will have a good answer for the residency interview? Why assume he must be lying or a criminal? I still think you owe him an apology.

  14. By the way, the anecdotes of “Oh, I don’t care where my doctor went to school…” are cute but irrelevant. We are talking about career climbing and getting into competitive specialties. When everything else matches up, the American grad is going to win over a foreign grad almost every time. After all, residency positions are paid for, in part, by American tax dollars. It’d be very screwed up if American students had to sit out because programs filled up with foreign medical grads.

  15. nybgrus says:

    First off, thanks to all for the kind words. Gears – it was a nice nerdy bro-moment. To more in the future.

    Secondly, as a warning to any other potential med students out there, do not have the attitude about MCAT scores that SH has. A single score, no matter what, even in the context of decent undergrad GPA does not absolutely guarantee you a spot anywhere, let alone a top Ivy League. It was exactly that arrogance and brashness that led to me shooting myself in the foot during my first round of applications. Also, bear in mind the very significant importance of excellent letters of recomendation. It is one of the lessons learned the hard way I pass on to those asking my advice on the topic.

    Beyond that, I feel little impetus to further explain myself except to say that as Dr. Hall pointed out, SH’s imagination is indeed extremely small and that I have absolutely zero concerns for my ability to match extremely well and achieve all the goals I have. Suffice it to say that my SoM has generated the highest USMLE scores ever achieved, has matched into places such as Dartmouth, has the support of state governments and my particular program has the official endorsement of the AAMC as an excellent up and coming program. Additionally, the dean of the UC San Francisco is a graduate of my SoM. I am not worried about explaining my choices. So indeed, assumptions make an ass out of you and me, but mostly you.

    Once again, thank you to everyone else here for the kind words. Don’t feel it falls on deaf ears (err… blind eyes?) and I do genuinely appreciate it.

  16. Harriet Hall says:

    @SkepticalHealth,

    “We are talking about career climbing and getting into competitive specialties”

    Maybe some of us are. But some of us aren’t the competitive, climbing type. Some of us only wanted to get an adequate education so we could be useful treating patients and continue learning by keeping up with the literature. Prestigious medical schools may make it easier to get into prestigious residencies, but is that really what makes a good doctor? I don’t know of any evidence that patient outcomes are better when doctors have had more prestigious educations. Do you? I can think of at least one very ambitious doctor who went to Harvard Medical School and was highly motivated to climb the ladder to fame and fortune by spouting woo: Andrew Weil. From what I have seen of Nybgrus, I bet he would be a better doctor than Weil even if he went to one of the lowest-ranked medical schools. At least he understands science-based medicine and doesn’t advocate “stoned thinking.” That counts for more in my book than fancy credentials.

  17. jmb58 says:

    I have always enjoyed Nybgrus’s comments and could care less about his MCAT score.

    I have been on a medical school admission committee and an admission comittee of a competitive surgical residency program.

    A 38 will get the attention of most US med schools. Not a guarantied admission, but the attention. When people ask me advice about which med school to go to I tell them to figure out what is most important to them. If you want to go to a competitive residency, go to the highest ranked med school you can. That will increase your chances. If other factors are more important (lifestyle, money, family location, wheather, or whatever), you can get a great education in many different schools. For the most part med school is more about the dedication of the individual student.

    As an exemple, my program has never accepted a foreign med grad or DO grad right out of school that I know of. Right or wrong, there is a bias. A number have joined after a preliminary internship and went on to be awesome surgeons.

    That said, I’ll bet med school in Australia was a blast. I echo the sentiment that Nybgrus seems like he will be a great physician. Don’t overlook the surgical field. Trauma/critical care is a great place for evidence based medicine. Not so much surgical oncology. (kidding, Dr. Gorski)

    @HH

    Thankfully, I think medicine as a profession has come a long way in regards to sexism. The overall first year class has been >50% women for a while now.

  18. Harriet Hall says:

    @jmb58

    “medicine as a profession has come a long way in regards to sexism”

    It certainly has! My book “Women Aren’t Supposed to Fly” shows how far it has come just in my professional lifetime. When I graduated, only 7% of American doctors were women. And when I was promoted to Colonel there were only 13 women in all branches of the service who held a higher rank, and most of them were nurses. I like to think I played a part in changing things by serving as a good example of a competent woman in what was then a man’s world.

  19. jmb58 says:

    @HH

    “I like to think I played a part in changing things by serving as a good example of a competent woman in what was then a man’s world.”

    That is definitely something to be proud of.

    I’ll check out your book.

  20. Jeff says:

    Nybgrus,
    Research has made substantial progress identifying the various constituents of many commonly used botanical supplements, including Rhodiola Rosea:
    http://www.ncbi.nlm.nih.gov/pubmed/20378318

    Artichoke Leaf Extract does have a history of safe use:
    http://www.sciencedaily.com/releases/2008/07/080702170607.htm

    The FDA is quite serious about monitoring adverse events for supplements. You can view the figures posted by the agency by searching the phrase, “Number of mandatory adverse event reports from the dietary supplement industry entered into CAERS”. Supplement manufacturers are required by law to report all serious adverse events related to their products.

    Number of all supplement adverse events (serious and non-serious) for 2010 submitted to FDA: 830

    Number of serious adverse events only for prescription drugs in 2010 submitted to FDA: 471,291

    Dietary supplements, including botanicals, have a completely different level of risk compared to drugs. Supplements are inherently safe; prescription drugs are inherently unsafe.

    1. Harriet Hall says:

      @Jeff,

      “Supplements are inherently safe; prescription drugs are inherently unsafe.”

      It would be more accurate to say that the average supplement is more likely to be safe than the average prescription drug. And that’s partly because drugs that have effects are more likely to have side effects.

      Serious adverse event reporting is skewed. Huge numbers of people take prescription drugs and they are more alert to side effects and more likely to report them. When people assume supplements are safe, they are less likely to consider them as a possible cause of new symptoms.

      A history of safe use doesn’t necessarily prove that a supplement is safe: problems may have occurred in a minority of patients and not have been recognized.

  21. @HH

    I can think of at least one very ambitious doctor who went to Harvard Medical School and was highly motivated to climb the ladder to fame and fortune by spouting woo: Andrew Weil. From what I have seen of Nybgrus, I bet he would be a better doctor than Weil even if he went to one of the lowest-ranked medical schools. At least he understands science-based medicine and doesn’t advocate “stoned thinking.” That counts for more in my book than fancy credentials.

    Very true! I think ‘ol @nyb will be a fantastic critical care specialist one day too, if not a little long winded. We all have that one pulmonologist at the hospital, who knows everything, writes the admission protocols for the hospital, and is the one you can always bounce off of if you need a little advice. I’d say maybe nybgrus will be that guy one day, but I don’t want to bump his ego too much. :)

    @jmb,

    Are you an older or younger surgeon? I ask because I’m curious about the call schedule you went through. I’ve heard stories from older docs about insane call for surgeons, I believe I’ve heard Q2. I heard one story about this malignant surgical attending in Houston that would require his residents to essentially live at the hospital, and they got like one afternoon off a week, or something along those lines. I believe they now have 80 hour workweek limits, which I’m sure no program actually abides by.

  22. nybgrus says:

    @Dr. Hall: I can certainly say that prior to entering med school I was not interested in being a competitive climber. I can distinctly remember my sister trying to convince me to go for an MD/PhD and me saying “Why in the hell would I want to do that? An MD to practice medicine is PLENTY good enough!” Things have changed a bit since a bit before I started med and I have made sure my CV will make the FMG status a non-issue.

    @jmb58: Thanks for the kind words. I actually had strongly been considering a surgical field but ultimately have decided against it. I like the OR but not that much. As for programs (such as yours) simply not accepting FMGs or DO’s, yes, I am well aware this exists. There are also programs that don’t accept from specific US medical schools and/or that do preferentially accept from specific US medical schools. I am well aware there are programs that simply will not look past FMG. However, many truly excellent programs do regularly accept FMGs and I did take all this into account when I made my specific decision. I had a few other options at the time and after speaking with many physicians, including a number who have sat on residency committees, I made the decision I did. To this day I have no regrets. A friend of mine went a different route and ended up at a lower tier US med school. In discussing our educations and opportunities for advancement and residency, it seems clear that I got the better end of the bargain on that one. Save for those programs which flat out have a policy against FMG and DO, my CV will look significantly more robust than his (well, except that now he has taken a leave of absence to do a year long regenerative opthalmology research fellowship funded by the NIH). Bear in mind (and this is not specifically directed at you) that there is indeed a difference applying as an FMG from the Carribbean vs and FMG from Oxford (not that I am at Oxford, but there *are* prestigious international programs). As I pointed out earlier, my SoM is ranked higher than many US SoM’s – even ones you wouldn’t think such as my undergrad alma mater, Brown, and Tufts. And I hold an EU citizenship in addition to my US citizenship (I was not born in the US) and that just added icing to the cake.

    @Jeff: I am not going to bother deconstructing and explaining where your reasoning is just not quite right, since it has been done before and refuse to learn. Your last sentence is absolutely incorrect – something I demonstrated with Robb, so go back and read that conversation.

  23. nybgrus says:

    I should add that the reason my CV would look more robust is because of the opportunities afforded that I took advantage of. In other words, we felt that it was easier to take advantage of more opportunities at my SoM than his, though of course there is no limit in either one. Since he was interested in an academic career and recognized that many academic programs have that bias against FMGs it was in his interest to attend a US SoM of lower quality for exactly that reason. I was not interested in an academic track. I am a bit more interested these days, which means if I do go that route I will have some ground to make up. But c’est la vie.

    Lastly, no ego boost. I know I have to work hard to achieve my goals and that is what I do. Thanks for the compliment though.

  24. jmb58 says:

    @nybgurs

    “there is indeed a difference applying as an FMG from the Carribbean vs and FMG from Oxford”

    Agree.

    @SH

    I’m a younger surgeon. Went through residency as the transition was made to the 80hr work week. Early on I went north or 100hr/week regularly, including one horrible stretch in the hospital from Friday at 5am to Monday at 8pm. By my cheif year my program was respecting it. All programs are now, because the ACGME (American College of Graduate Medical Education) has put some programs on probation for work hours violations. There are even more restrictions for interns now, and talk of a 60 hr work week (which is the standard in England, I think). The American College of Surgeons has seriously considered leaving the ACGME, and probably will if any additional restrictions are implemented. I guess that is a seperate discusion.

  25. Robb says:

    gears,
    Yes, discussion tangent mostly over but I wanted to clarify my argument is not the naturalistic fallacy any more than your position is that we must stop consuming broccoli immediately and perform safety studies to establish no hidden dangers exist. I’m perfectly aware just because something is natural doesn’t mean it is safe by definition. The difference vs. novel compounds is that we already know this. We already know about nutmeg, we already know about strychnine, etc. We don’t necessarily know all about new drugs entering the market. For herbs, a more important issue is ensuring proper raw material testing and following GMP. These regulations are already in place for most countries though.

    nybgrus’ comment that we don’t even know the ingredients in these herbs is also completely untrue. I’ve already referenced and addressed this in previous comments. Anyway, my point originally wasn’t even anything remotely like all herbs are all natural therefore all herbs are completely harmless. There are well-known potential dangers with certain herbs – herbs in pregnancy, herbs mixed with drugs, herbs with certain health conditions.

    My point originally was that most of these things are already well known, that cases of lurking unknown dangers of use are extremely rare due to most things having made themselves apparent by now. How do I know this? I’ll quote nybgrus’ earlier “source” and say “the corpus of scientific investigation” around the world, including experts on the subject and government health authorities reviewing the evidence have come to this conclusion. This point was made purely as a contrast to some new compound just having come out of trials and entering the market. They are in completely different positions relative to human exposure over time.

  26. nybgrus says:

    Sorry Robb, but you don’t know. I gave the example of aristocholia as used for quite a long time and everyone thought it was safe until finally it was actually looked at and determined to be unsafe – very recently in fact. I will agree that for the most part, the majority of compounds in the majority of herbs and plants do nothing in the majority of people. But we don’t know which ones do and don’t and in whom. Recommending them therapeutically is thus not an ethically reasonable position, especially knowing that the vast majority of herbs and plant supplements have proven to have near zero if any effect whatsoever. With so many compounds from so many potential herbs and plants, giving it to myriad people is essentially guaranteed to produce negative outcomes overall (because positive outcomes are shown to be nil or small as I said, and there will be a subset of people who suffer negative outcomes). Don’t get me wrong – this is not a dichotamous argument. I am not saying that we should thus cram pharmaceuticals down people’s throats because they will inevitably be better. I am saying that we shouldn’t do anything unless we have a clear indication to intervene and an actual understanding of what the intervention will do, beyond some old wives tales of “traditional use.”

    So your very premise that “most of these things are already well known, that cases of lurking unknown dangers of use are extremely rare due to most things having made themselves apparent by now” is simply false. The most obvious ones have become known. And even then some very obvious ones (aristocholia) still escaped scrutiny until just 7 years ago after thousands of years of use. You have no idea what less obvious dangers are still lurking, whom they may or may not affect, and every reason to believe that they are there.

  27. Robb says:

    It isn’t just me nybgrus, as I’ve pointed out. And your aristochlia example is an obscure counter example and an exception rather than the general rule. I’d never even heard of it before you brought it up – is it even available here? Kava would be a better example but most reviews I’ve read concluded that improper species selection, mould hepatotoxins, and health/lifestyle factors of the patients were the cause of complications rather than kava itself, which is why I brought up the GMP/QA testing point. I understand and appreciate your sense of caution. Let’s leave it at each case should be assessed independantly to get a better sense of what is known about it – whether herb or pharmaceutical.

  28. nybgrus says:

    It is not that obscure. It is common on TCM formularies and has had widespread use in China and yes, in the US as well. The “traditional use” stems from its resemblance to a uterus, so the TCM guys thought it was useful in childbirth to expel the placenta. That is “traditional use” and it was used since around the 16th century, with the most recent iteration being the 1999 Encyclopedia of Chinese Materia Medica which listed 23 species of Aristolochia… with no mention of toxicity. So once again, just because it has a “traditional use” and has been used widely for literally hundreds of years does not actually mean an herbal preparation is safe. But lets look at actual numbers. It was found to increase the risk of urothelial cancer by 50% (in addition to general nephrotoxicity). Wow! That’s a lot! How did nobody notice this? In 2008 there were 386,000 new cases of urothelial cancer worldwide. Out of a population of 6.7B that amounts to an incidence of around 0.006% (give or take a zero, doesn’t really matter). So if we increase this by 50% we get 0.009% (and that is assuming every single person on the planet consumed 200mg of Aristolochia daily). Do you see how small the signal is? And why it took so long to recognize it? A 50% increase in risk – which leads to such a small absolute risk increase – is still quite significant. That means that potentially an additional 193,000 people would get cancer and of those 75,000 would die.

    Furthermore, it was noted that it was a cumulative effect of continued usage that really increased the risk, which makes a signal even harder to detect. Supplements are not under the same scrutiny as pharmaceuticals – as Dr. Hall pointed out. And even if they were, once again, we are talking about myriad compounds being ingested all with the potential to be deleterious and all with the potential to have cumulative (and synergistically negative!) effects. Aristolochia is just one example of how much “traditional use” means. Do you realize we used to give babies lead pacifiers for years until we realized how bad it was for them? How about smoking? That is an “all natural” herb with measurable physiological effects. How long did it take to realize how bad that was?

    So yes, each formulation must be approached individually. The problem with a herb or plant is that you are taking a LOT of compounds at the same time. If there is a signal, you will have trouble pinning down the culprit. If it is a very small signal, it will take a large sample size to spot it. And if it is a very delayed signal, then it will be even harder.

    Quite simply, the numbers are against there being an overall utility for herbal/whole plant extracts having a net beneficial outcome and for it having a net negative outcome. We all have to eat, so cutting out brocolli or steak is a stupid argument. But yes, there *are* toxins and carcinogens in your char-grilled steak as well and eating too much of it has deleterious effects as well. The best strategy – especially when discussing implementing something in a nation-wide health system – is caution. Because that tiny increase in cancer incidence will lead to thousands of deaths because you thought an herb was somehow intrinsically better than a pharmaceutical agent.

  29. BillyJoe says:

    It amazes me that a person who presumes to be talking authoritatively about herbs, has never heard of aristolochia, to point even of misspelling it.

  30. Robb says:

    BillyJoe, I am glad to have amazed you. There is no edit function in comments so you’ll notice that sometimes people have spelling errors or grammar mistakes as in your own “to point even”. Do you honestly believe that people being knowledgeable about herbs = they must therefore have heard of ever herb in the universe? I’ll admit I do not know every herb in traditional Chinese use. Thank you for your fail troll contribution.

  31. nybgrus says:

    my other comment is awaiting moderation as it has three links. I do have to say though BJ that the spelling jab is a pretty weak one. I misspelled it as well, if you notice. It is an easy one to transpose the letters, even though I know what the latin roots mean.

    However, it is a fair point that when making assertions about the safety of herbs and claiming that traditional use for a long time is sufficient to assert safety one should actually know about pertinent refutations to that argument before engaging in it. It is always much more impressive to say “Here is my argument, and here is where you might head me off, but this is why it is an exception.” But Robb merely asserts it is an exception in reaction to my evidence, without actually demonstrating why it is an exception or relating it to fundamental principles. The argument boils down to (at best) an absence of evidence of significant harms from herbals means that there is no harm from them, without actually discussing why there is an absence of evidence, what that could actually mean, nor the fundamental principles involved (law of large numbers being one, which is in my comment awaiting moderation). All the while he continually offers up exceptions to his own rule – “but most reviews I’ve read concluded that improper species selection, mould hepatotoxins, and health/lifestyle factors of the patients were the cause of complications rather than kava itself.” Exactly. If you made the basic assumption you are asking us to make, then no one would have reason to think twice about the species, handling, and health factors of patients taking kava in the first place. And as my soon-to-come comment demonstrates minute absolute risk increases from aristolochia means tens of thousands of additional deaths.

    In law, one is innocent until proven guilty. In medicine one is dangerous and ineffective until proven otherwise for exactly that reason. I demonstrate that a potential 75,0000 additional deaths per year from cancer alone could be attributed to aristolochia… yet that signal is still so small it was very tough to detect unless one was specifically looking… and/or had a large enough sample size to pick up those deaths. Yet by the assumption that “traditional use” and “long term use” is a meaningful proxy for efficacy and safety we could be causing tens of thousands of additional deaths… with very little, if any, actual benefit.

  32. nybgrus says:

    I should add that Robb also self-contradicts within a single sentence:

    “but most reviews I’ve read concluded that improper species selection, mould hepatotoxins, and health/lifestyle factors of the patients were the cause of complications rather than kava itself.”

    Wait – the species is the kava. It demonstrates nicely my argument. In closely related species you can have some with deleterious effects… because you use the whole plant. Basing your assertion of therapeutic effect on traditional use means almost certainly a lack of highly specific species knowledge. So even then, you can’t claim “traditional use” gave you meaningful information and you can’t assert that “the kava itself” is not the problem when, in fact, the species of kava itself is the problem. Because that is what happens when you use the whole plant isnetad of determining which few – if any – compounds from it are actually the useful and non-toxic ones.

  33. mousethatroared says:

    Oh f$&k, My posts are full of spelling errors. Let’s not start picking on those now, cause that’ll be the last straw for me.

  34. @MTR,

    There is no need for foul language in the discussion forums.

  35. Robb says:

    OK, so I’ll return to my broccoli example. Why then should we assume safety of anything? Efficacy is a different question. What is your gold standard of safety that trumps the “known scientific corpus of commonly used herbs” that I’ve been referring to: long term use in large populations, human clinical trials, animal studies, and known pharmacological actions of ingredients? Remember, I have never said long term use alone is what is being used to judge safety here – I said that long term use gives the herb a headstart compared to new compounds so they can’t be equated. So your Chinese herb that I don’t want to try and spell again is an exception because not enough was known about it – there was probably nothing but long term use to support it. Knowing the compounds and their effects, which we do for most commonly used herbs that I’m referring to, helps a great deal when it comes to potential toxicity, obviously.

  36. Robb says:

    Also, nybgrus, this doesn’t make sense: “In closely related species you can have some with deleterious effects… because you use the whole plant.”

    It has nothing to do with use of the whole plant – it’s because you chose the wrong plant. The plant with different compounds/different effects.

  37. nybgrus says:

    I think we are talking past each other a bit Robb.

    Lets limit your argument to your last most succinct and clear point:

    Knowing the compounds and their effects, which we do for most commonly used herbs that I’m referring to, helps a great deal when it comes to potential toxicity, obviously

    I won’t belabor the point that we really don’t know the compounds, toxicities, and effects of most commonly used herbs. In part because “commonly” depends on context (what is common in China is not common here or in Africa).

    But lets back it up to your assertion that “long term use in large populations, human clinical trials, animal studies, and known pharmacological actions of ingredients” is what you meant by “knowing” the compounds and their effects.

    Superficially I certainly agree. But “long term use” is of such little use we can drop it from the list. The rest is purely pharmacognosy.

    So then where are we? A plant with myriad compounds which we have now tested for safety and efficacy in animal studies, bench science, and clinical trials. Just like any other drug small (side) effect sizes need to be monitored in Phase IV. The problem we have is that instead of just 1 drug or 2, we have a whole slew of them. And as I have demonstrated serious but small effect sizes can be easily missed for quite some time. So in other words, we are doing the exact same thing as regular ol’ pharmaceutical testing, just making it more difficult since we are not controlling for single variables but for a slew of them (i.e. all the compounds in the plant). The assumption that if the initial effect is positive then that means there must be solely beneficial synergy from the rest of the plant compounds is simply false. There may be 10 compounds with beneficial synergy and 1 with a deleterious effect.

    The next point is that the science of pharmacognosy has demonstrated that the effects we do see from beneficial plant extracts and compounds is usually not that great and the side effects are usually large. That is why we tweak the molecules to improve efficacy and decrease side effects. Taxol being a great example. Or vincristine. Or penicillin. Or any other such derived molecule.

    Lastly, the notion that any novel pharmaceutical is completely new and therefore we can’t have any idea what it does is bollocks as well. The vast majority are derived from natural sources to begin with. And rational drug design is a very new and very difficuly process. But by definition and in practice the point of rational drug design is the target a specific molecule with extremely high specificity and thus is actually quite well known what it will do… at least to the same degree as a naturally derived molecule from a bench science perspective. Then going forward with clinical trials is the same no matter what the source of drug.

    So no matter how you slice it, relying on something being a whole plant extract, or coming from traditional use, or long term use is of so little practical utility that it becomes rounding error. Truly, the only utility is that if people have been using something consistently there may actually be an effect, so it is not unreasonable to use that as a starting point since starting from a very low prior probability is better than starting from an extremely low prior probability (i.e. picking things at random). And of course, even that isn’t really true because of high throughput pharmacognosy screening which automatically searches for bioactive compounds in tens of thousands of sources constantly.

    We simply have better ways of doing things than whole plant extracts, herbals, or supplements these days.

  38. Jeff says:

    Nybgrus’ previous comment finally came out of moderation (I find this delay frustrating so I never put more than two links in any comment). He says, “Quite simply, the numbers are against there being an overall utility for herbal/whole plant extracts having a net beneficial outcome and for it having a net negative outcome.” A sweeping statement.

    There are many examples of botanical extracts showing efficacy in clinical trials. In an earlier comment Nybgrus mentioned Saw Palmetto. Certainly the results for Saw Palmetto have been mixed. Two recent trials concluded SP extract relieved symptoms of BPH and improved sexual function:

    1. http://www.ncbi.nlm.nih.gov/pubmed/22522969
    2. http://www.ncbi.nlm.nih.gov/pubmed/21304222

    Nybgrus also says, “The best strategy – especially when discussing implementing something in a nation-wide health system – is caution.” Fortunately in the U.S. we don’t have to wait for dietary supplements to be incorporated into a nation-wide health system. 1994′s DSHEA gave American consumers freedom of choice. They can do their own research and decide for themselves whether or not to try a safe, affordable product like Saw Palmetto extract.

    Robb asked about aristolochia. Steven Novella blogged about it on April 11, 2012. You can find it by searching for this: ScienceBasedMedicine – Herbal Medicine and Aristolochic Acid Nephropathy.

  39. jmb58 says:

    Wow. An appeal to Saw Palmetto. Two much better studies were done in JAMA and the NEJM. Nicely summarized by Mark Crislip.

    http://www.sciencebasedmedicine.org/index.php/the-prostrate-placebo/#more-16383

    Link one is to an 82 patient, non-blinded, non-placebo controlled “pilot study”.
    Link two is to a 120 patient, non-blinded, non-placebo controlled study.

    Newer, crappier studies don’t trump older, more rigorous studies.

  40. nybgrus says:

    thanks for that jmb58 – I was just about to post the same thing.

    How about a botanical that actually has genuine effects that are better than a pharmaceutical equivalent? Care to supply the research for that Jeff?

    They can do their own research and decide for themselves whether or not to try a safe, affordable product like Saw Palmetto extract.

    Boy. Really shot yourself in the foot with that one by demonstrating that you clearly don’t know how to actually research something for yourself, let alone the average consumer who has never even heard of “PubMed” or “Cochrane.”

  41. BillyJoe says:

    Okay, I perhaps overdid it with the misspelling thing, but it was a secondary point in any case.

  42. Jeff says:

    Here’s a recent meta-analysis concluding that Saw Palmetto is effective. The authors state their preference for SP extracts sold as drugs instead of supplements:
    http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3175703/?tool=pubmed

    It seems to me a carefully prepared standardized extract sold as a supplement would be as effective:
    http://www.jarrow.com/product/309/Saw_Palmetto_(Serenoa_repens)

    As I said, the results are mixed for Saw Palmetto. It has an acceptable safety profile, with relatively mild potential side-effects, especially compared to available drugs. There’s enough positive data to make Saw Palmetto extract a viable option for someone with BPH.

  43. kathy says:

    Just a small side-issue, for interest, re this business of botanicals and species. It may have some relevance to arguing with those who believe a plant has been used for 100′s or 1000′s of years. See if it helps.

    Identifying similar plant species (I do it daily) isn’t as easy as all that. Species can look remarkably like each other, even if they are unrelated.

    It can be interesting too, to look at the old herbals, which recorded the popular uses of plants for medicinal purposes those 100′s of years ago. The illustrations are frequently crude to the point of being unidentifiable and the names are far from standardised, pre-Linnaeus. I wonder how anyone managed to use them, and how many herbalists just guessed and hoped for the best.

    Those who are trying today to scan “traditional-use” plants for possible objective effects, are encouraged to deposit voucher specimens with a recognised herbarium, for this very reason. However, unfortunately, their supervisors and bosses seldom insist, and often neither do the journals they publish in. This may come back to bite them some day, if they do discover something useful but have no authoritative name for the plant, and no way of back-checking.

    I maybe cited (just my pers. exp.!) this one before, but I had a couple of cancer researchers come by a little while ago, that wanted me to help find them some plants that were traditionally used. I couldn’t go with them every day that week, so sent them off alone, and some of the plants they brought back were so far off base it was hard to not laugh. But of course that wouldn’t have helped so I didn’t. I’d sent them off with photos and a description, but what came back in their bags wasn’t even in the same family, let alone the same species. Oh, and they’d never heard of keeping voucher specimens.

    I’m a dyed-in-the-wool skeptic wrt medicinal plants, but I have to operate in a system that is not only replete with true-woo believers of the Californian variety, but 95% populated by indigenous-culture, our-ancestors-used-it-so-how-dare-you-disagree, folks. I’m trying me best to light a little candle, though how useful it will be I just don’t know. Thanks to you all for helping to light it up again when it gets blown out!

  44. mousethatroared says:

    SkepticalHealth “There is no need for foul language in the discussion forums.”

    SH – HH and DG gave YOU a warning and told you to tone it down. I’m assuming the rest of us can continue to behave as we have been.

  45. mousethatroared says:

    Kathy – That’s interesting. It make sense to me considering the number of times I’ve purchase mislabeled plants at HomeDeport :)

    Just out of curiosity… you post prompted me to check out “voucher specimens”. What are smart process, you’d think everyone would be onboard.

  46. BillyJoe says:

    Michele,

    I believe SH was being facetious. ;)

  47. mousethatroared says:

    Actuallly, no BillyJoe. I believe he was attempting to reframe his reprimand as a silly over-reaction to not-PC language.

    But I don’t accept that reframing. I have never seen such a high level of venom against patients in any other commentor on this site. I think that is the problem. Not swearing.

    Just IMO

  48. nybgrus says:

    @kathy:

    Thank you very much for that insight! That is essentially exactly what I have been trying to say in my posts but much less eloquently since I am not as intimately aware of the issues as you are. I have taken (I think?) 3 botany classes in my life and the last one was 11 years ago.

    But yes, that is exactly the point I was trying to make earlier that identifying the plants in question is not an easy task, if possible at all.

    @mouse: passive agressive reactions are indeed very childish and best ignored.

  49. nybgrus says:

    ahem, one of the points I have been trying to say, amongst a number of them…. sorry. Just woke up and only halfway through my coffee.

  50. nybgrus says:

    @Jeff:

    You don’t actually demonstrate your claim that “[people] can do their own research and decide for themselves whether or not to try a safe, affordable product like Saw Palmetto extract” when you continually demonstrate you haven’t even the foggiest of how to even begin reading a study.

    Here’s a recent meta-analysis

    It is not a meta analysis. It never claims to be. It is merely a literature review

    concluding that Saw Palmetto is effective

    And it does not conclude that SP is effective.

    Analysis of the existing clinical database indicates that extracts of Serenoa repens may be considered a viable first-line therapy for treating LUTS…However, the existing herbal formulations are extremely heterogeneous and thus difficult to assess in meta-analysis. More randomized, placebo-controlled, long-term trials are needed in order to eliminate all scepticism related to the use of phytotherapeutic agents in BPH-related LUTS patients

    As Dr. Crislip noted, GIGO – garbage in garbage out. Furthermore, this was published just prior to the JAMA article demonstrating no effect beyond placebo and thus wasn’t even considered. Furthermore you can see a clear bias of interest in the article – the authors start out by saying that the purpose of their work stems from “a revival of interest in phytotherapeutic agents.” They then proceed to blithely write off studies that demonstrated no effect of SP, including a a large systematic review in 2009, while touting other studies with poor methodologies such as a “trial [that] had no placebo arm” and one that “reported slight superiority of Serenoa repens” and another one that showed SP “improves urinary status by comparison with ‘watchful waiting.” Well, that last one sounds good at least, right? Well… except for the fact that they neglected to consider the study’s actual conclusion which was “All drug treatments showed some improvement over watchful-waiting for most patients over the study period: the alpha-blockers were found to be the most effective.” They also call these “studies with high scientific value” but neglect to mention that the last study, in which they cherry picked the wording, was not an intent-to treat analysis and merely a prospective survey study and just slipped in that it lumped together Serenoa repens and Pygeum africanum as the phytotherapy.

    Also note that the study with the “slight superiorty” actually looked at multiple analysis with the two main end points showing p-values of 0.051 and 0.049… which does not really meet the criteria of significant, even from a purely frequentist standpoint. And the last study of “high scientific value” only looked at mild to moderate BPH and found statistically significant changes, but in many of them they would be clinically insignificant (a mean prostate size decrease from 39.8 to 36mL) and interestingly never once cite a single actual statistic in the entire body of the full paper.

    Last point I will touch on:

    The authors state their preference for SP extracts sold as drugs instead of supplements:

    No, no they don’t. They say:

    Particular attention must be focused on differentiating between registered preparations, which are regulated as drugs, and those considered to be food supplements.

    In other words, they note that there is extreme heterogeneity in what is actually available as SP (“the problem was recently raised in a meta-analysis, although the evaluation included studies of various durations as well as some on mixed herbal drugs consisting not only of Serenoa repens extract”) and that the registered varietes are more likely to actually be SP and have a little more evidence of efficacy.

    The entire review is clearly biased in favor of phytotherapy and has nothing really interesting to add. They discuss the massive limitations in the studies, blithely lump in other herbals as if it meant nothing in the analysis, write of good negative studies in favor of bad positive ones, and obviously was published before the good negative study in JAMA.

    In other words, nothing even close to demonstrating utility of SP.

    And this took me roughly 22 minutes to write up in its entirety over my morning coffee. But that is because I have had a lot of practice doing this sort of thing. Perhaps you would like to demonstrate yet again your amazing ability to read and understand studies, when your opening sentence get the type of study wrong?

  51. @Jeff,

    You are severely out-classed.

  52. mousethatroared says:

    @nybrgus – I believe that passive aggressive behavior is often best ignored, but I make exceptions for people who are either in a position of authority or posing as a person in such as position.

    If I witnessed a teacher or a coach treating or talking about a child or teen-ager in a passive aggressive way I would deal with it.

    A doctor is in a position of authority because they are a gatekeeper to a patient’s access to healthcare. If I see a doctor (or someone posing as a doctor) acting in a passive agreesive way to patients, particularily a patient population that has already experienced frustration with access to healthcare, I confront it.

    Those are my ethics. I’m sorry if it ends up littering the board with off-topic comments, but so it goes.

  53. Jeff says:

    Nybgrus, the study authors merely state a willingness to examine the data using plant extracts as an alternative to side-effects laden drugs. I wouldn’t call this a phytotherapy bias.

    Their conclusion makes it clear they were analyzing studies as well as reviewing literature:

    “Analysis of the existing clinical database indicates that extracts of Serenoa repens may be considered a viable first-line therapy for treating LUTS. They offer significant improvements of urinary status while having a favourable safety profile.”

  54. weing says:

    “Nybgrus, the study authors merely state a willingness to examine the data using plant extracts as an alternative to side-effects laden drugs. I wouldn’t call this a phytotherapy bias.”

    I would call it biased. Unless they also studied side-effect free drugs as an alternative to side-effects laden plant extracts.

  55. Robb says:

    @kathy,
    Thin Layer Chromatography is what is used to verify a plant’s identity and its marker compounds. No manufacturer of herbal extracts is going to rely on visual identification alone. This is assuming they are relying on wildcrafted material or raw materials from another party rather than their own farms where identification would already be established.

  56. weing says:

    Cigars and cigarettes are known to have physiologic effects on patients. They are not side-effect laden. Nicotene gum and lozenges, and varenicline, on the other hand, are side-effect laden. I think cigarettes should come with their package inserts. Then patients would find excuses not to smoke because of side effects. I’ll keep dreaming.

  57. nybgrus says:

    Jeff, the bias is the way they frame the studies they use as evidence for SP vs those that cite as evidence against SP. The ones for it have poor methodology (as I outlined above) and don’t differentiate between multiple herbal extracts yet still cite as evidence for SP. The actually good studies (which once again don’t include the slightly later JAMA study) are framed as simply being the signal in the noise, even though the methodology was superior.

    Analyzing studies in the context of a literature review does not a meta analysis make. I should know – I recently co-authored a lit review on diastolic heart failure that is currently in peer review. A lit review doesn’t mean just listing a bunch of studies – any idiot can just type in key words and MeSH parameters into PubMed for that. It means putting into context and giving some analysis and discussion. This differs from a meta-analysis in that it doesn’t pool the studies together to give additional analytical power through complex statistical methodology. It even differs from a systematic review – that is when you create criteria and search for every single study in a specific time frame to analyze. It is more rigorous than a lit review but (much) less so than a meta-analysis.

    So yet again my point stands Jeff – you are clearly not equipped and educated enough to review the literature and understand what it means to make an informed decision, let alone the majority of people who don’t post on medical forums and post up PubMed links. That is not an insult by the way – learning how to read and analyze these studies is actually rather difficult. I think I am pretty good at it, but boy do I have waaay more to learn! Many doctors don’t even know how to do it. It really does take significant time, effort, and education to even get a handle on it.

  58. nybgrus says:

    @Robb:

    Mate, you are all over the place. What does TLC and having your own farm have to do with it? We may just have to start this over another time because you haven’t been able to put forth a unified, cogent, and coherent thesis as to what you are arguing. You keep wanting to hold on to this “whole plant extracts are better” thing, and yet keep having to concede various points without realize that they have thwarted your initial thesis.

    I mean, you say:

    their own farms where identification would already be established.

    Right… and….? How did they establish them? Why that particular plant? Where did they find out the information to decide to grow that plant and identify it in the first place before they started the farm?. Your rebuttal has no bearing on Kathy’s points.

    In as distilled and concise a version as I can, here is where we stand:

    1) Traditional use and long term use is not even remotely sufficient to establish efficacy and safety
    2) Identification of which specific plant is the subject of traditional use is extremely difficult
    3) Ergo, this means that not only is the farmed plant likely to not be the “traditional use” plant, but it is also likely that the “traditional use” plant is actually different depending on which geographic locale you ask, even in small areas
    4) Once you have a plant that you wish to test, it still must be tested in the standard scientific manner
    5) Testing multiple compounds at the same time makes scientific testing extremely difficult and rapidly unmanageable
    6) Compounds in plants can have cumulative, late, or very small effects which have been demonstrated to lead to tens of thousands of unnecessary deaths and still go unnoticed
    7) All things being equal, it is thus more desirable to have isolates of compounds and/or novel compounds being tested singly or in very small combinations in order to maximize understanding of effects and lend itself to monitoring for said cumulative, late, or very small deleterious effects
    8) Therefore it is unreasonable to say that whole plant extracts are “better” than purified pharmaceutical compounds (no matter the origin) since “traditional” and “long term” use are essentially useless and all compounds must go through the same scientific testing.

    Go back through our conversation and you will find that you have agreed with essentially every single bullet point I have listed above.

  59. Robb says:

    nybgrus,
    1) I consider long term use one factor of many when it comes to safety. All else being equal amongst compounds, one that has already got a long history of use in large populations is meangingful in terms of safety compared to something brand new. I don’t think it is a factor for efficacy although you would hope people wouldn’t continue to use useless remedies generally.
    2) and 3) I’m not sure how you came to this generalization. Yes, they didn’t have TLC in the past – just botany and Latin names to differentiate. Is it possible that the Matricaria recutita used today is not the same one described in traditional texts? It’s not impossible – but for most common herbs I think it’s highly unlikely.
    4) Agreed
    5) Difficult, yes. Unmanageable? I’d disagree and say you can’t generalize. Panax ginseng has many different ginsenosides all with different effects. They’ve been studied in isolation and in concert. It definitely makes the process of learning longer and more complex but there are herbs where the extra effort is deemed worth it (Rhodiola being another example).
    6) Your Chinese herb theory that it led to thousands of unnecessary deaths? In cases where there is a long history of use of something of unknown pharmacological properties, then yes, possibly. As I’ve said, most commonly used herbs are not unknowns like this.
    7) Ideally, I’d say standardized extracts with as many active constituents as it is feasible to use to get the best therapeutic effect. Stopping at one is not ideal in my opinion, based on known contributions of multiple constituents in herbs.
    I don’t think whole plant extracts are always better than purified pharmaceutical compounds. I’ve said you can’t generalize. In some cases there might not be any advantage in isolating single compounds and in some cases there may be.

  60. nybgrus says:

    1) I’ve illustrated quite clearly how it is not even a reasonable factor. It only lets you know that something isn’t acutely toxic. You wish that people wouldn’t continue to use remedies when they do nothing, yet they do… constantly. Homeopathy, reiki, chiropractic, acupuncture, trepany (yes, drilling holes in your head is STILL practiced today), TCM, power balance bracelets, blood letting (not any more but for hundreds of years). The point is that it is vastly more difficult to detect and pinpoint deleterious effects than you think.
    2/3)I suppose my confusion then is what do you mean by traditional use and how does it come into play? From the standard interpretation one would take it to mean that (for example) a village in China used [X] to treat fevers. It gets passed down for hundreds of years from village to village and everyone claims it works to great effect. They write a materia medica and include this herb in their TCM books and call it [X]. Researchers come and look in the book and try to find the plant… and there is where it all falls apart. Within a village it may be one species of [X], in another it is a different species. There is no differentiation. They take whatever it is that they have and study it. As we have seen, they typically demonstrate no effect or an effect different from what the traditional use claimed. And then we go down the rabbit hole.
    4) Glad we agree.
    5) Yes, it is vastly more difficult, as I illustrated above in how many studies you would actually need to do. Going to 5 or 6 compounds means thousands of trials to adequately quantify the synergistic properties. Is it possible? Yeah. Is it feasible? Not with our limited resources.
    6)So I guess we are limiting your entire argument only to those yet-to-be-defined “common” herbs? How do you define common? Are you really asserting that every herb used in TCM (which would be extremely common based on the population using it in China) is extremely well characterized? Especially in light of my example of a commonly used Chinese herb? Your premise was that ALL herbs were better… now you are retreating to just the “common” ones that have their compositions fully elucidated (which I would still argue is a pipe dream)… but how did they get there in the first place? Certainly through no utility of the concept that traditional use and long term use mean anything more than “hey test this first”
    7) And here is where it becomes unmanageable. How do you know how many is the ideal number to be synergistic and beneficial but not harmful? Seriously, I would love for you to focus only on this question and answer, in as much detail and using rigorous logic, how you will know how “many active constituents as it is feasible to use to get the best therapeutic effect.” Explain to me – in general – the experiments and trials that would be needed to come to this answer for a single herb, commonly used or otherwise.

    Stopping at one, in and of itself, may not always be the best – I agree. Taking advantage of synergy is an extremely useful concept. I am trying to explain to you that a) there is absolutely no reason to thinks plants evolved synergy for us and b) determing synergy of compounds becomes exponentially more complex (well, even worse actually since the calculations for the amount of increased testing for synergy needs to be expressed as a factorial). So yeah, in the far future, we will be able to do that. Just not now.

    And for many things a single compound actually IS best. As we become more sophisticated in our molecular targeting we really actually only want to activate (or inactivate) one specific receptor. When we target multiple targets there is a rational approach to it – we assume that these multiple targets will act in concert to further achieve the goal (antibiotics and chemotherapeutics come to mind). But even then we need to test it because the synergy can have wildly unpredictable effects even when we really, really know the effects of the single compounds.

    You are vastly oversimplying the scientific process that you agree we need to undertake and overplay the likelihood that plant [X] evolved this beautiful molecular synergy so it can best help get rid of our cancer.

  61. @Robb,

    How many years was blood letting used as the standard of care before we learned that besides being completely useless, it is incredibly dangerous?

  62. Getting one out of 20 right is not a great record to run on, just saying! And, having sanitary conditions probably has more to do with fewer diseases today than most anything. Do you all remember scurvy? yes..vitamin deficiency. Somehow, for some unknown reason to me, modern meds ended it there. Fact is, most (perhaps not all..but most) everything is a vitamin deficiency..that’s the reason for illness today…low immunity to them. Yes, that’s my hypothesis..and my experience, and it’s been proven to me time and again. Herbs contain vitamins/antioxidants and if used properly, are part of the solution. At the least, they contain more closely, what our living bodies need to fight off disease, what they are meant for. Not synthetic chemicals. …and, the “it’s the dose of the poison” doesn’t go over too well anymore, when over 100,000 people die each year from the “dose”..that wasn’t gotten right…imo nor the side effects and untold disease and damages caused by them, just to add more synthetic chemical concoctions to the mix. “First do No harm”..I believe doctors ..most mean well anyway..yea even you Skeptical : )..I only hope you all will come around to simply getting some other things right soon : ) Chris..perhaps look into pumpkin extract for Type I Diabetes, I think it’s something you might be interested in..http://www.healthcentral.com/diabetes/c/114/11209/blood-sugar?ic=1108

  63. Robb says:

    nybgrus,
    2/3) No, your nice story is not what would be considered traditional use. It’s the equivalent of the game of broken telephone. If you want to read some definitions and criteria for traditional use that are being used, check here:
    http://whqlibdoc.who.int/hq/2000/WHO_EDM_TRM_2000.1.pdf
    http://www.hc-sc.gc.ca/dhp-mps/prodnatur/legislation/docs/notice-avis-trad_claim-alle_sub-util-eng.php
    7) This is really a question about what is most efficacious, right? So let’s say there is a traditional claim that
    meets the criteria in the links above (the Canadian one is probably the best example because it is used to judge pre-market approval). To validate a traditional claim scientifically, it would make the most sense to start with the whole plant as it was traditionally used. So we are talking tea or alcoholic tincture. Do a study on whether the whole plant is effective for the claim. Now assuming the results aren’t a total failure, there is interest in what the individual compounds in the plant do. What are the main active ingredients? What do they do individually? How do they affect each other? What are the right proportions? Yes, I know the number of permutations increases exponentially the more active ingredients you look at. Yet it still is done. St. John’s wort is a good example where it was originally standardized for one active and then later more were standardized for as it was realized this would improve efficacy. Panax ginseng is also a good example where this has been done. It’s an incredibly complex herb with dozens of potentially important constituents yet that hasn’t deterred research.
    http://www.nature.com/aps/journal/v29/n9/pdf/aps2008134a.pdf
    http://www.nature.com/aps/journal/v29/n9/pdf/aps2008133a.pdf
    My ideal example may take forever to find with that many constituents. More realistically, what happens is research into validating traditional claims, identification and pharmacology of major ingredients, and optimal levels of standardization of these active ingredients is found. The question is really one of how far you need to drill down to find something effective. St. John’s Wort has basically stopped at 2 standardized ingredients (hypericin and hyperforin) being enough to be effective while it is still acknowledged that other ingredients present but not standardized for (certain flavonoids) do affect bioavailability in a positive way. Maybe they will be standardized for next as well. It’s usually on ongoing process that continues even after some degree of effectiveness has been found.

    I have no idea what you are talking about with your last comment though – I’ve said that plants possess some sort of intent or sentience in evolving their synergy for our benefit?? Don’t be silly. The happy coincidence of synergy between plant compounds that happens to benefit us is no more unlikely than plant compounds being able to interface with our chemical receptor sites in the first place. Stuff in nature just works out that way sometimes. Do you similarly question the mixture of gases that you breathe each day or marvel at the ridiculous number of fine tuned constants that astro-physicists tell us are required for the universe to exist at all? In context, I don’t find the fact that some plants happen to possess a synergy beneficial to us all that unlikely.

  64. nybgrus says:

    oh dear.

  65. nybgrus says:

    robb:

    2/3) First off, it is a false dichotomy to discuss “alternative” or “traditional” medicine as opposed to actual medicine. The discussion, including in that PDF you linked, hinges on essentially saying that “traditional” medicine is just as valid as actual medicine. It isn’t. But that is a whole separate topic. But let me demonstrate how incredibly useless a construct it is that you are trying to go by (and the Canadian PDF as well).

    From the PDF:

    Long historical use of many practices of traditional medicine, including experience passed on from generation to generation, has demonstrated the safety and efficacy of traditional medicine. However, scientific research is needed to provide additional evidence of its safety and efficacy

    So, the long historical use has demonstrated the safety and efficacy, but somehow we need science to demonstrate more safety and efficacy? If something has documented scientific proof of safety and efficacy (S+E), then the conversation is over – we are done. And if A + B = B then A = 0, right? So if “traditional” S+E + “scientific” S+E = “scientific” S+E… what use is the “traditional” part again? In other words, it doesn’t matter if something is “traditionally” safe and effective, since the science trumps that no matter what. The way it is postulated here begs the question and says that “tradition” establishes S+E, but somehow it still doesn’t because we need scientific proof anyways.

    From the defintion of “traditional medicine:”

    It is the sum total of the knowledge, skills and practices based on the theories, beliefs and experiences indigenous to different cultures, whether explicable or not, used in the maintenance of health, as well as in the prevention, diagnosis, improvement or treatment of physical and mental illnesses

    Aristolochia was used by the ancient Greeks, Romans, and Egyptians. It is part of the Traditional Chinese Medicine materia medica which is the modern version of the Ben Cao Gang Mu, which was used for over 400 years and included the use of Aristolochia. It’s uses as a “birthwort” is documented in the 1st century CE. Illustrative of my point, the ancient Greeks and Romans used it as a “birthwort” for around 1,000 years and the Chinese used it for arthritis and edema for for around 500 years. This fits the definition of “traditional medicine” as your chosen document defines it.

    So, which “sum total of the knowledge…” do we use to describe the “traditional” use of Aristolochia? Do the Romans win because they used it for 1,000 years? Is it safe because it has been used – documented and with great success – for 1,500 years? Well, science tested that one and found it to be lacking. It is neither efficacious (for ANY of the “traditional” uses) NOR safe. So once again, “traditional” S+E (says yes!) + “scientific” S+E (says no!) = no! not safe, not effective. Where does the “traditional” S+E matter at all?

    7) Sure, I agree it makes sense to start with the whole plant… and then whittle it down to the best bits. You’ve described pharmacognosy and high throughput screening. But that has extraordinarily little to do with “traditional use” and “long history” does not actually establish safety. So how does this support your point that whole plants are better?

    As for your studies linked note that they are both out of Southeast Asia, which has been identified in numerous studies as being completely unreliable with poor study methodology and rampant publication bias. If you look at ACTUAL studies and reviews on it you find that ginseng has no evidence of doing anything, as a whole or in parts.

    So once again, not only is the research complicated, but these traditional use herbs have a long and predominant history of having no effect.

    St. John’s Wort has basically stopped at 2 standardized ingredients (hypericin and hyperforin) being enough to be effective while it is still acknowledged that other ingredients present but not standardized for (certain flavonoids) do affect bioavailability in a positive way.

    Even St. John’s wort has extremely mixed results, with pretty much all the positive studies coming from Germany and Cochrane forced to say that overall it looks like there is an effect “but it cannot be ruled out that some smaller studies from German-speaking countries were flawed and reported overoptimistic results.” And with extremely mixed results, especially in subjective outcomes assessments, that is equivalent (at least for practical purposes) as a negative. There are simply incredibly few herbs/plants that actually have useful effects without further refinement. And “affecting bioavailability in a positive way” has nothing whatsoever to do with safety and essentially nothing to do with efficacy. In doing pharmaceutical research the appropriate manner is to standardize bioavailability so it is not a confounding factor.

    I have no idea what you are talking about with your last comment though – I’ve said that plants possess some sort of intent or sentience in evolving their synergy for our benefit??

    No you’ve completely missed the boat here. Going off on how the gasses and fine tuned astrophysics constants are not that crazy (the anthropic principle) has no bearing on plants evolving to cure our diseases. From an evolutionary standpoint it makes very little sense for a plant to evolve wanting to have its stems, leaves, and roots eaten. And in fact most plants evolved alkaloids exactly to prevent this. The opium poppy didn’t evolve to help our pain problems, it evolved to get animals high and fear eating the plant again. We harnessed it for a different reason. So yes, it is ridiculous and highly unlikely the a plant will have evolved a complex biochemistry suited to help a specific disease. That is why high throughput pharmacognosy has such an INCREDIBLY low yield.

    How about you give me a list of your top 10 plant/herbs that have demonstrated actual efficacy and are superior in both side effects and efficacy than a standard pharmaceutical compound. If that is too hard, how about just top 10 with proven efficacy? Shouldn’t be too hard, should it? Considering how common that is and how much you know about this topic. I’m genuinely curious to see how many you will come up with.

  66. Robb says:

    Not sure if that “oh dear” was directed at me or not since it appeared before my moderated comment appeared. On the whole plant synergy vs. single isolated compound topic, this is another example of what I’m talking about:
    http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3059462/pdf/1475-2875-10-S1-S4.pdf

  67. nybgrus says:

    No, it wasn’t directed at you. I’ll read that when I have a chance. I’m actually out of town on a vacation weekend so it may be a bit before I can get to it. that should give you time to find those top 10 herbal compounds

  68. @rustichealthy,

    I truly appreciate your “theory” that all illness is a vitamin deficiency. Can you please define a mechanism by which hereditary spherocytosis is caused by a deficiency in vitamins?

  69. Chris says:

    RH:

    Chris..perhaps look into pumpkin extract for Type I Diabetes, I think it’s something you might be interested in..

    Where have I commented on this thread? And how does that biased website substitute for the title, journal and date of the PubMed indexed paper. It is just a speculative editorial that has absolutely no references, and continues to prove you do not read the links.

  70. jmb58 says:

    @rustichealthy

    As I surgeon, I take care of a lot of trauma patients. I was wondering, what herbs and vitamins should I be using to treat my patients? I have looked in the trauma liturature and there aren’t any studies I can find looking at trauma and herbal/vitamin treatment. Must be big pharma (or maybe big blood bank) suppressing these important studies.

    Gun shot wounds to the chest continue to be particularly difficult. Do you think pumkin extract would help?

    After all, scurvy (ie. vitamin C deficiency) was cured with vitamin C.

  71. According to Trick of Treatment, the discovery that scurvy was cured with vitamin C is one of the earliest known uses of (very primitive) randomized trials. Ie, on the boats one group of sailors got the limes, another group got whatever, etc, and they saw which ones did not develop scurvy. It’s interesting that rustichealthy would pick that example, because the principles we learned there helped us learn what does — and more importantly does not — cause other diseases.

  72. jmb. sorry, I didn’t take the time to specify things like that in my statement.

    I actually meant internal illnesses..so prevalent today, like diabetes, hbp, cholesterol, candidas, skin conditions like acne & eczema, arthritis, osteoporosis..parkinsons, ms, alzheimers, cancers, heart disease, MMR, even pertussis….pretty much everything other than accidents, gunshot wounds, trauma… I do give great credit to modern med for. Of course surgery is needed..car accidents..broken legs, wars. etc..thank you

    But, I should add..perhaps. nutrients can be given in most all those cases to help speed healing also : )

  73. Chris..it doesn’t..I just thought you’d want to google it..perhaps ..to see if there’s something more to it. It’s what I would do anyway. Here’s a few other links that may be of interest..

    http://diabetes.webmd.com/news/20070709/pumpkin-benefit-for-type-1-diabetes
    7 — Asian pumpkin may help thwart type 1 diabetes, according to a preliminary new study from China.

    The researchers studied rats. It’s too soon to know if the findings apply to people.

    Normally, people control blood sugar naturally through a hormone called insulin, which is made by certain cells in the pancreas.

    But in type 1 diabetes, the body’s immune system mistakenly attacks those pancreatic cells. That wrecks the insulin-making process, leaving blood sugar uncontrolled without insulin shots.

    The Chinese study suggests that Asian pumpkin extract may help protect those pancreatic cells from the ravages of type 1 diabetes. The findings appear in July’s Journal of the Science of Food and Agriculture.

    http://www.sciencedaily.com/releases/2007/07/070708193019.htm
    Compounds found in pumpkin could potentially replace or at least drastically reduce the daily insulin injections that so many diabetics currently have to endure. Recent research reveals that pumpkin extract promotes regeneration of damaged pancreatic cells in diabetic rats, boosting levels of insulin-producing beta cells and insulin in the blood, reports Lisa Richards in Chemistry & Industry, the magazine of the SCI.

    http://medicsindex.ning.com/profiles/blogs/pumpkin-could-replace-diabetes-injections

    It would help in fostering good glycaemia and metabolic control
    Prevents long term complications due to the antioxidant protection
    It prevents the progressive destruction of pancreatic beta cells
    Research done at East China Normal University highlights the fact that diabetic rats fed the extract had only 5 per cent less plasma insulin and 8 per cent fewer insulin (beta) cells as compared to normal healthy rats
    The extract is good for pre – diabetic as well as those already suffering from it
    Insulin injections still need to be taken, but the number of injections will reduce

    Maybe you can ask your doctor.

  74. Skeptical..I didn’t include ‘hereditary’ diseases..being more difficult of course..however, I did find this ..

    http://www.freemd.com/hereditary-spherocytosis/treatment.htm

    It looks like B vitamins and iron would help. But, I do believe, somewhere along the line, the cause was either a toxin or vitamin deficiency, thereby weakening the mother’s and baby’s health..and so things are ‘inherited’..but, in any case. I’m not educated in all the specifics of all diseases. Nevertheless, it would seem to be something as an exception to deal with. Wouldn’t you think it’s a good thing to actually eliminate, certainly minimize all of the illnesses I listed above? I’m sure your patients would appreciate it too. I did say “most all disease”…I didn’t mean every single one. It was a joke..1 out of 20..you’re not being obnoxious today..as yet Skeptical..I appreciate it :)

  75. Robb says:

    nybgrus,
    You’re missing the point re: plant synergy and my other examples. You asked why should plant synergy exist. My answer was I don’t know but it’s not really that unusual compared to the many other fortuitous occurences that make up the natural environment. In my example of whole plant synergy in the treatment of malaria that I linked, obviously the plant did not evolve that combination for our benefit – it is luck. And there are many examples in nature of this “luck”. Some astro-physicists confronted with the mind boggling nature of the luck that allows the universe to exist at all start to get all theosophical about it – I’m not even going to go there as I’m agnostic and it’s irrelevant to our discussion. Point is, amongst the sheer number of plants humans have used, some do have these fortuitious combinations and while it may be a small percentage in terms of the whole plant kingdom, it’s not really that unusual in and of itself.

    Bringing up “from an evolutionary standpoint, it makes no sense for plants to do this”, is also a misguided assumption. Are you really going to argue that evolution of a species is always in a vacuum? That there are no ocurrences of co-evolutionary traits in nature? It’s a whole different discussion though and one that is unlikely to have an answer – I don’t think we know why.

    As far as your request for my top 10 most efficacious herbs – I’m not really taking homework assignments at the moment. I’ve mentioned a few already throughout the thread. For you, SJW has controversial efficacy, for others it doesn’t. Especially given that anti-depressant pharmaceuticals themselves have questionable efficacy to start with.
    http://www.plosmedicine.org/article/info%3Adoi%2F10.1371%2Fjournal.pmed.0050045

    You’ll choose a study to make your point, I’ll choose mine:
    http://www.ncbi.nlm.nih.gov/pubmed/22969004

    Your bias will guide you as well – interesting that you chose the 2005 Cochrane review for SJW and not the 2008 one which came to different conclusions:
    http://www.ncbi.nlm.nih.gov/pubmed/18843608

    The author’s explain the difference saying:
    “In previous versions of this Cochrane review (published in 1998 and 2005), included trials
    were not restricted to patients with major depression, whereas the inclusion criteria of the
    present study were restricted to patients with major depression. This is not to say that SJW is
    ineffective in depressed patients who are not classified as having major depression. Rather,
    this restriction helped to decrease variability in the analysis.”

    We’ll argue about quality of studies, publication bias, inclusion criteria in meta-analyses, confounding factors, likelihood of endpoint “goal posts” being moved mid-study, whether you trust the country the study was done in or not, etc. etc. The real problem is that there are a lot of cases where the consensus is not “no benefit” but is rather “preliminary evidence exists, but more good quality studies are needed”. It’s definitely a work in progress. Just for fun though, for your own interest, I’ll leave you with these to dissect as well:
    http://www.biomedcentral.com/1471-2318/10/14
    http://www.ncbi.nlm.nih.gov/pubmed/18254076
    http://www.ncbi.nlm.nih.gov/pubmed/21036578

  76. Robb says:

    Actually, on the topic of why synergy of secondary plant metabolites developed, while it may be “luck” for humans, it does make sense for the plant too. These metabolites play the role of attraction and inhibition of animals, insects, fungi, other plants, microbes, etc. and on the inhibition side it would explain why there is synergy amongst the ingredients in plant essential oils (antimicrobial effects) and on the attraction side for psychoactive effects. One paper looks into the latter while noting the similarity in roles of neurochemicals between humans and insects.
    http://advances.nutrition.org/content/2/1/32.full.pdf+html
    http://www.mdpi.com/1420-3049/17/4/3989/pdf

  77. jmb58 says:

    @rustic

    On another thread you say that you rely on us ignorant MDs for the diagnosis. Then you use nutrition and vitamens to unlock the body as a healing machine.

    So we are fine for diagnosis, but not treatment. Except for injuries, then we are okay for treatment. But only injuries on the outside? You’ve got the “internal illness” covered.

    What about internal injuries? Who should treat those?

    Why the distinction with injuries? Injuries are just a type of pathology. Why is this the only type we can treat and you can’t? So if a knife injures the colon I can fix it. But if it is cancer in the colon, a big chunk of colon cancer I can see clear as day on the monitor (during colonoscopy), then I’m lost but you are all over that. I believe you stated it’s easy. What if the immune system has attacked the colon and eroded a hole in the colon wall, internally. More pumkin extract?

    You mentioned you treat internal illness, like cancer. How about skin cancer? Not really internal. What do you do with a growing cancerous lesion on your arm? Have an MD diagnose it then take a vitamen? What if it’s a basal cell carcinoma that is almost completly cured with excision? Cut it off or more pumkin extract?

    “nutrients can be given in most all those cases to help speed healing also”

    Nutrition would be a better word. I spend a lot of time following the scientific studies related to nutrition in the injured patient. If there is evidence for improved outcomes, I implement the therapy.

  78. Jeff says:

    Two examples of synergy among plant constituents:

    1. Scientific evidence for synergy in a botanical product:
    http://www.sciencebasedmedicine.org/index.php/scientific-evidence-for-synergy-in-a-botanical-product/

    2. catechin-polyphenols and caffeine in green tea stimulate thermogenesis in rats:
    http://www.nature.com/ijo/journal/v24/n2/full/0801101a.html

  79. I love that rustic just blamed a vitamin deficiency for a hereditary disorder. Why are any of us entertaining this person?

  80. Harriet Hall says:

    @SkepticalHealth,

    “I love that rustic just blamed a vitamin deficiency for a hereditary disorder. Why are any of us entertaining this person?”

    Good point! He actually said “I do believe, somewhere along the line, the cause was either a toxin or vitamin deficiency, thereby weakening the mother’s and baby’s health..and so things are ‘inherited”

    Does he think vitamin deficiency somehow causes mutations? Or is this some distorted interpretation of what epigenetics means? And why does he put “inherited” in quotes? Oy vey!

  81. jmb..it’s certainly up to you and the patient how you wish to treat something. cut it out, if that’s the best you and your patient decide. I’m not determining that for you. As far as skin cancer is…I’d look up first, for myself that is, what if any natural treatment there might be. I’ve tried various things on different rashes..coconut oil works great, so does applecider vinegar, and baking soda! none of those I am kidding about! someone used ACV for her hemorrhoid…. I was mentioning it to take acv, but she actually applied it…and it worked! Of course skin cancer is another issue..I might even look up baking soda for it..and I’m not kidding about that either. You all need to open your minds to different ways of curing things..just because it was not taught in medical school..doesn’t mean it can’t be so!. Someone wrote not too long ago in CL how her eczema, that she had for a lifetime, was helped finally, with applecider vinegar and water..waiting 15 minutes then showering it off. I just typed in vitamins for skin cancer, and A, C and D all look very helpful..which would tell me now..it’s a deficiency of A, C and D..people are not getting enough of those vitamins. I would then go at it both ways..take the vitamins, administer whatever natural remedy..(baking soda I would try first personally)…it’s like going to war..if you mean business..you send in all you have. That’s how I would deal with something. Internally, find out vitamins lacking..externally, natural wholesome remedies..that have worked for others, and see if they’ll work for me. Basically, that’s my way of doing things. My son had bad allergies for years..over 10 I would say. ..sneezed and congested constantly…then he started organic diet, organic bee pollen, and basic vitamins C, D, omegas..and within perhaps 2 months gradually, he stopped all sneezing/congestion.

    As far as accidents, injuries..etc..I think you know, I would depend on surgeons to fix it…but then I’d take vitamins to help with the healing also. I know you’re being facetious..I do understand the difference of what I can and can’t ‘fix’. like a broken leg..just how to help it along also.

  82. Dr. Harriet..my premise of lack of nutrients..or..too many toxins..is to me plausible, since our bodies cells change because of illness, and so, quite possibly, if the mother is ill, is weakened in some area, and so the baby born will be weakened because of it in the same, if not then another area. I thought that’s how it would go..because of the close physical contact…growing, within the mother, why the baby is effected if the mother drinks/smokes..etc.. and….I’m a she :)

  83. mousethatroared says:

    Harriet Hall – NTD and folic acid

    http://www.chg.duke.edu/diseases/ntd.html#anchor2

    also CLCP and folic acid

    both seem to have a heriditary component.

  84. Harriet Hall says:

    @mouse,

    He linked to an article on the treatment of hereditary spherocytosis and his comment clearly indicated he believed that that particular condition was caused by a vitamin deficiency. It isn’t: it is caused by an abnormal gene inherited in an autosomal dominant pattern.

    Folic acid supplementation can reduce (but not eliminate) the risk of several congenital defects, but the mechanism is not genetic: defects result from interference with embryologic development. Folic acid deficiency does not cause mutations or inheritable diseases.

  85. mousethatroared says:

    HH – agreed RH is confused. But it’s good for any readers to be clear that a nutritional intervention (folic acid) does lower the incidents of NTD significately and probably CL/CLCP moderately (but not cleft palate in isolation), both of which have a hereditary component.

    I’ve seen a few comments in the past (rarely) saying something to the effect of “I’ve always been skeptical of those prenatal supplements”

    Maybe I’m being over cautious, but I didn’t want an important health message to be accidentally muddied in the wrangling with RH.

  86. @MTR,

    When we refer to a disease as being hereditary, we almost always mean that it is acquired through a defective gene, and we usually know which gene is responsible for the disease, and the patttern of inheritence. Hereditary spherocytosis, cystic fibrosis, Marfan’s syndrome, and sickle cell are all examples of these diseases.

    Other diseases, like NTDs and CL, along with diabetes, hypertension, heart disease, psychiatric conditions, many types of cancer (and there are heridtary forms of cancer, too!), etc, may have a heridtary component – that is, if someone in your family had it, you have an increased risk of having it too, but there is no definable pattern of inheritence where we can predict with reasonable accuracy, or do a genetic test, to determine if the patient will have the disease or not.

    @HH,

    I was curious if rustichealthy was going to try to say something like “if they had better vitamins, the DNA would have copied itself better and not had mutations!!” :)

  87. jmb58 says:

    @rustic

    “it’s like going to war..if you mean business..you send in all you have.”

    If you mean business you don’t waste time and resources on stuff that doesn’t work and/or makes no sense. I don’t see the Air Force adding natural, organic jet fuel supplements to their F-22s, or the Army incorperating ancient Chinese military technology.

    “..I do understand the difference of what I can and can’t ‘fix’.”

    No. You really don’t.

  88. Baking powder is very cheap jmb..so are vitamins comparatively.. and they have worked for me and some I know..I’m not here simply spouting out things I haven’t tried! actually, they’ve proven very effective! I just wonder how you all Know they don’t work? without even trying it for yourself? That kind of puzzles me. I mean..’scientifically speaking’..shouldn’t you want to find out something for yourself? I didn’t know until I tried. I do know I can get myself off of 4 asthma meds including steroids…and arthritis without without any pain meds. Those are small things I know..imo too..but, that’s why I’m amazed at how still prevalent they are today..with no end in sight, in conventional medicine.

  89. Chris says:

    RusticHealthy, is it baking soda or baking powder that does wonders? They are two completely separate chemicals.

    So what does baking soda work for? What is that evidence?

    And what does baking powder work for? What is that evidence.

    Why should we try “something for ourselves” when you cannot even keep your stories straight? Are you the person on this planet with the specific genome that defines the reaction to every protein or chemical on this planet? Do tell us. What makes you so unique that we must all react to the world like you?

    I have a severe allergy to nickel. If I touch a hand sewing needle coated with nickel I get a rash on my hands and my feet. Does that happen to you? My sensitivity to nickel is so bad that I cannot touch cheap gold, which is hardened with nickel (even the stuff from Tiffany, and I have asked). I also react to chrome. My feet get a rash from how much I touched the chrome trim of a boat we rented at a lake. So unless you have a severe allergy to nickel and get sick to your stomach from all narcotics, your personal experience means nothing to me. Plus I have been vaccinated for yellow fever, typhus, typhus and smallpox, and survived dengue fever. Has that happened to you?

    At least I know that the real doctors I talk to acknowledge my sensitivities. My family doctor also has issues with nickel allergy, and the clinic who did my colonoscopy was willing to deal with my narcotic sensitivity issues. At least there are some who understand why I am confused at those who would rob a pharmacy to get Percodan (why would anyone rob a store to get something that makes you vomit?), and they are often MDs.

    RusticHealthy, you are unique. Your experience only speaks for you. Plus you need to open your mind in order to relate to others around you. That requires that you open your mind and learn about the world. Go find your local community college and learn the basics in science, math history and literature. Because you seem to not know anything beyond yourself. And that is a very lonely place.

  90. Chris says:

    Aagh.. ” yellow fever, typhus, typhus” should be ” yellow fever, typhus, typhoid” All diseases that RusticHealthy never had to worry about since she has probably never left the USA.

    On the other hand, I get to now fear going to the Florida Keys because dengue has occurred there. The “fun” thing about actually surviving one of the four known versions of dengue fever is that if I get another of them my chances of getting a deadly hemorrhagic version of dengue fever has increased. Woo hoo. I am sure RusticHealthy will now come up with a vitamin I need to take to prevent bleeding to death from a mosquito bite.

  91. @Chris: Thanks for including literature, but I feel RH would end up accusing contemporary American poets of not being close enough to nature (even Gary Snyder), boring his classmates by proselytizing Traditional Chinese Poetry, which will have nothing to do with Li Po (and everything to do with Jane Hirschfield), while completely ignoring (or essentializing) contemporary Chinese poets like Bei Dao or Wang Ping.

  92. Chris : ) sorry…baking Soda..my son rubbed it in his bad case of poison ivy one time, and it went away .

    I did see something about apple cider vinegar also for one’s nickel allergy..

    http://www.skincell.org/community/index.php?topic=9511.0

    This is on baking soda…

    http://www.care2.com/greenliving/baking-soda-is-good-medicine.html

    Chris..I know I’m unique..everyone is..something may work for some, not for others.

  93. also, I’d mention vitamin deficiency..but I know you’re not open to it..I’m open minded…but, I like natural whole remedies as much as possible anyway..thank you : )

  94. Chris..I have an aloe plant I bought a few weeks ago, and it turned brown ..really bad..I looked it up..and it said it was a ‘fungus’..I read somewhere baking soda is an anti-fungal..so I sprayed it with baking soda and water. Wiped it off..one time..and it’s totally green now! just wanted to let you know..since you’re growing organic.

  95. and, I didn’t mean to say Every disease, I think I said most..but, looks like B vitamins for Typhoid/typhus, and honey, cloves and salt would be good to have around

    http://www.online-vitamins-guide.com/dietary-cure/typhoid.htm

    and, much more on Baking Soda..

    http://wakeup-world.com/2012/05/07/51-amazing-uses-for-baking-soda/

    is it against the conventional medical law to try some safer natural remedies? that’s the impression I get :)

  96. nybgrus says:

    @robb:

    I am back from my mini-vacation and would have left the conversation if it hadn’t been for 2 things: that I am working odd hours in the ER this week and thus find myself with time on my hands and the genuinely poor attempt at chucking up studies by Robb.

    From the beginning:

    You asked why should plant synergy exist.

    No I didn’t. I asked why would plants preferentially evolve synergy that is specifically useful for us?

    You answer the question correctly though:

    In my example of whole plant synergy in the treatment of malaria that I linked, obviously the plant did not evolve that combination for our benefit – it is luck

    Yes, it is. But you also make the fundamental error at the heart of our discussion:

    My answer was I don’t know but it’s not really that unusual compared to the many other fortuitous occurences that make up the natural environment.

    It is that unusual. Which is why there are orders of magnitude more failed attempts at drug synthesis and isolation and so few herbs with any actual efficacy… relative to the number that exist and that have been tested. It is a very low yield field. As for comparing it to “many other fortuitous occurences that make up the natural environment” this is a non-starter and an evidence free statement. What “other fortuitous occurrences?” The fact that physical constants are so “precise” down to the 19th decimal point? We have no frame of reference for the denominator on that and therefore any assumption as to its likelihood is pure and unadulterated guesswork. Additionally it is a pointless statement. Saying something is “common” relative to incredibly “uncommon” things proves nothing. I agree that finding herbs with curative compounds and synergy is more “common” than fatal famililial insomnia and vastly more “common” than a marble statue moving due to chance alignment of quantum states. So?

    And to top it off you can’t even hold a coherent argument in your own single paragraph as you close with:

    Point is, amongst the sheer number of plants humans have used, some do have these fortuitious combinations and while it may be a small percentage in terms of the whole plant kingdo></b?, it’s not really that unusual in and of itself.

    So which is it? Is it “common” or is it actually a “small percentage?” Because by any standard working definition things that are “common” have a “high” percentage chance of occurance. Things that are uncommon are the ones that have a small percentage chance of occurance. Since your entire argument up to this point has been about how useful and common whole-plant synergy is, I think we can reasonably end the conversation here on your own admission.

    And there are many examples in nature of this “luck”… As far as your request for my top 10 most efficacious herbs – I’m not really taking homework assignments at the moment

    That’s funny. It is so common, and there are so many examples of this “luck” yet the “homework assignment” is too arduous a task? If you asked me for 10 things to support something I am asserting – especially something as straighforward as simple examples such as these – it would be trivially easy for me to reference them. I had assumed that since you seem to assert with confidence that whole plant synergy and the efficacy of herbs is a simple statement of fact, a common phenomenon, and easily demonstrable that you were actually familiar with the relevant literature on the topic and that just a few clear cut and unambiguous examples would be easy to throw in my face. Seems not….

    For you, SJW has controversial efficacy, for others it doesn’t

    If studies are mixed and equivocal, with some showing efficacy by the majority of them showing little, if anything, that is by definition controversial. You don’t just get to focus on the minority that demonstrate efficacy and claim that means there is a consensus on efficacy.

    Especially given that anti-depressant pharmaceuticals themselves have questionable efficacy to start with.

    First off, complete non-sequiter. Whether pharmaceutical anti-depressants work or not is completely irrelevant to whether SJW works or not. Furthermore the study you linked is limited to only 4 of the newest generation of drugs. And as Jerry Coyne points out there is evidence that on the whole anti-depressants are indeed better than placebo and that studies in that field are either lacking or of very poor quality. Both references point out that depression is highly responsive to placebo, which makes sense, and further makes those few positive studies of SJW more likely to be an abberation of placebo effect in poorly controlled studies than a real effect.

    But fine, I’ll give you a freebie – SJW works. How about 9 more, since it is “so common?”

    You’ll choose a study to make your point, I’ll choose mine

    A study on Panax ginseng which I can only assume you tossed up to try and refute my other studies which demonstrated no effect from ginseng. Funny that the second line of the abstract is:

    “However, there is no conclusive evidence supporting its use in the treatment of any particular disease.

    I ask for evidence of efficacy of herbs and plants and that is the best you can toss up? They found 475 potential articles on the topic and only 65 were good enough to include and of these there were 12 different systems studied as PG having a possible effect. And too boot the abstract goes further to say “The risk of bias was unclear in most studies” And out of all of that they pull out that there might be benefit of PG in glucose metabolism and immune modulation – of which there are 6 and 4 studies respectively. So 475 articles, of which 65 aren’t crap, of which 10 show the possibility of having an effect on two completely different systems by one herbal supplement, all the while with caveats that there is no conclusive evidence supporting its use and that the risk of bias was unclear in the studies used.

    That’s some powerful science you are throwing at me Robb.

    Your bias will guide you as well – interesting that you chose the 2005 Cochrane review for SJW and not the 2008 one which came to different conclusions:

    Not bias – just didn’t come up in my search. Mea culpa. That said, your link actually doesn’t say anything fundamentally different but does has a slightly better spin to it:

    Here is the summary of the same Cochrane review you linked by the same authors that say the same thing… again… as my previous comment:

    “However, findings were more favourable to St. John’s wort extracts in studies form German-speaking countries where these products have a long tradition and are often prescribed by physicians, while in studies from other countries St. John’s wort extracts seemed less effective. This differences could be due to the inclusion of patients with slightly different types of depression, but it cannot be ruled out that some smaller studies from German-speaking countries were flawed and reported overoptimistic results.”

    From the original Cochrane review you posted we can note a few interesting points.

    1) “Results of placebo-controlled trials showed marked heterogeneity”
    2) Larger trials showed a smaller effect size than smaller trials (1.28 vs 1.87)
    3) “Both in placebo-controlled trials and in comparisons with standard antidepressants, trials from German-speaking countries reported findings more favourable to hypericum.”

    So we see a decrease in effect as trials get bigger and better, the trials actually testing the efficacy of SJW are “markedly heterogeneous,” and we still see the effect I pointed out previously that German speaking countries seemed to have a bias shifting the effect size up.

    Once again, hardly a slam dunk for SJW here….

    The real problem is that there are a lot of cases where the consensus is not “no benefit” but is rather “preliminary evidence exists, but more good quality studies are needed”

    Preliminary evidence always “exists.” That is why it is preliminary. Because it is early, typically much more sloppily done, and usually does not pan out in bigger more robust studies. Besides, you have been arguing that the synergy and efficacy of herbals and plants exists not that there is some preliminary data to support thinking that they might exist. There is a big difference. And if you go through and read this blog and other science blogs you will find a common theme – that the phrase “more good quality studies are needed” is a catch all reflection of the shortcoming of EBM, whic is why SBM became the coined phrase around here. In fact, Cochrane has even taken notice of SBM’s critiques and taken notice. “More studies needed” =/= evidence of efficacy.

    As for fun dissect:

    Effects of Ginkgo biloba in dementia: systematic review and meta-analysis:

    In the meta-analysis, the SMDs in change scores for cognition were in favor of ginkgo compared to placebo (-0.58, 95% confidence interval [CI] -1.14; -0.01, p = 0.04). If the CI contains zero (or 1, depending on the scale used) then we can consider the results to be more or less null. Granted, in a pedantic sense 0.01 does not technically cross that threshold, but it is close enough especially when dealing with something as subjective and difficult to assess as dementia. Additionally, as PZ Myers pointed out, that the significance threshold of 0.05 is arbitrary and data demonstrates that, particularly in psychology journals, there appears to be a clear bias to push the p-value just over that line with a massive spike in papers with a p-value just under 0.05. So especially in this context I find a p-value of 0.04 to be unexciting. But I am not just being a nitpicky a-hole here. The study goes on to say ” but did not show a statistically significant difference from placebo for activities in daily livin” and once again “Heterogeneity among studies was high” and of course the crux hinges on “For the Alzheimer subgroup, the SMDs for ADLs and cognition outcomes were larger than for the whole group of dementias.” Subgroup analysis to find significance when the whole group shows none or a very small effect size is the easiest way to make effects appear like magic. Even the conclusion is underwhelming:

    Ginkgo biloba appears more effective than placebo. Effect sizes were moderate, while clinical relevance is, similar to other dementia drugs, difficult to determine.

    Next up we have Hawthorn extract for treating chronic heart failure.

    I’ll agree that this demonstrates hawthorn has some effect on blood pressure and cardiac load. So does foxglove. However, the review does not compare hawthorn to actual heart meds, only 7 of the 14 included studies actually say whether patients were using standard heart meds at the same time, and the conclusion is that it could be a useful adjunct to existing therapy by lowering the necessary dosage of heart meds. It also notes that there is no demonstrable effect on mortality or morbidity at all. And a newer study “…does indeed demonstrate that [hawthorn] is not a harmful therapy, but it’s one that is not particularly helpful nor that would be recommended,” Fonarow said. “It’s naturally attractive to think there is something over the counter or naturally occurring that may help improve outcome. Unfortunately, we’ve not been able to identify that so far.”

    So we have one example of efficacy of an herb. With the gimmie from before that makes 2. But this one seems to also demonstrate that actual pharmaceuticals are a better option than some leaf tea, especially considering how many comorbid conditions CHF patients have and how much interaction is possible with a whole plant extract of hawthorn. Still waiting for 8 more… and then still some evidence that they are better than the equivalent pharmaceutical.

    And the last one, The effectiveness and efficacy of Rhodiola rosea L.: a systematic review of randomized clinical trials. which is a convenient one since my post-grad, pre-med research was on…. Rhodiola.

    RCTs testing the efficacy or effectiveness of mono-preparations of R. rosea as sole treatment administered orally against a control intervention in any human individual suffering from any condition or healthy human volunteers were included.

    In other words lets get a whole bunch of stuff and dredge the data to see if we can come up with any correlations.

    And out of all of that they come up with:

    “R. rosea may have beneficial effects on physical performance, mental performance, and certain mental health conditions. There is, however, a lack of independent replications of the single different studies.”

    You keep swinging for the fences with these studies offering resounding support of your thesis that efficacy of whole herbs/plants and synergy are “common” and “well established” and that “traditional” and “long term” use are useful indicators of this.

    That said, I did actually do research on R. rosea. And in my fly models it did have a genuinely robust effect in increasing their life span and it did so independent of an anti-oxidative pathway (which makes sense, since anti-oxidation as an anti-aging strategy is simply not panning out in the literature, but back when I designed and did my assays it was a legitimate question). That is called preliminary data and my PI was bombarded with journalists and TV people asking her to talk about this amazing new drug that would extend life. She was very, very clear to point out that this was preliminary and in flies. And so the research continues to isolate the compounds (yes, plural because it was in her classes and her labs that I learned the most about synergy which you claim is a concept denied to exist for some reason) that are active and responsible for this effect. And then see how it might be applied to humans. It really is exciting research and deserves more study.

    But none of this supports your central thesis that these effects are common, are better than purified and modified pharmaceuticals, or that more than a handful of herbs have an actually demonstrated efficacy.

    BTW – you could have said Papaver somniferum or Erythroxylaceae erythroxylum as plants with proven medicinal efficacy. But, as was pointed out before, there is a very good reason why opium poppy and coca leaf is not available OTC at your local herbalist and why even in medicne we use derivates of the active compounds instead of just growing a garden of poppies on the roofs of hospitals to administer to patients.

  97. Robb says:

    nybgrus,
    You are once again misquoting/misunderstanding my points – maybe my wording was poor or maybe the convolutions of the comments generally interfered. I wouldn’t say that I have a “thesis” for starters, but with regards to synergy, I don’t recall or see in recent posts me calling it “common”. I said it was probably a small percentage of available plants that displayed any kind of synergy beneficial to humans but that, plant synergy, as a concept or strategy, is not that unusual. I didn’t mean known cases of it being beneficial for humans was common statistically speaking, which I thought should be obvious from the first part of the statement. It is “lucky” when it occurs in beneficial ways to humans but as my follow up post brought up, it likely evolved as a response to insects, with cross over relationally to humans. As I’m sure you know it is also infinitely harder to prove or research and it’s impressive that there is more and more evidence coming out in favour of it.

    The discussion on synergy was different to efficacious herbs as a whole though – although it is one argument for why you would select multiple compounds at least vs. single ones. You somehow leapt from misunderstanding “not unusual” to common to me somehow saying clinically proven efficacious herbs were common? I said no such thing. I’m well aware conclusive studies are lacking and that “preliminary evidence” is the norm outside of a few examples that came up.

    I completely agree that ““More studies needed” =/= evidence of efficacy” and by the same token, lack of evidence =/= lack of efficacy. I’ve also repeated multiple times that generalizations aren’t helpful here. Your coca leaf example is a good case where the isolated cocaine alkaloid is more dangerous and acts quite differently compared to the whole leaf.

  98. nybgrus says:

    9/26/12 17:47:

    But I digress…your point was, I think, that “synergy is rare and/or unlikely to occur, therefore, herbs should just be raw materials for new drugs”?

    Synergy is quite common, not rare. Here are some citations concerning plant synergy if anyone at this point is still remotely interested:

    Otherwise it seems we more or less agree. And I think you may be correct that you did not actually assert that clinically proven efficacious herbs were common. My apologies for putting words in your mouth.

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