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Parents Convicted in Death of Toddler

Stephans

David and Collet Stephan, parents to the now-deceased Ezekiel Stephan.

This is a very sad and tragic case, and I have great sympathy for the extended family of Ezekiel Stephan, the 19-month-old who died of meningitis four years ago. In my opinion, there are many victims in this case.

The jury, apparently, agreed. Yesterday they returned a guilty verdict for Ezekiel’s parents, David and Collet Stephan, who now face sentencing for failing to provide the basic necessities of life to their son. It is reported that many of the jurors were crying when the verdict was given – clearly this was a difficult and emotional case.

Just the facts

As is often the case, there are different narratives of what happened, depending on your perspective. It is likely the jury had access to more facts than the public, and so their verdict, which was clearly difficult, needs to be taken seriously. Here are the basic facts as being reported:

In March of 2012 Ezekiel became ill with flu-like symptoms. His parents report that they thought this was a normal childhood illness and would pass. His mother reported to police that she thought he had croup. They treated him with natural remedies, mostly supplements. (more…)

Posted in: Ethics, Herbs & Supplements, Naturopathy

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Functional medicine: The ultimate misnomer in the world of integrative medicine

Functional Medicine practitioners like to make patients think that this diagram actually means something.

Functional Medicine practitioners like to make patients think that this diagram actually means something.

We at Science-Based Medicine often describe “integrative medicine” as integrating quackery with medicine (at least, I often do), because that’s what it in essence does. The reason, as I’ve described time and time again, is to put that quackery on equal footing (or at least apparently equal footing) with science- and evidence-based medicine, a goal that is close to being achieved. Originally known as quackery, the modalities now being “integrated” with medicine then became “complementary and alternative medicine” (CAM), a term that is still often used. But that wasn’t enough. The word “complementary” implies a subordinate position, in which the CAM is not the “real” medicine, the necessary medicine, but is just there as “icing on the cake.” The term “integrative medicine” eliminates that problem and facilitates a narrative in which integrative medicine is the “best of both worlds” (from the perspective of CAM practitioners and advocates). Integrative medicine has become a brand, a marketing term, disguised as a bogus specialty.

Of course, it’s fairly easy to identify much of the quackery that CAM practitioners and woo-friendly physicians have “integrated” itself into integrative medicine. A lot of it is based on prescientific ideas of how the human body and disease work (e.g., traditional Chinese medicine, especially acupuncture, for instance, which is based on a belief system that very much resembles the four humors in ancient “Western” or European medicine); on nonexistent body structures or functions (e.g., chiropractic and subluxations, reflexology and a link between areas on the palms of the hands and soles of the feet that “map” to organs; craniosacral therapy and “craniosacral rhythms”); or vitalism (e.g., homeopathy, “energy medicine,” such as reiki, therapeutic touch, and the like). Often there are completely pseudoscientific ideas whose quackiness is easy to explain to an educated layperson, like homeopathy.
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Posted in: Critical Thinking, Diagnostic tests & procedures, Herbs & Supplements

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More drugs, more supplements, and potentially more problems

drugs and supplements

Early in my career I was fortunate to be offered a role as a hospital pharmacist, working on an inpatient ward along with physicians, nurses, and a number of other health professionals. My responsibilities included conducting a detailed medication review with each newly admitted patient. We would sit together, often with family members, going through what was sometimes a literal garbage bag full of medications, and documenting the drug, the dose, and the reason for use. I can’t remember the most medications I ever counted, but a dozen or more was normal. Some were taking medications four or five times per day, every day. Were all these drugs necessary? In many cases, no. They’d been started at different times, often by different physicians. Some drugs treated the side effects of other medications. Few had ever had a health professional document them all in a single list. There had rarely been an overall review for safety and appropriateness. Few patients knew the treatment goals of their medications. Often, they’d never been asked about their treatment preferences.

In addition to auditing every prescribed medication, I asked about vitamins, supplements and over-the-counter drugs. I usually encountered the same scenario – multiple products, often without any clear medical need. There were vitamins for “eyes”, tonics for “the blood”, and supplements believed to treat or prevent illness. There was regular (and sometimes dangerous) over-the-counter painkiller consumption. Sometimes all of these combinations were clearly antagonistic: concurrent laxatives and treatments for diarrhea, or sleeping pills taken along with stimulants. Worryingly, few had disclosed the use of many of these products to their physician beforehand.

Medication reviews were a tremendous amount of work – but enormously rewarding. It was not difficult to find one or more cases of drugs potentially causing harm, or situations with clear drug-drug or drug-supplement interaction. In some cases, it was the medications that had put them in the hospital in the first place. Working with the residents and medical staff we could usually find ways to simplify their regimen, often discontinuing one or more drugs, reducing the doses of others, and suggesting ways to cut their supplement and over-the-counter drug use – or at a minimum, reduce the risk that these products could cause problems. Not only did patients end up with simpler medication schedules, we were helping them feel better, too. Before every patient was discharged, they’d get a follow-up visit from me. I’d provide a detailed list of current medications with a simplified schedule designed to make medication use easier. We’d provide copies for them to take to the pharmacy and to any specialist. In many cases, patients were still on a long list of drugs. But we’d cleaved away the most harmful and unnecessary, trying to leave only the medications that were appropriate. (more…)

Posted in: Herbs & Supplements, Pharmaceuticals, Science and Medicine

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Not natural, not safe: Grapefruit Seed Extract

The image is "natural", but is grapefruit seed extract a case of misleading advertising?

The image is “natural”, but is grapefruit seed extract a case of misleading advertising?

Where do you draw the line between “supplement” and “drug”? And how much processing of a “natural” substance can occur before it’s no longer “natural”? These seemingly-philosophical questions are very real when it comes to the supplement industry. In many countries, regulators have implemented weaker safety, effectiveness and quality standards for anything branded a supplement or natural health product. The result has been a boon and boom for manufacturers, with thousands of products flooding the market. This same boom has challenged consumers and health professionals who are seeking products that are safe, effective, and manufactured to high quality standards (and in the bottle you are buying). Nowhere is this challenge better illustrated than a supplement that I’ve seen for sale for some time. Grapefruit seed extract (GSE), according to promoters, is a panacea that destroy bacteria, viruses and fungi anywhere in the body, without any risk of harm. But the actual science is quite telling. Grapefruit seed is a supplement that’s of such poor quality that even herbal medicine boosters recommend against its use. (more…)

Posted in: Herbs & Supplements

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Is it ethical to sell complementary and alternative medicine?

Legal to sell, yes. But ethical to sell?

Legal to sell, yes. But ethical to sell?

Complementary and alternative medicine (CAM) is no longer fringe, and anything but the mom-and-pop image that manufacturers carefully craft. CAM is big business, and most Americans today take some sort of supplement. The impetus for my blogging (and tilting at CAM windmills) emerged from years spent working in a pharmacy with a heavy reliance on CAM sales. If it was unorthodox, this store probably sold it. Conventional drug products (the ones I was familiar with) were hidden off in a corner, and the store was otherwise crowded with herbal remedies, homeopathy, and different forms of detox kits and candida cleanses. All of this was unlike anything I’d ever seen or heard about in pharmacy school – so I started researching.

I looked at CAM from a scientific evidence perspective, the one I was taught in pharmacy school, using the same approach I’d take when assessing a new drug. Did the evidence support the claims made about these products, or not? The answers, as you might expect, were often the same. There was little or no credible evidence to demonstrate CAM had any meaningful benefits. I started blogging my own reviews as a way of documenting my own research, while offering some information to anyone on the Interwebs who might be searching for evidence.

Over time my blogging focus expanded, as I asked myself the inevitable questions: How could implausible products with no scientific backing even be approved for sale at all? I discovered the regulatory double-standard allowed for anything considered a dietary supplement (or in Canada, a “natural health product“) and the history and politics that have made CAM the “Wild West” of health care, with a marketplace that prioritizes a manufacturer’s right to sell over a consumer’s right to purchase a product that is safe and effective. Given the retail marketplace that’s been established by regulators like the FDA and Health Canada, I’ve turned my focus on to health professionals, who have an ethical responsibility to put patient interests above that of commercial interests. From a professional practice and medical ethics perspective, I have argued that health professionals that sell or promote CAM are on ethically shaky ground, and compromise the credibility of the profession.

Despite the lack of evidence that CAM (in general) offers any health benefits at all, it’s been remarkable to watch its popularity grow, to the point where even large pharmacy chains now sell aisles of products that are implausible and often highly questionable. Generally meeting these changes with a collective shrug, the pharmacy profession has even tried to lower its own ethical standards. While I do get the occasional encouragement from some of my peers, most just say “it’s business” or “the customer wants it, and these are legal products.” My argument today is CAM fails even this lower ethical bar. (more…)

Posted in: Ethics, Herbs & Supplements, Homeopathy, Medical Ethics, Politics and Regulation

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Puritan’s Pride Vitamin Advisor Gives Questionable Advice

puritan's
The Puritan’s Pride website has a Vitamin Advisor that claims to provide a personalized supplement plan, with expert recommendations chosen just for you. In my opinion it is deceptive, designed not to provide evidence-based personalized health advice, but to sell their products; and one can only wonder what kind of “experts” would support such ill-advised recommendations. Stephen Barrett and I have just co-authored an article on the Quackwatch site analyzing the Vitamin Advisor’s advice. I wanted to share what we found with our SBM readers, with some further comments.

Their recommendations are based on a series of questions like age, sex, health concerns, whether you are exposed to cigarette smoke, etc. The full list can be found in our Quackwatch article. The one-size-fits-all questions are useless because “eye concerns” might mean anything from needing glasses to glaucoma. (more…)

Posted in: Herbs & Supplements

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Prenatal Multivitamins and Iron: Not Evidence-Based

prenatal-vitamins small
When I was pregnant, I obediently took the iron pills and prenatal vitamins prescribed by my obstetrician. And I prescribed them for every pregnant patient I took care of as a family physician. I never questioned the practice. It seemed intuitively obvious that it was a good thing; we know pregnancy makes extra nutritional demands and depletes iron stores. It never occurred to me to question what I had been taught, because it seemed perfectly logical. I did question other things I was taught that didn’t seem so logical. In my internship, we were ordered to do episiotomies on every patient (the rationale was that it made birth less traumatic for the baby and prevented uncontrolled perineal tearing in the mother). I was severely chastised for omitting an episiotomy on a patient who begged me not to do one. She had had several babies and was stretchy enough to deliver easily without an episiotomy. In this case, my common-sense clinical judgment was vindicated by further research in the years after my internship; new evidence showed that routine episiotomies were of no benefit, practice changed in response to the new evidence, and episiotomies are no longer done routinely.

That was a long time ago. I have long since learned that even the most reasonable assumptions can be wrong. I happened to be right about episiotomies, but I might just as well have been wrong; and the only way to know whether a belief is true is to test it in controlled scientific trials. As Will Rogers said, “It isn’t what we don’t know that gives us trouble, it’s what we know that ain’t so.” It turns out that routine multivitamin and iron supplementation is not supported by any convincing evidence from scientific studies. And practice is changing. Recently, when one woman asked her OB what she should do about prenatal vitamins he pulled his wastebasket out from under his desk and said “put them there.” (more…)

Posted in: Herbs & Supplements, Nutrition, Obstetrics & gynecology

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The consumer lab rat: More questions about supplement safety

Laboratory Rats
Do you take a vitamin or dietary supplement? Over half of all American adults do, making this a $30 billion dollar business. Many of us even take supplements in the absence of any clear medical or health need. I’m often told it’s a form of nutritional “insurance” or it’s being taken for some presumed beneficial effect – like Steven Novella outlined in yesterday’s post on antioxidants. We love the idea of a risk-free magic bullet that improves our health and wellness. Especially one that avoids what are presumed to be toxic, unnatural drugs. Supplements are marketed as safe, natural and effective, and there is no question that messaging has been effective.

I used to take supplements. For me it was multivitamins. But as I’ve taken a closer look at the evidence for supplementation, my personal behaviors changed. The primary reason is a lack of evidence. There is no evidence to suggest that vitamins offer any health benefits in the absence of deficiency. The balance of evidence suggests that routine multivitamins are unnecessary for most people. Vitamins should come from your food, not from supplements. More generally, looking at the broader category of supplements that range from probiotics to herbal remedies, there is little evidence to support most of them. With a few exceptions, the research done on dietary supplements is unconvincing and largely negative. If you don’t supplement, you don’t seem to be missing out on any tremendous health benefits.

Going beyond the lack of evidence, there’s an even more compelling need for consumers to be wary of them. The safety of supplements is increasingly being called into question. Evidence has emerged demonstrating that quality standards for supplements sold in many countries are erratic and unpredictable. The root cause seems to be regulatory systems that prioritize manufacturer interests ahead of consumer protection. With supplements, products are effectively being tested for safety after they are marketed, and the consumer is the unwitting research subject. (more…)

Posted in: Herbs & Supplements, Politics and Regulation

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More Trouble for Antioxidants

Antioxidants are better acquired through food than pills.

Antioxidants are better-acquired through food than pills.

Antioxidants are now an iconic example of premature hype making its way into marketing and the public consciousness long before the science is adequately understood. There are multiple lessons to be learned in this story, and a new study just emphasizes those lessons further.

A brief history of antioxidants

One of the unavoidable consequences of metabolism (burning food for energy) is the creation of oxygen free radicals, or reactive oxygen species (ROS). These are molecules that are highly reactive. They essentially contain oxygen with an extra electron, which can react with another molecule, breaking bonds and causing damage.

As you might expect, the body has natural antioxidants which react with ROS to form benign molecules.

In the 1990s it became increasingly apparent that oxidative stress was playing an important role in cell damage, even sometimes triggering apoptosis, or programmed cell death. Many degenerative diseases, like Alzheimer’s disease, were shown to be driven in part by oxidative stress. In addition, it seemed that ROS play a role in aging.

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Posted in: Herbs & Supplements, Nutrition

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