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One more time: No, wearing a bra does not cause breast cancer

A red bra

EDITOR NOTE: THERE IS AN ADDENDUM, ADDED SEPTEMBER 10.

Besides being a researcher and prolific blogger, I still maintain a practice in breast cancer surgery. It’s one of the more satisfying specialties in oncology because, in the vast majority of cases I treat, I can actually remove the cancer and “cure” the patient. (I use the quotes because we generally don’t like to use that term, given that some forms of breast cancer can recur ten or more years later, but in many cases the term still fits, albeit not as well as we would like.) Granted, I get a little (actually a lot of) help from my friends, so to speak, the multimodality treatment of breast cancer involving surgical oncology, radiation oncology, and medical oncology, but breast cancer that can be cured will be primarily cured with surgery, with chemotherapy, hormonal therapy, and radiation therapy working mostly to decrease the risk of recurrence, either local in the breast or distant elsewhere in the body. Through this multimodality approach, breast cancer mortality has actually been decreasing over the last couple of decades.

However, as a breast cancer surgeon, I not infrequently have to deal with many of the common myths that have sprung up around breast cancer. Some are promoted by quacks; others are just myths that sound plausible but aren’t true. (That’s why they persist as myths.) One such myth has been in the news lately, in particular last week; so I thought now was a good time to take a look as any. Besides, I spent most of the weekend out of town visiting my wife’s family, and I didn’t have a lot of time for this post. So this week sticking to something I know well makes sense and inspired me to make like Harriet Hall and Steve Novella and keep my post to a reasonable length for a change. There’s also so much less mucking about on PubMed and Google that way to make sure I’m not missing something, too.
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Posted in: Cancer, Epidemiology

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The Detox Scam: How to spot it, and how to avoid it

The Detox and Cleanse Scam

Note to SBM’s regular readers: Today’s post revisits some older material you may have seen before. Happy New Year!

New Year, New You, right? 2014 is the year you’re finally going to get serious about your health. You’re winding down from a week (or more) of celebrations and parties. You’re pretty much recovered from New Year’s Eve by now. It’s time to make some resolutions. Conveniently, there is no shortage of solutions being advertised to absolve you of your sins while overhauling your body and soul for 2014: What you need to do is “detox”. You’ll see the detox kits at your local Whole Foods (or even your local pharmacy). Books, boxes or bottles, with some combination of “detox”, “cleanse” or “flush” in the product name. Supplements, tea, homeopathy, coffee enemas, ear candles, and footbaths all promise detoxification. The advertising suggests you’ll gain a renewed body and better health – it’s only seven days and $49.95 away. Or try to cleanse yourself with food alone: Dr. Oz is hyping his Holiday Detox plan. Bon Appetit is featuring their 2014 Food Lover’s Cleanse. Or what about that old standby, the “Master Cleanse”? It’s the New Year – wouldn’t a purification from your sins of 2013 be a good idea to start the year? After all, the local naturopath offers complete detoxification protocols, including vitamin drips and chelation. There must be something to it, right? (more…)

Posted in: Health Fraud, Herbs & Supplements, Homeopathy, Naturopathy

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Ask the (Science-Based) Pharmacist: What are the benefits of coffee enemas?

How do you like your coffee? Rectally.

How do you like your coffee? Rectally.

It might not occur to you, sipping your morning coffee, that you could derive tremendous health benefits by simply shooting that coffee directly into your rectum. Yet many people believe this. Suzy Cohen, who calls herself, “America’s Pharmacist™” and also “America’s Most Trusted Pharmacist®” is a proponent. Her syndicated column Ask the Pharmacist recently contained this question and response: (more…)

Posted in: Cancer, History, Naturopathy

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GAPS Diet

A correspondent asked me to look into the GAPS diet.  I did. I was sorry: it was a painful experience. What a mishmash of half-truths, pseudoscience, imagination, and untested claims!

GAPS stands for Gut and Psychology Syndrome. It is the invention of Dr. Natasha Campbell-McBride. According to her, a wide variety of health problems can be traced to a single cause: an imbalance of gut microbes.  She cites ancient wisdom: Hippocrates said all diseases begin in the gut. She says science confirmed that wisdom when it discovered that 90% of all cells and all genetic material in the human body belongs to the gut flora. She says the modern world poses many dangers for the gut flora, and once it is damaged, the health of the whole body enters a downward slide towards disease. She claims that autism and ADD, OCD, schizophrenia, epilepsy, depression, and numerous other ailments are all digestive disorders. (more…)

Posted in: Neuroscience/Mental Health, Nutrition, Vaccines

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Constipation Myths and Facts

When it comes to health issues, bowels are big business. Bowel movements are part of everyday life, and we notice immediately when our routine changes. Constipation, from the Latin word constipare (“to crowd together”) is something almost everyone has some experience with. In most cases, it’s an occasional annoyance that resolves quickly. For others, particularly the elderly, constipation can be a chronic condition, significantly affecting quality of life.  Depending on the question and the sample surveyed, prevalence seems to vary widely.  It’s estimate that there are 2.5 million physician visits per year in the USA, and the costs of management are estimated at about $7.5 billion annually. It’s not a trivial issue.

One of the biggest challenges in interpreting both individual patient situations, as well as the literature overall, is understanding what’s defined as “constipation”. One person’s regular routine may be another person’s constipation. From my dialogue with patients, personal definitions seem to vary. Some panic after a single missed bowel movement, while others may be unconcerned with daily (or even less frequent) movements. What’s the optimal frequency? It depends. Infants may be 3x/day. Older children may be once daily. Adults may be daily or less frequently.  The literature generally, though not consistently, defines constipation as a delay or difficulty in bowel movements ( usually less than 3 per week) lasting two weeks. Symptoms can include infrequent, painful bowel movements, straining, and lumpy or hard stools.  When these problems last for more than three months, it’s termed chronic constipation. When constipation is accompanied by other symptoms like bloating, diarrhea, and abdominal pain, it may be termed  irritable bowel syndrome (IBS).

There are multiple causes of constipation. It may be a consequence of other illnesses (e.g., high/low thyroid, diabetes, cancer, and neurological diseases like multiple sclerosis). Drugs, both prescription and over-they-counter, can also cause constipation.  Primary or idiopathic constipation is a diagnosis of exclusion, after other causes have been ruled out.  If there are no signs of a more serious underlying condition, treatments can be considered.

Many have firmly-held opinions about their colon and their bowel movements: what’s normal, and what’s not. And there are equally strong opinions about the causes of, and solutions to, constipation. But despite the ubiquity of constipation and the firmly-held opinions on treatments, there’s a sizable chasm between practice and evidence.  This is an area with crappy (sorry) data, and it’s hard to sort out what are true treatment effects. But an absence of evidence isn’t evidence of absence, so we’re challenged to make the best decisions possible, despite a disappointing evidence base. Here are some common statements I’ve encountered, and an evidence check on their veracity. (more…)

Posted in: Science and Medicine

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Fashionably toxic

It’s the toxins.

Toujours les toxines.

How many times have I read or heard from believers in “alternative” medicine that some disease or other is caused by “toxins”? I honestly can’t remember, but in alt-world, no matter what the disease or condition under discussion is, there’s a good chance that sooner or later it will be linked to “toxins.” It doesn’t matter if it’s cancer, autism, heart disease, diabetes, hypertension, or that general malaise that comes over people who, as British comedians Mitchell and Webb put it, have more money than sense; somehow, some way, someone will invoke “toxins.”

I was reminded of this obsession among believers in unscientific medicine last Friday when I came across an article by Guy Trebay in the New York Times entitled The Age of Purification. The article appeared, appropriately enough, in the Fashion section and was festooned with photos of cupping, surely one of the silliest of the many “detoxification” modalities that alternative medicine practitioners use to claim to draw the “toxins” out of their clients through the application of, well, cups or various other containers in which the air had been heated in order to generate negative pressure when sealed to the skin and presumably thus bring them to a greater level of purification and health. Indeed, the only “detoxification” rituals sillier than cupping that I can think of off the top of my head are detoxifying footpads and “detox foot baths.”

Oh, wait. Scratch that. I forgot about ear candling, which must surely be the undisputed silliest “detox” treatment of all time—until someone thinks of an even sillier one. Or not. There are just so many silly “detox” procedures that it’s hard to select a “winner.”

Be that as it may, Trebay mixes sarcasm with exposition throughout his article in a rather amusing way that’s worth quoting:

My friend, like everyone else around, seemed to believe that mysterious, amorphous sludge had lodged in the anatomical crannies of half the local adult population. Unseen toxins were lurking, like Communists during the Red Scare.

The “toxins” required elimination, somehow, and thus at lunches, at cocktails, at dinner parties, normal conversations turned abruptly from the day’s news to progress reports on juice fasts, energy alignments, radical purging. From painful sessions with traditional healers to toxin-leaching treatments designed, it might seem, to clean out not just body but wallet, a surprising number of New Yorkers (not all of them well-to-do neurotics) are caught up in a new New Age, the Age of Purification.

How had it happened, I wondered, that so many otherwise sensible, urban people found themselves in the grip of a dreadful feeling that systems are down? “I just bought five pounds of carrots, ginger and kale and put it all in my Breville juicer and pounded that all day,” said a corporate adviser of my acquaintance, far from a credulous woo-woo type.

Of course, as we have noted so many times before, hard-nosed skepticism in one area of one’s life does not necessarily translate to other areas. Many are the people who would never ever fall prey to scams in business, for example, but happily fork over money for scams such as “detox footpads”—or fall for anti-vaccine quackery, like J.B. Handley. Whatever the case, why this fascination with “detoxification” in alternative medicine? Why do so many of its treatments, be they dietary, chelation therapy, purges, colon cleanses, or whatever, claim to eliminate “toxins”? Why is it that, if you Google “alternative medicine” and “detoxification,” you find so many references, some of which claim external toxins need to be eliminated, some of which claim that internal toxins need to be purged, and still more of which blame various “parasites” for all manner of health distress? In this post, I’ll try to explain, but first a little history—self-history that is.
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Posted in: Naturopathy, Science and Medicine, Science and the Media, Vaccines

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Evidence-Based Medicine, Human Studies Ethics, and the ‘Gonzalez Regimen’: a Disappointing Editorial in the Journal of Clinical Oncology Part 1

Background: the distinction between EBM and SBM

An important theme on the Science-Based Medicine blog, and the very reason for its name, has been its emphasis on examining all the evidence—not merely the results of clinical trials—for various claims, particularly for those that are implausible. We’ve discussed the distinction between Science-Based Medicine (SBM) and the more limited Evidence-Based Medicine (EBM) several times, for example here (I began my own discussion here and added a bit of formality here, here, and here). Let me summarize by quoting John Ioannidis:

…the probability that a research finding is indeed true depends on the prior probability of it being true (before doing the study), the statistical power of the study, and the level of statistical significance.

EBM, in a nutshell, ignores prior probability† (unless there is no other available evidence) and falls for the “p-value fallacy”; SBM does not. Please don’t bicker about this if you haven’t read the links above and some of their own references, particularly the EBM Levels of Evidence scheme and two articles by Steven Goodman (here and here). Also, note that it is not necessary to agree with Ioannidis that “most published research findings are false” to agree with his assertion, quoted above, about what determines the probability that a research finding is true.

The distinction between SBM and EBM has important implications for medical practice ethics, research ethics, human subject protections, allocation of scarce resources, epistemology in health care, public perceptions of medical knowledge and of the health professions, and more. EBM, as practiced in the 20 years of its formal existence, is poorly equipped to evaluate implausible claims because it fails to acknowledge that even if scientific plausibility is not sufficient to establish the validity of a new treatment, it is necessary for doing so.

Thus, in their recent foray into applying the tools of EBM to implausible health claims, government and academic investigators have made at least two, serious mistakes: first, they have subjected unwary subjects to dangerous but unnecessary trials in a quest for “evidence,” failing to realize that definitive evidence already exists; second, they have been largely incapable of pronouncing ineffective methods ineffective. At best, even after conducting predictably disconfirming trials of vanishingly unlikely claims, they have declared such methods merely “unproven,” almost always urging “further research.” That may be the proper EBM response, but it is a far cry from the reality. As I opined a couple of years ago, the founders of the EBM movement apparently “never saw ‘CAM’ coming.”

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Posted in: Cancer, Clinical Trials, Medical Academia, Medical Ethics, Politics and Regulation, Science and Medicine

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Defending Isagenix: A Case Study in Flawed Thinking

The Internet is a wonderful new medium for communicating ideas and information in a rapid and interactive way. Many articles are followed by a “comments” section. Like so many things in this imperfect world, comments are a mixed blessing. They can enhance the article by correcting errors, adding further information, and contributing useful thoughts to a productive discussion. But all too often they consist of emotional outbursts, unwarranted personal attacks on the author, logical fallacies, and misinformation. They provide irrational and ignorant people with a soapbox for promoting prejudices and false information.

To illustrate, let’s look at the responses to something I wrote about a weight loss product called Isagenix that is sold through a multilevel marketing scheme. To quote the website,

The Isagenix cleanse is unique because it not only removes impurities at the cellular level, it builds the body up with incredible nutrition. Besides detoxing the body, Isagenix teaches people a wonderful lesson that they don’t need to eat as much as they are accustom to and eating healthy choices are really important and also a lot of the food we are eating is nutritionally bankrupt. [errors are in the original]

I didn’t set out to write an article about this. It started when I received an e-mail inquiry about Isagenix. I posted my answer on a discussion list and it was picked up and published on the healthfraudoz website.  Sandy Szwarc approved of it and kindly reposted it on her Junkfood Science blog

As I write, the comments on the healthfraudoz website have reached a total of 176. A few commenters approved of what I wrote, but the majority of commenters tried to defend Isagenix. Their arguments were irrational, incompetent, and sometimes amusing. (more…)

Posted in: Herbs & Supplements

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The science of purging, or the purging of science?

It’s Thanksgiving in the U.S., one of my favorite holidays.  Thanksgiving habits get set down early in life, and the while I may find your lima bean casserole execrable, to you it’s just not Thanksgiving without it.

And speaking of excrement, you can expect to see adds encouraging you to “detox” from all of your holiday excesses.  Outside the field of substance abuse, what the hell is “detox” anyway?  “Detoxification” is apparently the pinnacle of modern health care, if you believe the dozens of adds on late-night TV.

For me to explain to you why even the very idea is laughable, I have to teach you a bit of human biochemistry—just a little, I promise. My scientific readers will find this grossly oversimplified, but hopefully they will forgive me.

Detox sounds so simple, but in fact, human biology is more complex and beautiful than is dreamt of in the quacks’ philosophies.
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Posted in: Science and Medicine

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The (Not-So-)Beautiful (Un)Truth about the Gerson protocol and cancer quackery

Note added by editor: The complete movie is now available on YouTube:

The Beautiful Truth

Although this blog is about medicine, specifically the scientific basis of medicine and threats to the scientific basis of medicine regardless of the source, several of us also have an interest in other forms of pseudoscience and threats to other branches of science. One branch of science that is, not surprisingly, critical to medicine is the science of biology, and the organizing theory of biology is the theory of evolution, which was first reported by Charles Darwin and subsequently synthesized with the developing science of genetics in the early 20th century and then with our increasing knowledge of molecular biology, genomics, and proteonomics whose rise ushered us into the 21st century. However, the implications of evolution, namely that humans and apes both evolved from a common ancestor and that humans, for all their belief of being different and superior to animals, are in fact related to animals in the great chain of life going all the way back to single-celled organisms, does not go down well with certain religious fundamentalists, particularly Christian fundamentalists. Whereas I (and I daresay several of my cobloggers) find the interconnectedness of life, including humans, implied by Darwin’s theory to be beautiful and uplifting, many fundamentalists see it as a profound threat to their world view. Consequently, they have attacked the theory of evolution at every turn and tried to insert creationism, particularly the latest incarnation of creationism known as “intelligent design,” into science classes as an “alternative” to “Darwinism.” The manner in which they torture science, logic, and reason to try to cast doubt on a theory that is every bit as rock solid in terms of massive quantities of experimental and observational evidence to support it as any other theory in science, if not more so, is legendary and well documented at blogs such as The Panda’s Thumb and websites such as Talk Origins.

Although one day I plan on writing about how insights from evolutionary theory have led to deeper understandings of human disease and strategies to improve human health in the future, this time I want to concentrate on the similarities in techniques of spreading disinformation between creationists and purveyors of unscientific medical “treatments.” For background, first, you need to be aware of a movie that was released in April. The movie, Expelled!: No Intelligence Allowed was released. Starring Ben Stein at his most unctuous sporting a bullhorn and styling himself as a conservative, buttoned-down version of Angus Young through his choice of apparel in its promotional material, the movie’s main theme is that any academic who “questioned Darwinism” is “expelled” from academia. The basic idea is that “intelligent design” creationism is being “suppressed” by biologists who just can’t accept the thought of the existence of a “designer” (i.e., God). Indeed, the movie goes so far as to equate biologists and scientists who accept the theory of evolution as the best current explanation for the diversity of life to Hitler and the Nazis and their “suppression” of “alternatives” (word choice intentional) to “Darwinism” to Nazi and Stalinist persecution of dissidents and perceived threats to the regime. The movie even features a sequence where Ben Stein visits Dachau and Auschwitz, as though to imply that biologists are busy firing up the ovens for the Brave Maverick Scientists who “dissent from Darwin.”

These Brave Maverick Scientists are a lot like the Brave Maverick Doctors who champion unscientific medicine. After all, Kevin Trudeau has made a cottage industry and sold millions of books based on the claim that there are “natural cures” that “they” (as in doctors, pharmaceutical companies, and the government) don’t want you to know about and that as a consequence the full forces of these groups are being marshalled to “suppress” them and “persecute” the Brave Maverick Doctors who dare to question the “orthodoxy” of “allopathic medicine,” up to and including claims of “Nazi”-like suppression. (Just read those repositories of quackery NaturalNews.com and Whale.to if you don’t believe me.) For the “alternative medicine” movement, it’s all there, in websites, blogs, and books. But one thing that the movement pushing unscientific treatments has lacked, and that’s a movie to call its own, a movie to spread the same message.

That is, until now.

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Posted in: Cancer, Dentistry, Health Fraud, Science and the Media

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