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…)
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…)
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.
One of the main, but perhaps underappreciated, reasons quackery thrives in the United States is that the states legalize it by licensing practitioners of pseudoscience as health care providers. These practitioners are placed under the regulatory jurisdiction of, well, themselves. I call the whole deplorable process Legislative Alchemy, and you can see all posts on the topic here. It gives practitioners an underserved imprimatur of state authority and leaves public protection from harmful practices to the oversight of those who are themselves engaging in the very same conduct. Each year, dozens of bills are brought before the state legislatures to establish initial licensure or, once that goal is achieved, scope of practice expansion.
Most attempts fail, but CAM practitioners are a dogged bunch, and they will come back each year until they get what they want. It took chiropractors about 60 years to become licensed in all 50 states. Acupuncturists are almost there. Naturopaths lag far behind, but are slowly gaining ground each year, even if it is only via practice expansion in states where they are already licensed. 2015 was a losing season for all, but not without advancement toward larger goals.
New Year, New You, right? Here’s a perennially popular post, revised for 2016.
With 2016 upon us, it’s finally time get serious about your health. You’re resolving to eat better and exercise more. But first, you need to reset your body – and purge yourself of all of your lifestyle and dietary overindulgences. But how? The options seem limitless, and everyone has advice: There’s Dr. Oz, Gwyneth, and even your favourite Kardashian has advice: They’re all telling you how it’s essential to “detox”, “cleanse” and “flush” away all of your toxins. Your local pharmacy has an ever-growing section of products promising a newer, more pure you: supplements, homeopathy, ear candles, and an entire aisle of “detox kits” all promise to suck toxins out of your body. Don’t forget your local naturopath who sells IV vitamin drips as the detoxification solution to your problems. The approaches may differ but all the advocates are completely convinced of one fact: Detoxing will deliver a renewed body and better health. Not only will you look better, you’ll feel better. It is a new year. Wouldn’t a purification from last year’s habits (dietary and otherwise) of last year be the best way to start? Well before you pull out your credit card, there is one fact that “detox” advocates are reluctant to tell you. (more…)
Listen to your science: Eat your vegetables.
This is an expansion of a post I did over on the Society for Science-Based Medicine blog about this time last year. The original post, which got far more traffic than is usual for the SFSBM, is a good example of how science works and the good that it can do. The hard work of real science illustrated here serves as a striking counterpoint to the slap-dash system of pseudoscience, which churns out fake diseases, causes, and cures by the dozen based on a fuzzy understanding of real science fueled by a healthy dose of imagination.
Naturopaths and “functional medicine” practitioners would have the public believe that they are the true experts on nutrition and health. Even though their nutritional advice contains a large serving of hooey and a big helping of dietary supplements, which they are happy to sell to patients.
So it was with great interest that I read the obituary of Dr. Lee Wattenberg in the New York Times.
Dr. Wattenberg published a landmark paper in the journal Cancer Research that reviewed 36 years of animal studies on the effects that certain compounds had on the development of cancer. The paper laid the framework for understanding how these compounds work. . . .
He showed that cabbage, brussel sprouts, cauliflower and broccoli inhibit the development of carcinogens. He isolated a compound in garlic that decreased “by a factor of three” the chances that animals injected with cancer agents would develop that cancer. He found two chemicals in coffee that neutralize free radicals, which are harmful chemicals commonly implicated in the onset of cancer.
An analysis of 26 Traditional Chinese Medicine products found 92% were contaminated with pharmaceuticals, heavy metals, or the DNA of animals, including traces of cat, dog, rat, or pit viper.
Two weeks ago I detailed the pervasive problem of poor quality supplements. The main reason for this seems to be weak regulatory standards that prioritize the rights of manufacturers to sell supplements over the rights of consumers to buy safe, high quality, properly-labelled products. Call it “health freedom“, where the freedom belongs to producers, who in many countries are largely freed from most of the quality and safety regulations that are in place for licensed prescription and non-prescription pharmaceuticals. The result of weak regulation is that few supplements sold on the market today have been properly tested for safety or effectiveness, and there are few quality standards for the production of these products.
Not surprisingly, there are persistent signs that consumers may face real risks to their health from using these products. Now a new study from Australia confirms what past studies have already shown: adulterated and contaminated herbal remedies are the rule, rather than the exception. They often contain undeclared ingredients ranging from potential allergens to heavy metals to endangered species. (more…)
When it comes to supplements, you can’t trust what’s on the label
The idea that “natural” products are safe and effective has been so effectively marketed to us that many don’t recognize it as a fallacy. Much of the supplement industry is built around an appeal to nature. Supplements are described as natural, gentle, and “holistic”. Medicine, especially prescription drugs, is the opposite. They’re “chemicals”. They’re risky and dangerous – just look at that list of side effects! Supplements are packaged beautifully, have impressive claims, and are for sale at Whole Foods. Drugs are hazardous: They may come in a plain vial, with warning labels, detailed information sheets, and cautious statements about their effectiveness. Is it any wonder that many consumers, when faced with health concerns or medical issues, instinctively think of supplements as a safer alternative? Purveyors of supplements and alternative medicine have leveraged this fallacy so effectively that it’s even guided the regulations that allow their sale. Regrettably, the result is a marketplace that puts consumers’ interests last. The supplement industry has completely stacked the odds against the consumer, challenging their ability to make informed decisions about their health. Most supplements on the market have never been properly tested for safety or effectiveness. And those that have been tested have largely been shown to be ineffective – or in the case of products like vitamins, often unnecessary. And while there are undoubtedly some ethical companies out there, the industry is regularly revealed to resemble a wretched hive of scum and villainy. Despite this, the industry has gone from success to success – in terms of sales, at least. In 1994 supplement sales were about $4 billion in the US. It’s now a $37 billion industry that is remains only lightly regulated – or largely unregulated. With recent action taken against fraudulent products, there are more questions than ever about how to force the supplement industry to make consumer protection a priority. A new paper in Drug Testing and Analysis makes a provocative suggestion: Local and state governments already regulate another hazardous product: tobacco. Can lessons learned from the tobacco wars improve the safety of supplements? (more…)
Health care systems around the world are being pressured to “do more and spend less”, to make healthcare more cost effective. Owing to aging populations and the growing cost of providing health services, there’s more scrutiny than ever on the value of different health treatments, with the goal of reducing the use of treatments that don’t help. The Choosing Wisely initiative was establishing expressly for this purpose. Regrettably, while well-intentioned, Choosing Wisely hasn’t had as much of an effect as you might expect. Medicine can be slow to change, as David Gorski discussed earlier this week. Unless we ruthlessly scrutinize what we do for effectiveness, and are willing to act on what we learn, self-driven change is unlikely. One way that governments (and insurers) can dramatically reduce the use of a health service or treatment is to simply stop offering it, or paying for it. Yet stopping funding is something that is relatively uncommon in health care. It seems to be much more difficult to stop a practice, possibly owing to inertia, a reluctance to change, and the sometimes-vociferous protests that can emerge from patients or physicians that may feel that their preferred therapy is effective. The formidable challenge of stopping health care funding, once it has started, is one reason why this blog has been very critical of the expanding scope of practice being granted to alternative medicine purveyors – the legislative alchemy that is the first step towards insurance coverage. Because once that’s in place, it will be far more difficult to stop it. So it’s essential to understand the evidence. (more…)
The Robert F. Kennedy building in Washington, DC, headquarters of the United States Department of Justice
It is shaping up to be a good year for those of us advocating more effective regulation of supplements and unproven therapies in the US. The Food and Drug Administration (FDA) is reviewing its regulation of homeopathy, and recently also announced it is taking public comment on its regulation of the term “natural.” The Federal Trade Commission (FTC) is also reviewing the claims made by the homeopathy industry, and even gave a nudge to the FDA to fix its regulation.
Now the US Department of Justice (DOJ) is getting in on the fun:
USPlabs, which sold the best-selling workout supplement Jack3d, and six of its executives face criminal charges for the unlawful sale of nutritional supplements, the U.S. Justice Department said Tuesday in announcing a larger probe by federal agencies aimed at stemming the sale of unproven products.
This action by the DOJ raises the stakes to a new level – criminal charges. While the FDA and FTC do the best they can, they often lack teeth when it comes to supplements. The FDA might issue a polite request and then escalate to a stern warning when companies step out of line. The FTC can issue fines which amount to little more than a slap on the wrist – the cost of doing business. Both agencies are playing whack-a-mole and losing.