Articles

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

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

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

Oz on What to Eat

Oz acknowledges that the science of nutrition is not simple and that much of what we once believed has been discarded in the face of new knowledge. He debunks a number of popular misconceptions about diet. Most of what he says is consistent with scientific evidence and with mainstream diet advice.

  • It’s not necessary to restrict ourselves to low-fat foods.
  • It’s OK to eat eggs, whole milk, salt, fat, nuts, wine, chocolate and coffee — as long as we don’t overindulge.
  • The only fat accepted as “bad” is trans-fat, and that has been stripped out of most foods.
  • Dietary cholesterol is less important than we used to think and is irrelevant to some people who have good genes.
  • Excess salt is dangerous mainly for the minority of people with salt-sensitive high blood pressure.
  • Foods labeled “fat free” don’t taste as good, so manufacturers add more salt, sugar, and thickeners, and people tend to eat more calories.
  • Fad diets work by restricting food choices: they result in fluid loss and decreased calorie intake, and the weight lost comes right back when people stop the diet.
  • The low carb diets change nutritional balance in ways that may not be desirable.
  • The paleo diet?  Maybe not ideal: cavemen were shorter than modern people and died earlier.
  • Individualized nutrition? Blanket recommendations don’t fit all individuals, but nutrigenomic studies do not yet have clinical applications.
  • Weight loss is hard. To maintain a healthy weight, calories consumed must equal calories burned.
  • High fiber foods augment satiety.
  • One study showed that the foods most associated with weight gain are French fries, potato chips, sugary drinks, meat, sweets and refined grains and the foods most associated with successful weight loss are yogurt, nuts, whole grains, fruits and vegetables.
  • There are no elusive “superfoods.”
  • Exercise is important, but we mustn’t over-estimate its caloric benefit.

He mentions that coffee is the number one source of antioxidants in the Western world. I knew there was a reason I like coffee so much! Isn’t it refreshing to read an article about diet that doesn’t tell you to give up any of the foods you love? Isn’t science wonderful?

He doesn’t recommend vegetarianism, saying we are omnivores and there are multiple food groups for a reason. He concludes with the advice to

  • Eat in moderation
  • Choose foods that look like they did when they came out of the ground (minus the dirt, I hope!)
  • Be an omnivore
  • And get some exercise.

This is entirely consistent with what we have been hearing from other sources, from Mom to the American Dietetic Association, and with Michael Pollan’s advice to “Eat food. Not too much. Mainly plants.”

Going Beyond the Evidence

He does say a few things that I would argue with because I think he goes beyond the (good) evidence:

  • Since red wine is good for you, you should drink some every day and also take resveratrol supplements.
  • When you take all the fat out of milk, you’re left with too high a concentration of natural sugars, which interacts like candy with your hormones.
  • Berries have a profound impact against age-related diseases
  • Broccoli is good for the liver and strengthens the body’s natural detoxification systems.
  • You should take a multivitamin.

Some of these are open to discussion and I can’t object strongly to any of them. On the whole, his advice is moderate and mainstream, without a hint of the kind of woo-woo he promotes on TV. Maybe writing for TIME has a restraining influence on him.

Nutrition in a Pill?

John Cloud experimented on himself. He consulted a supplement company and followed a plan custom-designed just for him. It involved 22 pills a day plus protein bars, powder drinks and psyllium fiber. He followed the plan for 5 months. It cost $1200 but TIME paid the bill. He had a panel of blood tests done before and after, and found that the supplements made no difference. Only two measurements changed significantly: his vitamin D level (which he could have raised much more cheaply with a generic vitamin D tablet) and his HDL level (which was unexplained by the supplements). He felt better on the supplements, but he attributed that to placebo effect.

He had one unfortunate side effect: he gained 10 pounds over 2 months. He attributes that to “the licensing effect.” He felt virtuous. He knew he was getting his nutrition in the pills, so he felt licensed to eat a less healthy diet with more calories. He managed to lose the weight, but it took him 3 months. When the experiment was over, he threw the rest of the supplements away. He discusses the history of vitamins and the inconclusive science behind supplement recommendations. He provides insight into way nutraceuticals are marketed. He interviews skeptical scientists including one who calls the vitamin business “the damnedest racket ever perpetrated upon the public.”

His conclusion makes a lot of sense to me:

On nutraceuticals, I had come to believe that health could be a set of tablets to take rather than a series of responsibilities to meet — water instead of soda, an apple instead of chips, real fish instead of giant fish-oil capsule. You can take vitamins on the faith that they will make you better and if you have a real vitamin deficiency, they will. But there’s more science behind another way of getting your vitamins: eating right.

Conclusion

Both of these articles are informative and reasonable, well written and entertaining, and are examples of good science journalism. TIME is no Science-Based Medicine, but it does a pretty good job for a popular publication.  All too often, the media get science wrong; but sometimes they get it right. And when they do, we should say so. Good job, TIME!

 

 

Posted in: Nutrition, Science and the Media

Leave a Comment (116) ↓

116 thoughts on “TIME Magazine, Dr. Oz, What to Eat, and Supplements

  1. rmgw says:

    “He doesn’t recommend vegetarianism, saying we are omnivores and there are multiple food groups for a reason. “….this sounds like an argument for “intelligent design”!!. “For a reason”??

    I should point out (yet again) that the reasons for a vegetarian – and still more, vegan – diet (affirmed as perfectly adequate for human nutrition from cradle to grave by the American Dietetic Association) are purely ethical. It is not a matter of taking whatever route to adequate nutrition one has in one’s power – when suffering and death CAN be avoided, as is by now perfectly clear they can, supposedly moral beings have a duty to avoid these misfortunes to the utmost – this is now an easy and pleasant option with no untoward side effects for most people (at least those in a position to read this blog) – those who decide to go the amoral route are able to, of course, as society rules today, but why do it?

  2. wdygyp says:

    “The paleo diet? Maybe not ideal: cavemen were shorter than modern people and died earlier.”

    I consider the “Paleo diet” to be overall a pseudoscientific fad, but this argument is ludicrous as (statistical) body height and life expectancy are influenced by so many factors. The same could be said of people of the Neolithic Age, Antiquity, the Middle Ages, etc..

    In general, I dislike this celebrity physician circus where the “Dr.” in front of one’s surname is supposed to guarantee ultimate credibility and respectability.

  3. majkinetor says:

    Vegetarianism might be ethical but its irrational as life simply doesn’t function that way. Its also NOT ethical to the children as we have seen numerous times. Also, its not ethical thing for many people – there is substantial number of folks thinking this is actually healthy way of living. Suffering and death can not be avoided if it means your own suffering and death.

    So, Harriet, I am surprise that you take this N=1 from John Cloud so seriously to devote special attention to it (perhaps because results don’t look beneficial and hold up to your preconceived ideas) ? Kurzweil for example doesn’t have a weight problem popping up more in a week then this dude in 5 months. Perhaps Cloud should have made his entire protocol public, and let the pro’s examine it – complete dietary log, symptoms/feelings/notes log, medical diagnostics log.

  4. Anthro says:

    I am a very healthy lacto-ovo vegetarian (omnivore?) I don’t eat dead flesh for ethical reasons. Vegetarianism can easily be a healthy and satisfying option, even veganism if carefully approached. Why do people insist on trying to push meat onto people who do not want it?

    At any rate, it is good news that Oz is handing out reasonable advice as so many slavishly hang on his every word.

  5. weing says:

    “It is not a matter of taking whatever route to adequate nutrition one has in one’s power – when suffering and death CAN be avoided, as is by now perfectly clear they can, supposedly moral beings have a duty to avoid these misfortunes to the utmost – this is now an easy and pleasant option with no untoward side effects for most people (at least those in a position to read this blog) – those who decide to go the amoral route are able to, of course, as society rules today, but why do it?”

    Could you please clarify?

    What is ethical about a vegetarian diet? Does that mean other diets are not ethical?

  6. Mojo says:

    @Anthro:

    I don’t eat dead flesh for ethical reasons.

    I don’t eat live flesh for ethical reasons. And practical ones.

    And no, you are not an omnivore.

  7. majkinetor says:

    Vegetarian diet can be healthy. Its just highly unlikely that you will do it right. Most people I see and hear about don’t.

  8. DevoutCatalyst says:

    Aren’t children raised vegan of short stature?

  9. Draal says:

    “Maybe writing for TIME has a restraining influence on him.”

    The editor should be applauded for either restricting the article to include science/fact based material only (fact checking) or recognizing legitimately good material and not insisting on the inclusion of Alt Med (CAM) stuff.

  10. Ian says:

    @rmgw erm, food groups were intelligently designed. do you think nature herself grouped everything?

    you are a vegetarian for purely ethical reasons, certainly that’s not true for all vegetarians.

  11. Mojo says:

    @rmgw

    “He doesn’t recommend vegetarianism, saying we are omnivores and there are multiple food groups for a reason. “….this sounds like an argument for “intelligent design”!!

    No, it doesn’t. The concept of multiple food groups follow from the way our bodies are, not the other way around.

  12. tuck says:

    “The paleo diet? Maybe not ideal: cavemen were shorter than modern people and died earlier.”

    The anthropological evidence is clear that “cavemen” were taller than modern people, had larger brains, and much lower incidence of nutrition-linked diseases like dental malformation and cavities.

    That’s the whole rationale for the paleo diet in the first place.

    “Grain, disease, and innovation”
    http://blogs.discovermagazine.com/gnxp/2011/06/germs-disease-and-innovation/

    As far as lifespan, we really have no idea, since there are, by definition, no hunter-gatherer societies to study that haven’t already been impacted by civilized life.

    Just the act of contacting them spreads disease and changes mortality rates and lifespan.

    There is enough information out there, however, to make it pretty clear that the modern American diet is a pretty deleterious thing: just introducing it into a healthy, traditional society is enough to cause obesity, diabetes, and heart disease.

  13. Can we get away from the distractions? The point is that it isn’t necessary to be a vegetarian to achieve maximal nutritional benefits (ethics is another matter). Oz overstated the point by suggesting that since we have always been omnivores, we ought to remain omnivores. That the latter doesn’t follow from the former is easily seen by considering similar statements, e.g.:

    –Since we have always been violent, we should remain violent.
    –Since we have always been jingoes, we should remain jingoes.
    –Since we have always feared and despised other (races, tribes, religions, etc.) we should continue to fear and despise other (races, tribes, religions, etc.)
    –Since we have always been sexist, we should remain sexist.
    –Since we have always been irrational, we should remain irrational.

    Ecksettera

    Regarding the substance of the post, I differ from Harriet (and Draal) in that I have, if you’ll excuse the stupid metaphor, a “glass is half empty” view: Oz is a buffoon, an embarrassment to modern medicine, and a danger to society, period, even if some of the things he says happen to be true. The editors of Time were mistaken to have invited his two cents in the first place, whether or not they deleted any overt woo. His presence there amounts to one more PR victory for him, but is nothing more than a juicy morsel of bait for his ongoing bait’n'switch project of quack advocacy (and Oz bank account advocacy).

  14. majkinetor says:

    Vegan concept is more like intelligent design.

    If you don’t see the fact that plants are living creatures but are there to serve as a food, that involves divine intervention.

    Contrary, all evidence say that plants are capable of protecting themselves against predators since they aim for survival as all other life on Earth.

    Why is the plant life less ‘sacred’ then animal life ? And what about cross species like sponges ? Are those eatable ?

  15. cervantes says:

    Sponges are not “cross species,” they are metazoans. But they lack any nervous system, so some people might think that’s the key. (As far as I know none are edible.) The strongest arguments for vegetarianism have to do with the much greater ecological damage caused by eating meat — it takes 8 times as much land to feed cattle for human consumption as it does to feed humans with the produce. Also the meat industry is highly abusive to animals. If the meat we eat had lived in its natural habitat until it was killed by hunters, that would replicate out ancestral carnivory. But that’s not what eating meat means today.

  16. HH, thanks for an excellent clearcut review of the articles. I think it is a credit to your approach that you were able to point out when Dr Oz gets it right.

    Another explanation for the improvement of the quality of Dr. Oz’s approach in this piece could be that DR. Oz is being pushed into the woo by the network, but Time magazine allowed him to do it his way. :) without knowing him better, I can’t say which would be correct.

    Boy, is it just me or do the comments seem unusually wacky today?

  17. Harriet Hall says:

    @Kimball,

    While I agree with your assessment of Oz and I lament TIME’s decision to choose him as their medical authority, I think the article in question is good science-based journalism no matter who wrote it. That was my point.

    Oz has a lot of good medical knowledge and is good at explaining it, which makes it doubly sad when he departs the scientific arena on his show. And doubly deceptive to viewers who have no way of separating the wheat from the chaff.

  18. Purenoiz says:

    Tuck,

    Are you referencing Neanderthal as having a larger brain? You notice that they went extinct 30,000 years ago right? So how is their diet right for us?

  19. icewings27 says:

    I eat no factory-farm meat, only meat from small local farmers who in my opinion treat their animals quite well (up until their slaughter of course). Does that make me more ethical than someone who eats Tyson chicken and Hormel pork? I dunno….But the meat sure tastes better!

    I have been trying to convince my husband that the only way to lose weight is to burn more calories than you take in. But he insists that you need to eat certain things at certain times of day, that there are different kinds of protein and some of them directly affect your metabolism, and that you can eat more in the two hours after exercising because you’ll “burn it off” more efficiently. Sigh…I’m going to print this article and hang it on the fridge.

  20. HH, I figured he was referencing that it appears that stone age people appear to have had larger brains. Doesn’t seem there is consensus on why. As I recall, some ideas are that larger frame size needed larger motor centers, civilization has caused domestication changes in average environmental temperatures, etc.

    It’s a good reminder that bigger brains do not nessasarily translate to more intelligent, healthy or adapted species.

    Pretty interesting really.

    Check it out http://discovermagazine.com/2010/sep/25-modern-humans-smart-why-brain-shrinking

  21. CarolM says:

    So, it looks like the lowfat diet fad is official kaput – ? I am surprised to see some of Gary Taubes’ arguments validated, if not all the way to to Paleo/Atkins level.

  22. Calli Arcale says:

    Regarding larger brains/bodies in “cavemen”, if we’re talking about non-Homo sapiens, I’m not sure how relevant it can be. I mean, blue whales are bigger and have much bigger brains — that doesn’t mean we should all eat krill. They’re bigger because their genes tell them to be. Likewise, don’t go over to Greg Laden’s blog and tell him that Pygmies (a word he isn’t very fond of) are stupid or malnourished just because they are short and, being normally proportioned, have smaller brains. For that matter, go try telling that to Warwick Davis (a very smart man who happens to be 3′ 6″).

    Homo neandertalis was a different species. We may possibly have interbred — the evidence is mixed — but there are *genetic* reasons for differences between us and them. Given that, it’s stupid to assume that because they had bigger brains, they must have been better fed.

    Actually, another point comes to mind. If bigger brains are better, and are evidence of being better fed, what would that suggest about autistics? Though not all of them have large brains, it’s a common trait of autistics. If being better fed is related to bigger brains, and cavemen had bigger brains because they ate right, would that mean autism is a result of eating a paleo diet? ;-)

  23. WilliamLawrenceUtridge says:

    I can’t wait for vat-grown meat to become a realistic possiblity so I don’t have to make the ethics-versus-environment-versus-health-versus-flavour decision. Some points:

    a) Animals in the wild are often consumed by predators while still alive. Say what you want about a steel bolt to the head, but in most cases it’s quick and relatively painless if done properly. For humans, the most delicious meat is also the most humanely killed due to the effects of stress on the intravascular constituents.

    ai) Also means adults don’t have to watch their babies get eaten by predators; of course, they also don’t get to see most of them grow up.

    b) Meat is convenient (five minutes in a frying pan for a thin cut), delicious and nutritious. It’s a ready source of iron, protein, fat and B12, which vegans in first world countries (and thus effective water treatment facilities) must supplement with vitamins. Humans evolved eating meat, we can’t survive on just plants without chemistry.

    c) Cows, chickens and pigs, the primary meat sources in much of the world, are now among the most evolutionarily successful species on the planet in terms of numbers of offspring.

    d) In the US, Canada, and probably many other parts of the world, the issue is excess of food rather than deficit. Using parts of the land to grow vegetables to feed to cattle isn’t an inherently bad thing.

    e) Eating “like our ancestors” (as if we knew what that meant, and as if “our ancestors” were a single group with a single diet) as commonly conceived would entail starvation for much of the world. Hunter-gatherer lifestyles require huge amounts of space.

    f) Organic farming and hunter-gatherer-style eating actually means less land for genuinely wild animals as you need a greater area in which to grow/hunt food. Not to mention you’d quickly depopulate the areas of flora and fauna in short order if more than a tiny minority of people tried to eat this way.

    Feeding people is complicated and jingoism or single-point-solutions don’t help. Probably the best thing would be a low birth rate population that brings down the number of humans to a more reasonable, highly-educated level – which totally isn’t a jingoist, single-point solution. Or, of course, another option is zombie apocalypse.

  24. ConspicuousCarl says:

    It is very strange to read this stuff from the same guy who promotes total nonsense elsewhere. I seriously doubt, based on TIME’s record, that editorial control had any influence on this.

    Maybe Dr. Oz’s decision to offer good advice this time is something like a super villain’s decision to let someone live because he knows with such certainty that he could kill them if he wanted to. One can get away with so many offenses that they occasionally choose to do something honest just to make life interesting.

  25. Josie says:

    “suffering and death can be avoided”
    no actually, they cannot.

    Death is a consequence of life and as far as have seen suffering is too.

    Show me a being that does not suffer and I’ll show you at least one that suffers in their support.

    It’s the amount of suffering and the unnecessary/cruel death that can be minimized.

    Saying it is unethical to eat meat is to deny our heritage and how we were able to overcome our environment. Overcome it so well that we can pontificate from our cozy armchairs over the morality of farming.

    Oz’s article is superfluous. They probably should have snagged Michael Pollan to reiterate his ‘mostly plants’ philosophy. Good for us and better for the planet than what we’re doing now.

  26. Josie says:

    WLU –

    let’s hold on the zombie apocalypse ’til i finish with my fortifications :D

  27. Harriet Hall says:

    @ConspicuousCarl,

    My guess is that he is playing to his audiences in two different roles: as a medical doctor and as an entertainer. (I was going to say as a media whore, but I decided to be nicer.) We all act differently in different situations. My husband used to say he could tell by my tone of voice whether I was talking to a friend or a patient on the phone – I sounded like an entirely different person.

  28. stanmrak says:

    A few quibbles:

    “Dietary cholesterol is less important than we used to think and is irrelevant to some people who have good genes.”

    Dietary cholesterol is totally irrelevant.

    “The paleo diet?  Maybe not ideal: cavemen were shorter than modern people and died earlier.”

    Comparing modern man to prehistoric man? LOL. And because he was short, that makes him less healthy?

    “To maintain a healthy weight, calories consumed must equal calories burned.”

    It’s not that cut-and-dried. Some years ago, cattleman thought they could fatten up cows quickly by feeding them tons of coconut oil, a highly-saturated, calorie-laden fat. It backfired – the cows lost weight. Coconut oil does not promote weight gain.

    “He mentions that coffee is the number one source of antioxidants in the Western world.”

    He meant most POPULAR, not the BEST. You could certainly do better than coffee for antioxidants. Coffee happens to be one of the most heavily-sprayed crops there is – so enjoy your cup of steeped malathion!

    I think there is too much emphasis here on scientific proof for everything. People assume that because you can’t prove something scientifically, it can’t be true. They couldn’t “prove” O.J. did it, but does anywhere here think he was innocent?

    Yeah, peer-reviewed, double-blind studies may be the best we have for now, but even then, it’s about 50/50 that they are accurate, as this study shows:

    http://www.plosmedicine.org/article/info:doi/10.1371/journal.pmed.0020124

  29. stanmrak says:

    To elaborate on my assertion about dietary cholesterol being irrelevant:

    My 4 siblings agree that high cholesterol “runs in the family” – they all have it. I have “exemplary” cholesterol levels (not that it means anything) all across the board, even though I consume 3 whole raw eggs, half-and-half, butter and coconut oil every day.

    The Swiss consume more cholesterol than any Western country, and have the highest levels of blood cholesterol, but have one of the lowest rates of heart disease. Aborigines in Australia have the lowest measured levels of cholesterol, yet the highest rate of heart disease of any known culture.

    Cholesterol numbers are nothing but a marketing tool for the pharmaceutical companies. They will find a way to keep lowering the numbers for “healthy” cholesterol until they have EVERYONE on statin drugs.

  30. chaos4zap says:

    I do not find it appropriate at all for one person to decide that their specific views on ethics are, necessarily, the same ethics that all others should adopt. If the ethical stance is that nothing should die so you can eat, then you can take that statement and ask…what about the insects and small animals that die because of pesticides on the crops? If you say (and I know most trendy hipster types will) that you only eat crops that don’t use pesticides, well there are still insects and small animals killed from the harvesting of the crops. Heavy machinery vs. small animal and small animal dies every time. Should we move to only non-pesticide crops that are hand-picked only? These may seem like ridiculous questions, but they are valid given the stance that most self-righteous vegans or vegetarians take. This is all beside the point of the article and it frustrates me to no end that people actually had to take it there, get on their soap-box and talking about how they are more ethical. Vegan’s and Vegetarians have much in common with recycling, it makes people feel good about themselves but really has no impact on anything other than their inflated image of self-importance.

  31. Calli Arcale says:

    “To maintain a healthy weight, calories consumed must equal calories burned.”

    Stanmrak:

    It’s not that cut-and-dried. Some years ago, cattleman thought they could fatten up cows quickly by feeding them tons of coconut oil, a highly-saturated, calorie-laden fat. It backfired – the cows lost weight. Coconut oil does not promote weight gain.

    More accurate would be to say calories actually absorbed must equal calories burned. That’s the rub. Cows aren’t really equipped for a high-fat diet; their gut biology is oriented towards eating and processing cellulose for nutrition. They can get fat eating grass (though you can fatten them faster with grain); humans, on the other hand, will starve on grass. That a cow doesn’t get much caloric benefit out of coconut oil doesn’t invalidate the point.

    That is the point behind some diet plans, including the traditional veggie-heavy ones involving lots of raw veggies and fibrous fruits. The reason fiber helps with weight loss is simply because humans have a hard time digesting it — not all of the calories theoretically present in it are available to us. It’s also the logic behind Alli, the weight-loss drug. It makes it harder to absorb fats. (It also will tend to give you the runs, because what you don’t absorb has to go *somewhere*.)

  32. Harriet Hall says:

    @stanmrak,
    “Dietary cholesterol is totally irrelevant.”
    Not true, and your anecdotal evidence is not proof. Your comments hopelessly confuse dietary cholesterol with blood cholesterol levels and you are wrong about several things. See http://www.sciencebasedmedicine.org/index.php/the-international-network-of-cholesterol-skeptics/

    “Comparing modern man to prehistoric man? LOL. And because he was short, that makes him less healthy?”
    What makes me LOL is trying to reach any reliable conclusions by comparing our ancestors’ diet to a modern diet. Anyway, being short can be an indication of inadequate nutrition in childhood.

    “ cattleman thought they could fatten up cows quickly by feeding them tons of coconut oil, a highly-saturated, calorie-laden fat. It backfired – the cows lost weight. Coconut oil does not promote weight gain.”
    This in no way refutes the statement about calorie balance for weight maintenance.

    “You could certainly do better than coffee for antioxidants. Coffee happens to be one of the most heavily-sprayed crops there is – so enjoy your cup of steeped malathion!”
    He doesn’t claim that coffee is the “best” source of antioxidants. And I seriously doubt that there is any measurable malathion in my coffee, much less in amounts that would have any adverse health effects. Do you have any references measuring the malathion content of coffee?

    “I think there is too much emphasis here on scientific proof for everything. People assume that because you can’t prove something scientifically, it can’t be true.”
    That’s a misrepresentation of our position. We only say that you can’t assume something is true without evidence. Scientific evidence is a more reliable guide than any “other ways of knowing.”

  33. pmoran says:

    Kimball “The editors of Time were mistaken to have invited his two cents in the first place, whether or not they deleted any overt woo. His presence there amounts to one more PR victory for him, but is nothing more than a juicy morsel of bait for his ongoing bait’n’switch project of quack advocacy (and Oz bank account advocacy).”

    Maybe. Or, if you want to get people to actually read and take notice of some dietary advice, mostly running counter to that arising within CAM, who would you get to deliver it? Some dreary unknown of a college professor, who can be portrayed as having ties with Big Pharm and the medical mafia whether that is true or not, or someone who already has an established connection, and credibility of sorts, with the relevant sections of the public?

    I was glass-half-full about the Curious George episode, too. It explicitly positioned naturopathy as something that “may help you feel better”. CAM was equated to getting something from the pharmacist for minor illness, not as a suitable resort for more serious medical problems. Read it again, and you may see what I mean.

    That is precisely the kind of message that I would like to see us promoting, along with any scientific commentary that we think may help explain our viewpoint.

    It is a more saleable and supportable message than one that is entirely dismissive, if not prohibitive.

    .

  34. Harriet Hall says:

    @pmoran,

    Your point about TIME getting a popular celebrity to write about health is well taken. Oz surely attracts more readers and sells more magazines than, say, Steven Novella would.

    I don’t think we ought to be promoting the message that it is a good idea to see a naturopath because it might help you feel better, even for minor illnesses. And while we might be able to explain our viewpoint, it’s too complex to be offered to children in the Curious George age group. It would be far better to offer them a role model going to see a medical doctor.

  35. Lytrigian says:

    Amazing how people react when you puncture their sacred cows.

    I do have a question about dietary cholesterol. Back in the 80s when I was getting by bachelor’s, our basic biology course (required of all science-related majors whether or not you were studying chemistry) was being taught by a biochemist — overqualified for this course, but it was his first year on staff so he had to pay is dues. When it came to dietary cholesterol, he was very much in the “totally irrelevant” camp, on the grounds that there was no known metabolic pathway where it might end up as serum cholesterol. (That is to say, the known metabolic pathway of dietary cholesterol did not lead to serum cholesterol.) His advice was to not eat so much fat, but don’t worry so about eggs, which were being popularly demonized at the time.

    This was the early 80s, and it would be surprising if the field has stood still. I take it there’s some known connection now?

  36. pmoran says:

    Harriet: It would be far better to offer them a role model going to see a medical doctor.

    Why “far better”, when all the doctor had to offer for a cold was his own placebos and old wives’ tales? And do we want people seeing doctors for colds — that has as much potential for harm as for good, if doctors feel obliged to prescribe something?

    So it was good that the Curious George TV show did not present that as an option –further evidence of some serious thought behind the messages that show sent?

    Look, I am partly just teasing, but partly deadly serious.

    We are experts at certain aspects of patho-physiological science, not at communication, or politics, or human psychology, or the sociological aspects of CAM, all those matters that should feed into any strategy for dealing with its supposed and its real dangers.

    And I insist that this (the risks) should be our true objective — forget the urge to transform the public into miniature medical Einsteins. It can’t be done.

    I observe that most of the public and even of the media is able to put CAM into a proper context (as a kind of lifestyle or hobbyist or folk medicine) and we can, if we choose, reinforce that trend while also advancing our credentials where serious medical outcomes are concerned.

    I fear that we play into the hands of the more dangerous forces, whenever we lurch into stereoptyical, intolerant, controlling extremes at just about any manifestation of CAM.

    You are a more moderate voice and that suits me fine. So is Dr Barrett, actually, at least in the sense of always sticking closely to verifiable facts.

  37. Harriet Hall says:

    The American Heart Association guidelines (http://circ.ahajournals.org/content/114/1/82.full.pdf) recommend limiting dietary cholesterol to 300mg a day. It is not clear to me what studies they based that recommendation on. They say
    “Increased dietary cholesterol intake also raises LDL cholesterol concentrations.” but there is no footnote reference for that statement.

    Now I’m wondering if they actually have good evidence for their recommendation. And if they do, is the cholesterol itself a documented problem, or could it be that foods high in cholesterol are coincidentally high in the kinds of fats we should avoid? Perhaps one of our writers or commenters knows more and can enlighten us.

  38. Harriet Hall says:

    @pmoran,
    “whenever we lurch into stereoptyical, intolerant, controlling extremes at just about any manifestation of CAM.”

    I don’t see us doing that. I see us protesting health claims that go beyond the evidence.

  39. regarding Curious George, I think the point of showing a role model who visits a doctor is not really relevant to the show’s format. To the extent the show is educational, it is suppose to help the kids explore science concepts through everyday experiences. The “experts” on the show are given the opportunity to teach these science concepts.

    In that context, the information that a doctor could give could be quite interesting. Kids are fascinated with sicknesses, every time I get a cold or flu, the kids are right there asking me questions. Why are you talking funny? What made you sick? When are you going to get better? Do you need a shot? Why do we sneeze? Why do we take temperatures? What is “a temperature”? A cold is a great biology teaching opportunity!

    In my opinion, it doesn’t even have to be a doctor who answers those questions, a lot of those segments are teacher’s discussing the concepts with their class and doing projects. That’s great too!

  40. qetzal says:

    I agree that many of Oz’s recommendations are surprisingly sensible (especially considering the source!). However, I think you let him off much too easily on his “Going Beyond the Evidence” claims.

    Last I knew, the jury was very much still out on whether resveratrol supplements are worthwhile. Lots and lots of such seemingly promising compounds have utterly failed to live up to their hype. (Witness leptin.)

    Claiming that berries definitely have a “profound impact” against age-related diseases is certainly going wayyyy beyond the evidence. Sure, berries have lots of antioxidants, but it’s already clear that “antioxidants = good” is not a given. Witness some of the recent data on Vitamin E.

    Does it even mean anything to claim that broccoli “strengthens the body’s natural detoxification systems?” That sounds like pure woo-speak to me.

    And finally, we’ve seen over and over that multivitamins do not offer any measurable benefit to most people (absent an actual vitamin deficiency). And again, we’ve also seen evidence that some vitamins are detrimental when taken in excess.

    So I disagree. I think we can and should disagree strongly with most of those. To me, they’re part and parcel of Oz’s inability to think critically, and his willingness to buy into all kinds of unsupported claims – whether they’re clearly bogus (like reiki), or merely wildly extrapolated beyond some very preliminary data (like resveratrol).

  41. weatherwax says:

    chaos4zap: “If the ethical stance is that nothing should die so you can eat, then you can take that statement and ask…what about the insects and small animals that die because of pesticides on the crops? If you say (and I know most trendy hipster types will) that you only eat crops that don’t use pesticides, well there are still insects and small animals killed from the harvesting of the crops. Heavy machinery vs. small animal and small animal dies every time.”

    There’s actually more too it than that. Too grow crops you have to remove the natural landscape and turn the area into a monoculture, thus displacing the animals that lived there.

    Then there’s the problem of the hebivores that want to eat your crops. The most common solution is to have hunters kill and eat them.

    Back in college we discussed the number of deer taken every year to protect the soy crops in Michigan and Wisconsin. It’s going back about 15 years now, so I don’t remember the exact number, but it was in the area of 25,000.

  42. David Gorski says:

    I fear that we play into the hands of the more dangerous forces, whenever we lurch into stereoptyical, intolerant, controlling extremes at just about any manifestation of CAM.

    Yes, you fear that. You’ve repeated that “fear” ad nauseam. Personally, I think your fear is massively overblown.

    I also wonder about your language. We’re “intolerant”? “Controlling”? Really? Oh, well, at least, given how little you apparently think of skeptics and how willing you are to use extreme language to describe us, I don’t feel in the least bit guilty (or “radical” or “intolerant”) to point out that your assiduously graded pose of “radical moderation” is no less radical than the insulting parody of the “intolerant” skeptic you paint so often.

  43. weing says:

    stanmrak:
    You made several claims and I can’t find anything that supports them. Take this one for instance:
    “Aborigines in Australia have the lowest measured levels of cholesterol, yet the highest rate of heart disease of any known culture.” Do you have anything other than hearsay? The articles I found regarding this had nothing like this. It would really bolster your claims if you had actual data supporting them.

  44. wlondon says:

    The nutrition advice given at http://www.doctoroz.com/nutrition-center has a different flavor than the information in TIME summarized by Dr. Hall. I can think of a few possible reasons. There might be others. But I think it should be noted that it is not at all clear which of the many published works with Oz identified as author were actually written or scrutinized by Oz to a significant extent.

  45. Diomedes says:

    The evidence for admixture with Neandertals is now pretty strong. Even more interesting is the possibility of later admixture with another group of ancient hominids, the Denisovans.

    An excellent article published this month in Nature Reviews Genetics summarizes the genomic evidence for this admixture:

    Stoneking & Krause. Nature Reviews Genetics 12, 603-614 (September 2011) | doi:10.1038/nrg3029. Learning about human population history from ancient and modern genomes.

  46. CarolM says:

    “Now I’m wondering if they actually have good evidence for their recommendation”

    I know Taubes is not popular here, but according to his books the “known connection” was never proved.

    What was proved was that taking statins to lower serum cholesterol reduced heart attacks or artherosclerosis (not sure which) so the AHA made the leap that reducing dietary saturated fat to lower cholesteral would have the same result.

  47. WilliamLawrenceUtridge says:

    @Stan

    I think there is too much emphasis here on scientific proof for everything. People assume that because you can’t prove something scientifically, it can’t be true. They couldn’t “prove” O.J. did it, but does anywhere here think he was innocent?

    And to paraphrase Dara O’Briain, just because science doesn’t know for sure, doesn’t mean you get to fill in the gaps with whatever you want. For instance, claiming that cows (ruminants) can’t get fat through eating raw oil, therefore neither can we (not ruminants). Cows gain no nutrition from grass, they get their nutrients from the volatile fatty acids that are the byproduct of bacterial metabolism in their guts (ref). We absorb most of our nutrients directly from digested food and the activity of bacteria is much less relevant. RCTs may only be right 50% of the time, but if you keep replicating and extending them, eventually you arrive at a closer approximation of the truth – generally through a single, large, well-designed RCT that is publicly announced and tracked.

    Dietary cholesterol may be irrelevant, but saturated fat intake (the main driver of LDL cholesterol) is not. As for your anecdote about your family, have you compared your activity levels and attention to diet? Have you compared genetics, because unless you are identical quintuplets you’ve all got fairly different genes.

    Though it’s easy to poke holes in a theory, and I relish doing it, the real issue is that statements shouldn’t be made without evidence to substantiate it. Pointing out flaws in a positive statement is low-hanging fruit, making the positive statement is harder but only if you’re including any substantiation. If you’re not including substantiation, you better be citing uncontroversial, well-established facts. Otherwise you’re just speculating. Which is fine, as long as you clearly state you are speculating, and not pretending you’re unleashing some Great Truth onto the intertubes.

    It’s a pity Dr. Novella doesn’t attract more readers than Dr. Oz (and surprising, he’s quite the silver fox).

    @Diomedes

    Thanks for the ref, that looks like a cool paper! I’m going to request a copy.

  48. tmac57 says:

    I just got through perusing Dr Oz’s website, and I may be wrong,but it does seem a lot less wooy than the last time I was there.
    Does anyone here ever watch his daytime show enough to detect if there has been some sort of shift in it’s content? We can hope can’t we?
    BTW,when I typed only the letters ‘DR’ in my Google search box,Dr Oz’s name headed the list.That’s why we may want him in the “Good-guy” camp.

  49. pmoran says:

    I also wonder about your language. We’re “intolerant”? “Controlling”? Really? Oh, well, at least, given how little you apparently think of skeptics and how willing you are to use extreme language to describe us, I don’t feel in the least bit guilty (or “radical” or “intolerant”) to point out that your assiduously graded pose of “radical moderation” is no less radical than the insulting parody of the “intolerant” skeptic you paint so often.

    I exaggerate little. As I have explained before, it is the perceptions we create that matter.

    When there are no clearly stated objectives or policies for a group such as this, readers are free to deduce those from what is said, including the language used and any statements from commenters that go unchallenged.

    I think there can be no question that we come across as being ready to obliterate CAM from the face of the earth if we were able.

    Does that help our cause or not? What is our “cause” for that matter, and are we succeeding in it?

  50. Harriet Hall says:

    @pmoran,

    “readers are free to deduce those from what is said, including the language used and any statements from commenters that go unchallenged.”

    Can you provide some examples of what you read here that created the perception that our goal is to obliterate CAM from the face of the earth?

  51. JPZ says:

    Humans did not evolve to be vegans (no animal source foods at all), e.g. dentition, digestion and inability to synthesize vitamin B12. We can be vegans if we monitor our diet, and it is not much more difficult than keeping kosher or halal. It is easier to get a complete, balanced diet as an ovo-lacto vegetarian. If you have ethical problems with how conventionally-raised production animals are raised, don’t eat them. And, production animal farms spill huge amounts of animal waste, other run-off and chemicals (antibiotics, feed additives, etc.) into the environment. If this bothers you, don’t eat conventionally raised meat. Include religion and there are lots of reasons not to eat meat.

    Back to John Cloud’s comments, “custom-designed” nutritional plans can be a scam, and it sounds like John found one. “Personalized nutrition” is based on a small amount of science – most of which wouldn’t make sense to the general public (receptor genotypes, etc.). The scam works because people think they are special and have nutritional needs totally unlike everyone else. I did a professional evaluation of one of those online personalized nutrition sites. I carefully entered data for a 30-something white male who ate a balanced diet, exercised, low stress, etc. – an unusually healthy guy by today’s standards. The site found he needed about a dozen supplements, three different kinds of tea (including licorice), a skin cream, etc. This seedy niche of the nutritional products industry is hardly the place to extrapolate his n=1 study into the whole industry. It is as bad as tarring all vaccines because one parent blames their childs autism on an immunization.

  52. ConspicuousCarl says:

    You have to dig for it, but the stupid is definitely there…

    The first thing I noticed was what appears to be greatly overstated results from food:
    http://www.doctoroz.com/videos/5-foods-starve-cancer

    Then some standard BS about acupuncture and “Qi”:
    http://www.doctoroz.com/videos/acupuncture-and-weight-loss

    Google finds a page which includes the text “Dr. Oz explains why he believes that acupuncture is a powerful treatment.” but I can’t get it to display on the current website:
    http://webcache.googleusercontent.com/search?q=cache:QBfgfB3CUMcJ:www.doctoroz.com/videos%3Ftid%3D197%26tid_1%3DAll%26date%3D365+acupuncture+site:doctoroz.com&cd=7&hl=en&ct=clnk&gl=us&client=opera

    Chiropractic!
    “Dr. Oz explains how your spine gets misaligned and what this treatment could do for you.”
    http://www.doctoroz.com/videos/back-pain-relievers

    I don’t know what “biopuncture” is, but it sure sounds like bottlesocks…
    http://www.doctoroz.com/videos/alternative-cure-biopuncture

    Homeopathy!!!
    “Dr. Oz discusses the benefits of homeopathic remedies and the controversy surrounding them.” (guest says there is evidence for it, Oz says he uses homeopathy for his kids)
    http://www.doctoroz.com/videos/Alternative-Pain-Treatments-Pt-1

  53. Lytrigian says:

    @weing — Thank you!

  54. Angora Rabbit says:

    @Dr. Hall:
    “is the cholesterol itself a documented problem, or could it be that foods high in cholesterol are coincidentally high in the kinds of fats we should avoid? Perhaps one of our writers or commenters knows more and can enlighten us.”

    Sorry – the semester has launched here and web reading time has gone down. To specifically answer this, the evidence for cholesterol and CVD is solid (pun intended for the chemists). The studies draw, in part, from the natural human experiment: people who have a genetic impairment in apolipoprotein B100, the liver receptor that normally clears LDL (and its attendant cholesterol) from the bloodstream. Those people have massive cholesterol depositions in the vasculature as well as subcutaneously, and they (used to) die from atherosclerosis. Study of these families by Brown and Goldstein greatly informed our understanding of the relationship between LDL, cholesterol, and atherosclerosis (and led to their Nobel prize). And then there were animal models that replicated their findings, additional studies of other lipoproteins that affect lipid fate, etc. So the relationship between elevated cholesterol and CVD risk is quite good and is backed by real biochemistry and not just epidemiology relationship studies. I think this is the question that you asked, and my apologies if I’ve misunderstood.

    Regarding fat intake, we know from human and animal studies, as well as years of biochemistry, that high dietary fat intake elevates VLDL lipoproteins. Normally those are cleared by the liver, but the VLDL remnants that remain after the triglycerides are depleted, known as IDLs, can be converted in the bloodstream into LDLs, especially if VLDL (= triglyceride levels) are high. So its pretty clear that elevated VLDL can lead to elevated IDL and then LDL, hence the general recommendation to lower triglyceride and cholesterol intakes, to lower VLDLs and thus LDLs.

    Regarding Oz, your summary left my gobsmacked, in a good way. I wonder who straightened him out? Most of what you summarize is consistent with what we are recommending as professional nutritionists, though for obvious reasons he’s simplifying the underlying mechanism for his recommendations. Could Dr. Oz have finally gotten religion? Hmmm…

  55. JPZ says:

    @Harriet Hall

    Regarding dietary cholesterol, Dr. Bill Connor at OHSU did much of the pioneering work in this area. This is a 2002 review by him and his wife:

    http://www.ncbi.nlm.nih.gov/pubmed/12361489

    I had the pleasure of working with him a few times while he was still with us. You can also look into his original papers on PubMed by searching on “Connor WE”

  56. Harriet Hall says:

    @Angora Rabbit,

    “So the relationship between elevated cholesterol and CVD risk is quite good and is backed by real biochemistry and not just epidemiology relationship studies. I think this is the question that you asked, and my apologies if I’ve misunderstood.”

    My question was not about the relationship between blood cholesterol level and CVD risk. That is well established. My question was whether the AHA’s 300 mg daily dietary cholesterol limit is based on solid evidence. JPZ’s reference helps but doesn’t explain the 300 mg.

  57. weing says:

    @Harriet

    The dietary guidelines that I am familiar with recommend 200 mg.
    Check out this article:
    http://atvb.ahajournals.org/content/8/1/95.full.pdf+html

    1. Harriet Hall says:

      @weing,

      Thanks for that link. That is exactly the kind of information I was looking for. Obviously there is still reason to think dietary cholesterol is not irrelevant.

  58. mikeh_ says:

    “The paleo diet? Maybe not ideal: cavemen were shorter than modern people… ”

    Source ? Wikipedia suggests otherwise ie http://en.wikipedia.org/wiki/Neolithic_Revolution#Social_change

    “It is often argued that agriculture gave humans more control over their food supply, but this has been disputed by the finding that nutritional standards of Neolithic populations were generally inferior to that of hunter gatherers, and life expectancy may in fact have been shorter, in part due to diseases. Average height, for example, went down from 5′ 10″ (178 cm) for men and 5′ 6″ (168 cm) for women to 5′ 3″ (165 cm) and 5′ 1″ (155 cm), respectively, and it took until the twentieth century for average human height to come back to the pre-Neolithic Revolution levels.[25] “

  59. Bogeymama says:

    Did anyone see Dr. Oz on GMA this morning? Dr. Besser took him on over his claims of arsenic in apple juice…video is available.

    http://abcnews.go.com/GMA/

  60. pmoran says:

    @pmoran,

    “readers are free to deduce those from what is said, including the language used and any statements from commenters that go unchallenged.”

    Can you provide some examples of what you read here that created the perception that our goal is to obliterate CAM from the face of the earth?

    Yes. Zero tolerance for CAM is strongly suggested by —

    – the frequent use of slippery slope arguments at any suggestion of a selectively softer approach.

    – allegations of “bait and switch” tactics from CAM suggest a “tar it all with the same brush” approach..

    — “all of medicine should be held to the same standard” (and the rest can be discarded? — portrayed as intentional fraud?– what? ) has similar implications in practice. What IS intended by that, if not to prohibit anything less?

    – the inability by some to acknowledge even the possibility of placebo or other beneficial influences from CAM with subjective and psychosomatic complaints, under present conditions, justifies more extreme reactions to it. “It doesn’t work (– so why not get rid of this blatant fraud?)”.

    I admit that the science of placebo is woolly, as is almost everything to do with the human mind. But let’s be wary of a hypothesis that sits so comfortably with the instinctive reactions of the medical skeptic, while also disregarding highly plausible alternative interpretations of the available data.

    The above is a sample of what can lead readers to deduce intentions that may not be meant or fully thought through. There are more explicit expressions of zero tolerance and of the need for tighter controls from some commenters and I am sure you will be aware of them.

    Of course, this is the public face of medical skepticism. In private consultations, where the patient CAN rule the roost, we have little choice other than to go along with whatever the patients may wish, at least where it has little potential for harm.

    Perhaps the same considerations should apply to our public dealings with CAM. We can apply the approach I have tendered to both.

  61. weing says:

    ” In private consultations, where the patient CAN rule the roost, we have little choice other than to go along with whatever the patients may wish, at least where it has little potential for harm.

    Perhaps the same considerations should apply to our public dealings with CAM. We can apply the approach I have tendered to both.”

    I am definitely in the camp that we not lie to our patients. I seriously doubt that patients wish us to lie to them, which is what would happen by going along with their false beliefs. I believe they come to us for the knowledge that we have. If and when they do realize that the emperor has no clothes, how will you explain your lying to them about it? Sure, no actual harm occurred from going along with their wish. But can you be trusted to help them when it does matter?
    Do you really think our precious resources should be wasted on supporting charlatans and not real R&D?

  62. Harriet Hall says:

    @pmoran,

    You have cherry-picked some statements that you interpret as supporting your idea that this blog’s goal is to obliterate CAM from the face of the earth. You say they “can lead readers to deduce intentions that may not be meant.”

    There are plenty of counter-examples where the opposite intentions are spelled out. I have said repeatedly that I have no objection to anyone using CAM; my objection is to advocates who go beyond the scientific evidence and mislead patients with false or distorted information.

    I submit that if readers are deducing intentions that are not meant, the fault may be that of the readers for not reading carefully and not considering the context and the blog as a whole.

    I don’t think any of our authors is foolish enough to think CAM could ever be obliterated or to make such a chimerical notion a goal.

    You say “we have little choice other than to go along with whatever the patients may wish.” I would say we have no right to interfere with a patient’s health decisions when the patients have access to accurate information, but we have a duty to inform them when their information is faulty. We can “go along” and condone their choice and support them while stating that we disagree with their choice and explaining why.

  63. pmoran says:

    Equating any tolerance of CAM with lying to the patient is yet another way of justifying zero tolerance.

    Is the following lying to a patient with difficult-to-control pain? “Would you like to try acupuncture before we up your medication? I suspect it mainly works as placebo, but many people swear by it.”

  64. Harriet Hall says:

    Would you say “Would you like to try a sugar pill before we up your medication? It seems to work for some people.”?

  65. ConspicuousCarl says:

    pmoran on 15 Sep 2011 at 5:44 pm

    Zero tolerance for CAM is strongly suggested by —

    – the frequent use of slippery slope arguments at any suggestion of a selectively softer approach.

    Selectively softer? That’s quite a soft description of practices which typically have no evidence at all and no rational basis for expecting them to work.

    In contrast to your ultra-soft description of fake medicine, you use a specific accusation of a fallacy. But the “slippery slope” is not always illogical or unfair. The CAM proponents are arguing for allowance of completely unsubstantiated claims. That’s not a slope, it’s a cliff, and they are asking for it.

    And you are also wrong in your implication that the normal non-CAM medical standard has no “degrees”. Lots of real drugs meet the standards of being generally safe, as well as effective in at least some cases. Those drugs DO get a “soft” approach, and are sold over-the-counter to people who want to see if they might work for their specific condition. But you have to do the scientific work first.

    – allegations of “bait and switch” tactics from CAM suggest a “tar it all with the same brush” approach..

    No they don’t. Bait-and-switch accusations have no inherent implication of hasty generalization. Non sequitur.

    Regardless of what you call it, it is a common theme among many specific CAM practices (chiropractic, acupuncture, and magnet therapy to name some) to offer up a claim that their service has a complete cure for many or even all conditions, and then settle for evidence of placebo effects as their benefits.

    — “all of medicine should be held to the same standard” (and the rest can be discarded? — portrayed as intentional fraud?– what? ) has similar implications in practice. What IS intended by that, if not to prohibit anything less?

    You are pulling the old “you callin me a liar?” argument. A subset of arguments from final consequences. You think we should lower our standards because it would somehow be too insulting to note that a particular thing is, in fact, ineffective?

    – the inability by some to acknowledge even the possibility of placebo or other beneficial influences from CAM with subjective and psychosomatic complaints, under present conditions, justifies more extreme reactions to it. “It doesn’t work (– so why not get rid of this blatant fraud?)”.

    Maybe you haven’t been paying attention. Placebos are considered by many to be a kind of moral dilemma, though the people who run this website have noted that the supposed benefits of placebos which are actually documented are overblown and almost entirely worthless, save for some very mild and subjective conditions. The dilemma is mostly false.

    Besides, I don’t know of any CAM practitioner who advertises benefits anything like the actual placebo effects documented. Come to Bill Smith, acupuncurist, and get temporary mild relief from your vague and non-serious symptoms without actually changing any underlying problem! So yes, it is either fraud or ignorance.

  66. GeekKnowledge says:

    There are a few misconceptions here in the comments I’d like to take a chance to clear up:

    -Not all vegans/vegetarians care what other people eat. It’s your choice, it’s a free country. People who do go vegan/vegetarian for ethical reasons understand it won’t end all factory farming, etc. It’s a matter of not giving money to continue to supply demand for something that we find unethical. Just like some people choose not to support a company who uses slave labor or pays political parties who they don’t support.

    -Studies have proven it’s possible to live a healthy entirely vegan life. (With one except, if a baby is formula fed there’s no true way to be 100% vegan but you can come very close with soy formula)
    Largely most of the studies are from vegetarians and not vegans though because it’s easier. (Some groups like Seven Day Adventists are vegetarian for religious reasons) There is not significant enough studies to indicate it’s *more* healthy but there is enough to say it’s reasonable to live without excess harm from being vegan/vegetarian.
    http://www.veganhealth.org/articles/dxrates
    http://www.ncbi.nlm.nih.gov/pubmed/16441942
    http://www.vegsoc.org/page.aspx?pid=784

    I am guilty of reinforcement bias but I suggest looking at the already existing studies before assuming a heart surgeon is going to be an excellent judge of whether or not a diet is “required”. If you’re interested in a more in-depth guide to vegan nutrition you can look to the book “Vegan For Life” to make sure if you choose to go that way, you can be one of the good statistics.

    Have a great night all.

  67. weing says:

    “Is the following lying to a patient with difficult-to-control pain? “Would you like to try acupuncture before we up your medication? I suspect it mainly works as placebo, but many people swear by it.””

    That’s being cruel to the patient. Why even suggest it? I mean if the patient asks about it first, then you could tell him that it hasn’t been shown to be better than placebo, but if he wants to try it, it’s his pain.

  68. Geoff says:

    Robb Wolf posted a response piece to this Time article as well. You can find that here: http://robbwolf.com/2011/09/14/framework-matters/

    If you don’t feel inclined to read the blog post, he says that Dr. Oz’s people engaged specifically with Robb with regard to this article, in large part because one of his staffer’s has a close relative who reversed her MS in a couple of months eating paleo. Yet another anecdote of someone reversing an “incurable” autoimmune disease in a matter of months eating paleo.

    His comments with respect to height and life expectancy of preagricultural humans illustrate his complete ignorance on the subject, despite having requested and been sent numerous materials on the subject.

  69. Harriet Hall says:

    Whether or not Dr. Oz’s comments about our ancestors were wrong, I applaud him for not promoting the paleo diet, because it is not backed by sufficient scientific evidence for responsible science-based physicians to recommend it as preferable to other approaches. Your assertions and your evolution-based speculations have not convinced mainstream science, they have not convinced us here on SBM, and they didn’t even convince Dr. Oz. Not saying you aren’t right, just that you don’t have enough real evidence.

    The MS anecdote is meaningless since the disease is characterized by remissions and exacerbations: it is common for symptoms to subside even without any treatment, and when the patient is using any treatment at the time, it is common for them to give it the credit. We hear reports like these about MS for everything from chiropractic to snake oil, but we never see credible followup evidence that those MS patients had a better long-term outcome than those who didn’t use the treatment.

    Such reports may well turn out to be like the series once published in the JAMA where they put a testimonial about a cancer cure on one page and reproduced the patient’s death certificate on the opposite page showing that he had died of his cancer shortly after he testified to his miraculous “cure.”

  70. Geoff says:

    @Harriet

    I think that’s fair, and acknowledge that there is not nearly enough high quality evidence out there to prove that a paleo-ish approach is optimal. That said, I have seen these results in autoimmune diseases consistently enough to be convinced.

    The post is entitled “Framework Matters” because he is basically saying the same thing that I have been saying since I started commenting here. Evolution is the framework within which all experimental findings must be interpreted. It’s still surprising to me that this is controversial.

    1. Harriet Hall says:

      @Geoff,

      “Evolution is the framework within which all experimental findings must be interpreted”
      Sez who? Evolution is crucial to science, and it is important not to disregard it, but that’s a long way from saying all experimental findings must be interpreted in its framework. If a new antibiotic works better than an old one, we can adopt it without any need to interpret anything. Evolutionary explanations may be satisfying, but all too often they amount to speculative after-the-fact just-so stories. They are not scientifically rigorous and may well be wrong.

  71. WilliamLawrenceUtridge says:

    pmoran:

    “I admit that the science of placebo is woolly, as is almost everything to do with the human mind.”

    The science of placebo should be completely separate from medicine. That’s really the central issue – most CAM isn’t supported, and many are fairly unambiguously little more than effective placebos. The side effects of this are well-discussed in the skeptical literature:

    * corrosive impact on critical thinking
    * cost (time and money) of unproven or obviously ineffective treatments
    * delay of actual treatment for serious conditions
    * practitioners who downplay or badmouth actual medicine

    CAM shouldn’t exist for the simple reason that if it’s worthwhile, it should be demonstrated as such and promulgated as a part of the medical armory. If it’s not worthwhile, it’s simply a waste of time if not outright harmful. CAM practitioners who promote unproven treatments are being unethical. Proven treatments should be adopted by physicians and be integrated as soon as possible into medical training and continuing professional education.

    There’s simply no excuse for CAM to exist. Were it placed on the same playing field as medications, we would have no complaints because it would either be restricted to investigational trials only, genuinely proven effective or discarded as worthless. To repeat the “joke”, what do you call complimentary and alternative medicine that is proven effective? You call it medicine.

    Offering placebos as your only treatment is unethical and contemptible. Medicine and CAM should be held to the same standard, and I can only imagine the results if pharmaceutical companies were permitted to promote their products the same way CAM practitioners do. For CAM practitioners to decry drug companies for selling effective products while practicing unproven interventions is a fundamentally absurd, hypocritical double-standard that I find outrageous.

  72. Geoff says:

    @Harriet

    Yes, if a new antibiotic works better than an old one, we should adopt it, although this seems pretty strawman to me. Don’t really see how interpreting these results in the context of an evolutionary framework would change that result. That said, much of our understanding of how antibiotics work would make no sense without the context of evolution, particularly with respect to drug resistance.

  73. JPZ says:

    @Geoff

    Just because a diet ameliorates the symptoms of an autoimmune disorder does not make it healthy. Something like 50 years ago, physicians would change the diet of their autoimmune disorder patients so that they would become essential fatty acid deficient. It relieved symptoms quite well but required careful monitoring so as not to cause a host of additional problems.

  74. pmoran says:

    Harriet:You have cherry-picked some statements that you interpret as supporting your idea that this blog’s goal is to obliterate CAM from the face of the earth.

    It was not “my idea”. These are logical extrapolations from common lines of argument wihtin medical skepticism.

    I have talked to many CAM users and sympathizers and as a matter of fact they rightly or wrongly see skeptics as agents of oppression.. Are we happy with that perception?

    Possibly only an clear and detailed expression of policy would go anywhere towards countering this impression, but look how we also grumble whenever doctor’s organizations, or any body for that matter, looks to be offering the slightest leeway towards CAM in their policies..

    So it appears we skeptics just don’t care how we look to those we wish to influence. All that matters to us is that we are “right” according to our own highly specific, absolutist scientific considerations, to the exclusion of everything else.

    For Pete’s sake, I KNOW that those considerations are critical for most of the really important medical questions but we seem temperamentally unable to consider what could be a more mature and realistic approach, by making some allowance for the possibility/probability of non-specific nurturing “effects” from CAM in many settings, also the trivial clinical importance of specific claims, and the fact that most CAM use is reasonably safe (simply because most of it doesn’t do anything other than as placebo).

    Why not focus on safety? Genuine concern for their safety is something that everyone can understand and relate to, but definitely not if it is accompanied by exaggerated, if not absurd perceptions, as to the dangers of CAM, such as the slippery slope. We should allow that most of the public does have some sense and ability to discriminate, and those that don’t cannot be reached anyway.

    Again and again it has been shown that many people could not give a fig for our scientific concerns when they have to endure a problem that we have no satisfactory answer for. ( By sheer coincidence my wife, normally a skeptic but suffering from bad arthritis has just stated “yes, when you are in pain all the time you will try anything” in response to someone saying much the same in a section of Krill oil on “A Current Affair”.)

    There are plenty of counter-examples where the opposite intentions are spelled out.

    Oh? Could I see those, then, if I have been cherry-picking only those themes that support my contention? I suppose we occasionally say, somewhat grudgingly, that people can “decide to do what they want with their own health”, so I guess that is one that counts for you.

    I agree with you about supplying accurate infomation to patients but why should that exclude allowing that some people may have derived genuine benefit from CAM in some contexts, simply for reasons other than those the proponents think?

    I don’t intend a blanket license for CAM use as there is always the rider that no CAM modality has been shown to affect the progress of serious illness.

  75. Harriet Hall says:

    @pmoran,

    “some people may have derived genuine benefit from CAM in some contexts”

    What counts as “genuine benefit” – perceiving reduced symptoms temporarily in the absence of any objective improvement, as in the asthma study? Being comforted? Being sustained by false hope? Heroin produces genuine short-term benefits, and so do Ponzi schemes. Selling people $5 wine in $100 dollar bottles gives them the “genuine benefit” of thinking their wine tastes better.

    “some allowance for the possibility/probability of non-specific nurturing “effects” from CAM in many settings,”

    I’ll gladly allow that. I also allow the possibility/probability of nurturing effects from arrant quackery and health fraud in many settings. Perhaps you think we shouldn’t be so harsh in our discussions of them.

    We get it. People like CAM and sometimes benefit subjectively from it, and they have the right to use it. That doesn’t mean we have to bend ourselves into contortions to make them not feel insulted when we point out the facts. They are grown-ups. It can be argued that the strength of forceful CAM hype needs to be countered by an equally forceful statement of scientific rigor. Who’s going to listen to us if we are so politically correct that we dilute our message? Don’t we need to say bluntly that homeopathy is just water? Should we be saying homeopathy is really OK because it does help some people?

    Sure, we should try to find ways to make our message palatable and attractive, and we are willing to listen to constructive criticism, but yours is destructive criticism. You go too far, and you have only offered generalities, not any specific proposals for how we should present our criticisms of CAM.

  76. David Gorski says:

    At the risk of being perceived as the mean skeptic (and, make no mistake about it, whenever Peter talks about those “intolerant” skeptics on SBM, he is almost certainly referring primarily to me because I don’t pull any punches and have developed a—shall we say?—reputation), let me point out yet again that Peter is doing nothing more than what is known as tone trolling or pearl clutching. He is oh, so, hurt by anything less than total civility that he cedes the scientific side of the debate before it is even under way in his eagerness not to be perceived as “even handed” and not excessively strident.

    Let me tell Peter a story. Sure, it’s an anecdote, and therefore not science, but it demonstrates that he is wrong that being forthright and even mocking won’t work. Several months ago, I gave a talk about alternative medicine, specifically the “big three” (to me), homeopathy, acupuncture, and reiki. During my talk, I made extensive use of what I considered to be humorous ridicule and sarcasm about the ridiculousness of the principles behind homeopathy. Not only was the talk a success but people came up to me afterward and told me that they never knew, never understood just how ridiculous and nonsensical the principles of homeopathy, acupuncture, etc. are.

    Now, by Peter’s view, I would have done a horrible, horrible thing. I didn’t show respect for practitioners of homeopathy or even believers in it or the beliefs of homeopaths. I openly and publicly mocked the principle of “like cures like.” I showed a picture of a duck when discussing Boiron’s oscillococcinum homeopathic flu remedy. I was not “civil,” at least by Peter’s apparent definition. Yet I nonetheless succeeded in convincing a significant chunk of that audience that these remedies are nonsense and did it in a way that they understood. These were not skeptics. These were members of the general public with no affiliation with the skeptic movement.

    What Peter doesn’t realize or refuses to admit is that it takes a wide range of tools to get through to people. I’m all for being civil, certainly in face-to-face discussions. (I even do it myself most of the time, although no doubt Peter will find that hard to believe.) However, blogs, magazines, and public forums like this often require a more—shall we say?—strident approach. I would argue that a range of styles is required, ranging from Peter’s über-civil, bend-over-backwards-to-be-inoffensive schtick to outright mockery, and all points in between.

    Here’s the other thing. One can’t help but note that Peter doesn’t always practice what he preaches. He can get quite worked up, quite vociferous, quite insulting even, but only when he’s criticizing skeptics for being too worked up, vociferous, or insulting. When dealing with quacks? Not so much. Not anymore.

    And that’s a pity.

  77. Artour says:

    The society is obsessed with food as if there is no other systems in the body that is more important than digestive. Chronic diseases are generally based on cell hypoxia. Why oxygen is low?
    Tens of studies demonstrated that the sick with heart disease, diabetes, asthma, COPD, cancer, etc. breathe 2-3 times more than the norm:
    http://www.normalbreathing.com/buteyko.php

    But hyperventilation, according to laws of physiology, must lead to tissue hypoxia. Hence, we need to study how to breathe. But even most doctors cannot answer the most basic question: How should we breathe for maximum body and brain oxygenation?
    Surely through the nose, using the diaphragm, but without any deep breathing rubbish. In fact, the ideal breathing frequency is only about 3-4 breaths per minute (for automatic or basal breathing at rest). More info about respiratory patterns:
    http://www.normalbreathing.com/patterns.php

  78. shawmutt says:

    On one hand it’s great that Time is publishing some science-based articles, on the other I regret they chose Oz as the authority. This just lends him more credibility to the masses when he again goes off the deep end. One quick look at his show’s website and I need to throw on my b.s. waders again.

  79. “Here’s the other thing. One can’t help but note that Peter doesn’t always practice what he preaches. He can get quite worked up, quite vociferous, quite insulting even, but only when he’s criticizing skeptics for being too worked up, vociferous, or insulting. When dealing with quacks? Not so much. Not anymore.”

    It’s quite common to be more willing to criticize associates that you consider equals and respect highly while going easy on strangers or people you feel are subordinate to you. I suspect that is what pmoran is doing. BUT, I don’t know the guy.

    If you two could stop fussing at each other, you could probably form an effective good cop/bad cop strategy, but I won’t hold my breath.

  80. marilynmann says:

    Here is what UpToDate has to say about dietary cholesterol:

    “Dietary cholesterol — Dietary cholesterol raises the total serum cholesterol but is a less important contributor than saturated fat [78,79]. In a pooled analysis of four cohort studies, the relative risk of incident coronary heart disease was 1.30 for each 200 mg increment of dietary cholesterol per 1000 kcal of energy intake (95 percent confidence interval 1.10 to 1.50) [80]. More recent studies, however, have not corroborated this association [43,81-83]. Consumption of up to one egg per day (containing about 213 mg of cholesterol per egg) does not appear to substantially influence the risk of coronary heart disease or stroke among men and women without preexisting diabetes mellitus or hypercholesterolemia [84].
    Consumption of dietary cholesterol in the United States has dropped in recent decades, chiefly due to a lower consumption of eggs [85]. Since dietary cholesterol intake is relatively low, and it is a weaker predictor of disease than saturated fat, only minor emphasis on this factor is currently needed in the United States.”

    If anyone wants to review the references but doesn’t have access to UpToDate, email me at mannm@comcast.net and I will email you the article from UpToDate.

    Serum cholesterol come from two sources: cholesterol synthesis in the liver and cholesterol absorption in the intestine. The body has compensatory mechanisms such that an increase in cholesterol absorption will reduce cholesterol synthesis and reduction in cholesterol synthesis will reduce absorption. Statins work by inhibiting the HMG-CoA reductase enzyme, leading to reduced cholesterol synthesis and upregulation of the LDL receptors (as noted by a previous commenter, familial hypercholesterolemia is a genetic disease in which the LDL receptors don’t function properly, leading to increases in serum LDL and premature heart disease).

    In addition to reducing serum cholesterol, statins have other (“pleiotropic”) effects including reduction in production of certain molecules that have inflammatory vascular effects. Statins reduce these molecules because they are downstream of the HMG-CoA reductase pathway.

    Interesting, there is drug that inhibits cholesterol absorption: ezetimibe (Zetia, Ezetrol). It also is sold as a combo drug with simvastatin (Vytorin). Ezetimibe was approved by the FDA on the basis that it lowers LDL. There are no studies so far showing that it reduces the risk of heart attacks and other cardiovascular endpoints. There is an ongoing clinical trial called IMPROVE-IT in patients with acute coronary syndrome comparing 40 mg simvastatin to 40 mg simvastatin plus 10 mg ezetimibe. This trial may shed some light on whether reducing dietary cholesterol is beneficial.

    The bottom line is I don’t have a definitive answer as to whether dietary cholesterol should be limited, but the fact that the drugs that inhibit cholesterol synthesis (statins) have been shown to be very beneficial in reducing the risk of cardiovascular disease, while drugs that work in the GI tract (ezetimibe, bile acid sequestrants) have not shown similar benefits makes me suspect that dietary choleterol is not very important. In addition, as noted above, reduction in cholesterol absorption leads to increased cholesterol synthesis (i.e., the opposite effect of statins), making me suspect that the overall effect may not be beneficial or may have marginal benefits.

  81. Harriet Hall says:

    Artour,

    Please stop posting here until you understand what we mean by credible scientific evidence and have some of that to share with us rather than just references to your own website. You would have been banned long ago from a less tolerant blogsite.

  82. Artour is so clearly spam, I don’t understand why you don’t filter him… or at least charge him for ad space.

  83. DrBette says:

    Our bodies benefit from the vitamins and minerals found in foods known to be rich in antioxidants such as oranges, dark chocolate and red wine. We’ve all been led to believe that if we eat these foods and other foods like them, we’ll receive tremendous antioxidant rewards. But you can’t necessarily eat your way to excellent health.

    Surprisingly, scientific studies show that your body can’t possibly ingest enough antioxidants to eliminate the number of free radicals your body makes every day. You would need to eat ridiculous amounts of foods rich in antioxidants (32 pounds of strawberries, 31 pounds of raspberries, 15 pounds of dark chocolate per day for example), to achieve the antioxidant power you get from one Protandim caplet each day.

    When you take Protandim (see http://whatisantioxidant.org), you trigger what your body already knows how to do, only better. You ‘tell’ your body to increase production of its own two antioxidant enzymes, which helps prevent free radical damage to your cells thousands of times more effectively than any conventional antioxidant therapy. Healthier cells mean a healthier immune system, and decreased chance of disease as you age.

    1. Harriet Hall says:

      @DrBette,
      Ah, the promise of Protandim! See http://www.sciencebasedmedicine.org/index.php/protandim-another-kind-of-antioxidant/ Still no human studies with clinical endpoints.

  84. ConspicuousCarl says:

    Artour on 17 Sep 2011 at 5:40 am

    The society is obsessed with food as if there is no other systems in the body that is more important than digestive. Chronic diseases are generally based on cell hypoxia.

    All of those fools who think eating right is the cure for all diseases. Don’t they know that BREATHING right is the true cure?

    Well, you’re ALL wrong. Scientific research shows that people with chronic diseases, on average, take 2.3 times as long to fart as healthy people:
    http://www.southparkstudios.com/clips/151181/everybody-farts

  85. weing says:

    “I have talked to many CAM users and sympathizers and as a matter of fact they rightly or wrongly see skeptics as agents of oppression.. Are we happy with that perception?”

    Talk to any criminal, and he’ll tell you that police are seen as agents of oppression.

    “So it appears we skeptics just don’t care how we look to those we wish to influence. All that matters to us is that we are “right” according to our own highly specific, absolutist scientific considerations, to the exclusion of everything else.”

    No. What matters is what the science shows.

    “For Pete’s sake, I KNOW that those considerations are critical for most of the really important medical questions but we seem temperamentally unable to consider what could be a more mature and realistic approach, by making some allowance for the possibility/probability of non-specific nurturing “effects” from CAM in many settings, also the trivial clinical importance of specific claims, and the fact that most CAM use is reasonably safe (simply because most of it doesn’t do anything other than as placebo).”

    1. We can’t be nurturing?
    2. Is CAM’s safety really a fact?
    3. What if it’s used instead of real medicine for actual medical conditions? We have IRBs that look out for patient safety in clinical trials, you are asking for clinical trials by unscrupulous individuals without IRB type protections. To be consistent, are you looking to abolish IRBs for actual clinical trials?

    “We should allow that most of the public does have some sense and ability to discriminate, and those that don’t cannot be reached anyway.”

    If you legitimize CAM, you seriously think the public will be able to discriminate better? You also don’t think more people will use it because of advertisement?

    “Again and again it has been shown that many people could not give a fig for our scientific concerns when they have to endure a problem that we have no satisfactory answer for.”

    So what’s wrong with admitting that we don’t have the answer? What’s wrong with using our precious resources for scientific, as opposed to marketing, R&D to address these problems with the most effective tools we have? Why be satisfied with leaving the afflicted grasping at straws?

  86. pmoran says:

    David, it is only your ultra-sensitive ego that leads you to assume that I have had your specific style of “quackbusting” in my sights in recent posts. The fact is everyone here invokes arguments that if left unqualified would logically lead to zero tolerance and maximal prohibition of CAM.

    While thanking you for no longer using names such as “altie” and shruggie” for groups of people you presumably despise, I note that you still could not resist finding demeaning, “explanatory” names for me.

    This is weird from one so keen to uncover the logical fallacies of others. Apart from the obvious fact that it is the actual content of the arguments , not their tone, that leads to the false (?) perceptions I am trying so hard to get you to think about, if I were a mere “tone troll” I would have been cowed into silence long ago.

    While you are listening, I ask you to consider that only top-notch privileges arising from accidents of birth, upbringing and often long immersion in medical sciences enables people like us to look at a vast body of evidence pro and con CAM and reach a sufficiently confident conclusion that it “works” (to the extent that it works at all) as placebo.

    This is why I think we have no right to be too disrespectful of those less fortunate.

    Note also:- “they work only as placebo” is as destructive of the underlying pseudo-science as any detailed analysis of the physics or chemistry, while also helping to explain the strong grip of the pseudo-science on some users and practitioners.

    Now if we could just reach some agreement as to what precisely “working as placebo” means we might be some way towards a more clearly science-based policy towards CAM, one that allows for the fact that we cannot in all honesty at present say that some people are not deriving modest benefits from it and ones not necessarily readily obtainable elsewhere.

    (Harriet, responding to one of your comments, if millions of people are getting a little relief from their arthritis from the placebo glucosamine, and perhaps a few are even avoiding potentially hazardous joint transplants, that is not a trivial matter. It is very likely that this is so, or that at least many are through this able to avoid the risks of NSAIDs. )

    If the potential for such phenomena is explicitly allowed by SBM policy I would like to be shown where. Meanwhile people deduce our policies and react to them on what we DO say.

    I predict that the selectively softer approach I am exploring will NOT justify doctors offering CAM to patients and especially not at public expense.. The cost/risk benefit analysis will NOT be favorable enough under the conditions that prevail within the mainstream, and there is also the problem of knowing where to draw the line against the innumerable options that CAM can offer.

    Nevertheless there are hints in the present evidence of surprises yet to come, and there is still the small matter of having a rational and if possible non-alienating public policy towards those aspects of medicine that are outside the direct control of the mainstream.

    In looking at the available evidence on placebo and other non-specific influences you have to bear in mind that a lot of the supposedly negative evidence is derived from studies that are not designed to test their potential.

    Studies that try to find them DO invariably find them.

    What does it all mean? There is a dark room here into which we can see only very dimly. That is actually what some of the integrative medical people are trying to tell us, but they then lapse into mystical vocabularies that lead us to assume that they there is no legitimacy to the questions they raise. There is actually fairly definite evidence for something and “placebo’ is not necessarily a sufficiently neutral, value-free or all-encompassing descriptor either.

    So I don’t believe I am just being soppy. These are legitimate scientific questions.

    I can’t respond to everyone. The above may help explain part of my position.

  87. Harriet Hall says:

    @pmoran,

    “everyone here invokes arguments that if left unqualified would logically lead to zero tolerance and maximal prohibition of CAM.”
    Ah, but we don’t leave them unqualified!

    ”we have no right to be too disrespectful of those less fortunate.”
    Who’s being disrespectful?

    “if millions of people are getting a little relief from their arthritis from the placebo glucosamine, and perhaps a few are even avoiding potentially hazardous joint transplants,”

    Are they getting relief from glucosamine? Are they avoiding transplants (I think you mean joint replacements)? That remains to be established by scientific studies.

  88. pmoran says:

    — everyone here invokes arguments that if left unqualified would logically lead to zero tolerance and maximal prohibition of CAM.”
    >Ah, but we don’t leave them unqualified!

    That is arguable. The blog also owns any comments that go unchallenged and that is where medical skepticism can become a highly competitive sport.

    David’s response to my attempts to rethink skeptical objectives reveals tribal pressures towards conformity. Medical skepticism actually has few better friends than I.

    >Who’s being disrespectful

    Not you, as I have often stated. I don’t want to name names and I don’t even really blame people for their anger. CAM has its appalling, intolerable aspects . So has the mainstream, yet we object to being wholly characterized by our worst elements, don’t we?

    Are they getting relief from glucosamine? Are they avoiding transplants (I think you mean joint replacements)? That remains to be established by scientific studies.

    The thing about science is that it can predict likely outcomes.

    So, we would expect 30-50% or even more to report improvements even if glucosamine is completely inactive. We just don’t know how much of that is “real”, yet typically we will choose to interpret those reports in such a way as to make those users feel either foolish or liars. .

    Also over time outcomes with osteoarthritis are so unpredictable that merely tiding someone over a prolonged bad patch can be expected to enable some to avoid a hip or knee replacement.

    In the placebo arm of the famous endoscopic debridement study for knee osteoarthritis there were some very spectacular results in the placebo arm. These could be a variety of “reversion to the mean” rather than “true” placebo response but the implications for my prediction are the same.

    Actually I had an appointment with a surgeon to arrange a hip replacement about five years ago. Other medical problems intervened, and by the time they were resolved I was in less pain, probably from a period of reduced activity and less stress on the joint.

    I am still bothered intermittently by this hip, but I can get by, playing golf and able to most of what I want. I take nothing at all for it..

    The point is that the practice of medicine is more complex than EBM-based medical skepticism can easily elucidate. SBM expands understanding just a little. But often medicine a waiting game, while people get better for no obvious reason — perhaps inconspicuous adjustments to behaviour, changed perceptions or better tolerance for symptoms. This surely accounts for a lot of the apparent success of CAM, as well as that of the mainstream.

    1. Harriet Hall says:

      @pmoran,
      “We just don’t know how much of that is “real”, yet typically we will choose to interpret those reports in such a way as to make those users feel either foolish or liars.”

      So how would you interpret the study where people who believed glucosamine worked for them were given a placebo substitute without their knowledge and couldn’t tell the difference? I don’t call them foolish or liars, but I call their belief wrong.

      “people get better for no obvious reason — perhaps inconspicuous adjustments to behaviour, changed perceptions or better tolerance for symptoms. This surely accounts for a lot of the apparent success of CAM, as well as that of the mainstream.”

      Agreed. That’s why we must rely on science to tell us whether a treatment results in more people getting better. If a treatment hasn’t been shown to result in more people getting better, why should we recommend it?

  89. qetzal says:

    If a treatment hasn’t been shown to result in more people getting better, why should we recommend it?

    Indeed! Especially since these tend to be out-of-pocket expenses for the patient.

    On top of this, why should we assume that glucosamine, for example, must either be mildly beneficial or neutral? If the data isn’t good enough to whether it helps or not, then it’s very likely not good enough to say whether it hurts or not.

    CAM promoters, and even CAM apologists, never seem to acknowledge that issue. That seems to apply to you as well, pmoran.

  90. pmoran says:

    If a treatment hasn’t been shown to result in more people getting better, why should we recommend it?

    How does this recent statement of mine equate to “recommending” it?
    —-
    I predict that the selectively softer approach I am exploring will NOT justify doctors offering CAM to patients and especially not at public expense.. The cost/risk benefit analysis will NOT be favorable enough under the conditions that prevail within the mainstream, and there is also the problem of knowing where to draw the line against the innumerable options that CAM can offer.

    Nevertheless there are hints in the present evidence of surprises yet to come, and there is still the small matter of having a rational and if possible non-alienating public policy towards those aspects of medicine that are outside the direct control of the mainstream.
    —-

    I am suggesting that this latter policy should be influenced by what we know about the science of placebo-type interactions, and also by the risks and costs of medical options that may have to be offered instead.

    Let me add that the question posed above does not make sense on what we actually know about some kinds of illness and symptomatology in general. It is based upon a sceptical/EBM based mind-set that says that “not working better than placebo” equates to “not useful in any way”.

    I will go so far as to say that no true scientist should say that. To do so underestimates the abilities of the human mind to the same extent that some CAM schools of thought over-estimate it.

  91. Harriet Hall says:

    @pmoran,
    “How does this recent statement of mine equate to “recommending” it?”
    You have made it clear that you would recommend certain CAM treatments to patients in the absence of good evidence that they result in more people getting better, such as acupuncture.

    “not working better than placebo” equates to “not useful in any way”.

    No one has said they are not useful in any way. The question hinges on how you define useful. Placebos are certainly “useful” for helping patients perceive a lessening of their symptoms. And any treatment that is equivalent to a placebo is equally “useful” too. Since not working better than a placebo equates to useful, then lying to patients and giving them sugar pills is useful. Unfortunately it isn’t ethical.

    What about the wine analogy? It is “useful” to jack up the price of cheap wine so people will think it is higher quality wine and will enjoy it more. Would you be willing to be overcharged for re-labeled wine to increase your drinking pleasure? I think you would consider that unethical.

    Isn’t it equally unethical to “re-label” a treatment that is equivalent to a placebo as something effective and “sell” it to patients? I have a problem with this. Apparently you don’t, and I doubt if anything I could say would have any impact on your certainty.

    I’ll say once more: I am proposing black and white rules, but I recognize that medicine is a gray area of applied science. Once we have rules, we can break them on occasion but only with good reason and with the controlling influence of guilt feelings.

  92. pmoran says:

    “How does this recent statement of mine equate to “recommending” it?”
    You have made it clear that you would recommend certain CAM treatments to patients in the absence of good evidence that they result in more people getting better, such as acupuncture.

    Did I? I felt I was examining reasonably tenable positions, but I may have on occasions slipped into a devil’s advocate role. If people want a truer understanding of my drift they should look at what you have cut out, and the following –.

    I note that you yourself later allow that the use of those methods can help “patients perceive a lessening of their symptoms.”

    This suggests that you at least among those present are aware of the conflicting impulses that I am trying to reconcile in a rational, compassionate and science-based manner.

    Basically, how should you react to CAM when it is such a variegated collection of human activities, some of which are almost entirely a bad thing, while others are almost certainly satisfying deep human needs and helping to relieve some kinds of medical suffering through highly evolved psychological responses? Is blanket abreaction a rational and effective strategy? What, for that matter, are we trying to achieve?

    And any treatment that is equivalent to a placebo is equally “useful” too.

    We can get tired and a little careless in these long discussions. I know that you know that that is not true.

    The reason I emphasise acupuncture is because it produces better results than other methods we regard as placebo, perhaps through the incorporation of a number of extra non-specific influences.

  93. Harriet Hall says:

    @pmoran,

    “such a variegated collection of human activities, some of which are almost entirely a bad thing, while others are almost certainly satisfying deep human needs and helping to relieve some kinds of medical suffering through highly evolved psychological responses?”

    Some snake oil scams and quackery almost certainly satisfy deep human needs and relieve some kinds of medical suffering through highly evolved psychological responses. It seems to me that if you support one kind of placebo it would only be logically consistent to support them all, absent specific evidence of harm.

  94. pmoran says:

    It seems to me that if you support one kind of placebo it would only be logically consistent to support them all, absent specific evidence of harm

    Ah, I agree with that. In theory that should follow. I have used the difficulty in drawing the line as one of the reasons why the mainstream should not get involved in CAM in any systematic way, especially if is to be a drain upon scarce resources.

    In actual practice, however, placebo responsiveness will be highly variable — individual even, , depending upon numerous factors relating to patient perceptions, expectations and hopes, and practitioner influences.

    So before we could even consider more routine use of any form of CAM within the mainstream there would have to be highly sophisticated cost/risk/effectiveness studies showing worthwhile overall benefits under prevailing conditions.

    It is unlikely many CAM methods could pass that test, but some might, possibly even demonstrating equivalence to commonly accepted conventional methods (look up acupuncture for prophylaxis of migraine).

    We should not need to even consider CAM for objective pathological outcomes because there is already sufficient indication that they are mostly not responsive to psychological influences.

    But there is yet another problem looming for the skeptic, if evidence continues to favour the possibility of clinically significant placebo influences. Once you allow that CAM is placebo-based medicine, AND that there is some possibility of benefits through this and other non-specific influences, there surfaces a germ of truth to the claims of CAM practitioners concerning the difficulties of scientifically testing their methods to a firm conclusion, again, with subjective conditions only.

    For placebo-controlled studies intentionally control against many of the factors that CAM practitioners think are important, and they provide means and averages of outcomes that may easily obscure important idiosyncratic responses for some individuals or for the kind of patient who self-selects themselves into CAM care.

    This is why I am urging a more cautious approach to CAM. Our position is not as intellectually sound as we think.

    1. Harriet Hall says:

      @pmoran,

      I think you are saying that CAM methods might benefit certain individuals even though RCTs show no effect. That is equally true of any pharmaceutical. If a drug has not been shown effective in RCTs, we can’t just willy-nilly try it on individual patients to see if they are uniquely responsive to it. There are ways to test that idea scientifically. The pragmatic studies you advocate are full of pitfalls and tend to make questionable treatments look more effective than they really are. It sounds like you are arguing for a double standard. If the nonspecific effects of CAM treatment are what helps patients, shouldn’t we try to find a way to provide nonspecific effects without silly and potentially harmful woo-woo? I see this as analogous to herbal remedies: if there is an active ingredient, it’s usually better to separate that out and purify it.

  95. pmoran says:

    I am aware of the problems with pragmatic studies when it comes to testing treatments for intrinsic medical activity. That does req

    But we already know or very strongly suspect that CAM mehods suspect

    But herewe cannot preach about the need for CAM and convenitioanl methods to be held to single standard, and then require CAM to perform with one hand tied behind its back.

    . if you are going to insist upon a single standard for both

    But, as throughly despised agents of the forces of evil properties but is it not a little devious to insist on a “single standardnd then insist on one which precludes one of the ways in which pateints can respond to medical interactions.

  96. Harriet Hall says:

    @pmoran

    “one which precludes one of the ways in which pateints can respond to medical interactions.”

    What on earth are you talking about? There is nothing in the standards of medical research that precludes using scientific methods to study any of the ways patients can respond to medical interactions.

Comments are closed.