If you hear a health claim sounds too good to be true..

We all have things we believe without evidence. We particularly have things we believe without good evidence. I am not even talking about religious beliefs, which are, by definition, acts of faith, but what we can call lay beliefs about the world. One area in which this is both important and widely variable is health and medicine. There is a tremendous amount of information out there, and much of it is correct, and much is not, and sometimes some correct stuff seems, on the surface, to contradict other correct stuff. If that is true, what is a person to do?

One option is to learn about things in detail, understand the scientific method, understand statistics, and understand how “truth” evolves and changes with new discoveries. Or, alternatively, to know that there are people who do know and understand these things, who have spent years and decades learning about them, being trained in the subtleties of science and research, and listen to what they say. For decades, say roughly from WWII, this is how our public health developed. We didn’t just trust scientists, we trusted science. We could see the progression of scientific knowledge, and how it positively impacted ourselves, our communities, and our nation and world.

You don’t have to be a statistician and understand all the intricacies to understand, for example, the basics of probability. When something is more likely than something else, that doesn’t mean it will always happen. When you throw a pair of dice, it is more likely to come up 7 than any other single number (6 of the 36 possibilities – 1 in 6 -- are 7). This does not mean it will always be 7, or usually be 7, or even be 7 a majority of the time, but (given enough throws) it will be 7 more often than any other number. If you understand this, you are on your way to interpreting scientific data. If you don’t, don’t shoot craps.

In medicine, a diagnostic test or treatment that works only 1/6 times is not likely to be used, so the probability that it will give an accurate diagnosis or a successful treatment is going to be much higher. But almost never 100%. 99% is very good; 1% is a small chance, and if you had a 1% chance of getting 7 and crapping out, or getting a wrong answer on a test, you’d go for it. But if something is done a million times, 1% is 10,000. You, or a loved one, could be one of the 10,000 in whom a test is inaccurate, a treatment fails, or even a side effect kills you. That is terrible for you, but doesn’t increase the likelihood of it happening to the next person. If you throw dice, the odds of a certain combination are the same every single time. Even if someone, say, rolls 11 six times in a row it doesn’t change the probability (1/36) of getting an 11 the next time. There is no such thing as “hot dice” or a “hot shooter”. If you don’t understand that, don’t play craps.

Enough of probability now. The main point is that because something bad sometimes happens with a test or treatment doesn’t make it bad. Some of the issues in health that are most controversial now, like vaccines, are phenomenally and overwhelmingly good. Most of the bad things attributed to it are completely made up (not that the bad thing happened to someone, but that it was the result of the vaccine), and the others are very rare, far more rare than the bad things happening to the unvaccinated.

While truth does evolve and change with new discoveries, those changes are usually logical and stepwise. We know about something, and new information increases our knowledge. It rarely completely contradicts everything we know; it theoretically could and there have been some discoveries that did, but if a claim seems to it is very unlikely. It is usually internet spam, promulgated by people who think you are a sucker and may pay them for something that magically solves a problem. If you have a health problem, this is almost never the way to go. Sure, pharmaceutical companies are scum-sucking parasites who would kill their mothers, not to mention you, to make a buck, but that doesn’t mean the medications that they make are bad, ineffective, or more dangerous than what you can buy over the internet because somebody says it works. The FDA (at least historically, before it became decimated) required rigorous testing of medications before they are released to the public, while the miracle cures you see on the internet have not. In addition, the doses are standardized and consistent. You can know what you are getting, and if you cut the dose in half or double it, that is what you are doing. With unregulated drugs, you don’t know.

Yes, there are many natural substances that can help, and indeed many prescription and regulated drugs have their origin in them. But even though aspirin may have originated from willow bark, how much willow bark is the right dose for you? From what age tree? Growing in what conditions? In what season? What about next time? Or your next door neighbor? Or your kids? A good rule of thumb is the old saying: If something seems too good to be true, it probably is. “Magical” cures on the internet never are. Another old saying, attributed to P.T. Barnum, is “a sucker is born every minute”. No one wants to be that sucker, but people are remarkably inconsistent about when they will be judicious and when they will swallow the Kool-Aid whole.

If someone you hate and think is stupid tells you something that sounds ridiculous and unbelievable, you probably won’t believe them. But what if it is a friend? If what they say is something that you already think might be true? Looking things up on the internet (sometimes called “doing your research”) is actually not a bad way to start. You usually find accurate information. This is really different from reading something sent to you or spammed out by bloggers (like me) or “influencers”; if someone is “reaching out” to you, it is basically marketing. Think of the difference between you calling your bank to find something out about your account and getting a call from someone that says that they are your bank!

How does this relate to social justice? Are there not believers and non-believers in data and science in both majority and minority groups, among the young and old, among the rich and the poor, among liberals and conservatives? Sure, but the impact is different among these different groups. Many people are not only acting on their own fringe and unscientific views, but pushing and promulgating them to others. And, as always and as in almost everything, it is the poorest, least empowered, least educated, most marginalized, those with the thinnest safety net, who suffer the most. We may occasionally read of someone who has been hoist on their own petard, refused vaccination and died of the disease, followed a wacko diet or taken unregulated medication who gets ill or dies from it, but when the society or government rejects science in favor of public health policies based on fringe beliefs, it is the least well off who are most often harmed.

Remember, there may be magic in the movies, but there is not real magic in the world. If something sounds to good to be true…

Tallow and unsaturated fats: What is "natural" and what is good -- not the same!

The NY Times “Eat” section recently had an article titled ‘How Beef Tallow Made a Comeback’, asking in the subhead ‘When McDonald’s stopped frying with beef tallow in the 1990s, most people saw it as a win for America’s health. What changed?’. The short answer, in terms of the science of the relative benefits of saturated animal fats like tallow and lard versus the unsaturated (olive oil) and poly-unsaturated (several types of vegetable oil) fats, nothing. What has changed, at least to some degree including among the restauranteurs cited, is people’s opinions and beliefs. One of them ‘said he felt a “moral and ethical obligation” to change his menu earlier this year…after reading that seed oils, like the canola oil he used to cook his fries and tortilla chips, carried potential harms. Tallow, he said, made for a healthier, more “natural” frying oil.’

There is a lot to unpack here. First is whether “seed oils” carry potential harms. Where did he read it? A reliable source? A wackjob? An earlier “Eat” piece, in January (link in the previous paragraph) was called ‘Are Seed Oils Actually Bad for You?’. It concluded that, new (not yet confirmed when the article appeared) Secretary of Health and Human Services ‘Robert F. Kennedy Jr., and others, claim they’re harming our health but the evidence suggests otherwise.’ In both articles, accomplished and respected nutrition scientists dispute this claim, and emphasize the increased risk of heart disease (and cancer) from animal fats like tallow and lard. There are physicians in the US, certainly here in Tucson, who dispute the idea that saturated fats are bad for you in terms of causing a higher risk of heart disease, but they are a distinct minority. There are at least a couple of research studies indicating they are not, but hundreds indicating that they are.

‘In 2002, a review study raised the question of whether consuming foods with high levels of omega-6 fatty acids relative to omega-3 fatty acids (a ratio typical of many seed oils) might increase inflammation in the body. “But I’ve gone through these papers and there’s not a single shred of evidence that this is actually true,” Dr. [Walter] Willett [Harvard School of Public Health] said. “This is all theoretical.”’

It should go without saying (but apparently doesn’t) that it is illegitimate to pick and choose the research you cite based not on its quality or methods but on whether it gets the results you already agree with. The American Heart Association (AHA) recommends diets with lower levels of saturated and higher levels of unsaturated fats, but critics say that this recommendation is tainted because AHA got money from Procter and Gamble, which manufactures Crisco, which contains both saturated and unsaturated fats and is not actually a particular favorite choice in the polyunsaturated sphere. While the appearance of bias/corruption always can exist when money is involved (see my piece from August 20, 2010 The AAFP, Coca-Cola, and Ethics: Serving the public interest?), it does not necessarily, or usually, mean the research supporting recommendations is flawed. P&G denies any association, but much more important is the breadth and consistency of the research supporting the use of unsaturated fats.

The other big issue is ”natural”. This one is huge. People of all political stripes love “natural”. It sounds so – well, natural! If it’s natural, it must be good – or at least better – right? Well, first of all, for this discussion, seed oils are also natural. They are, indeed, usually processed, but there is nothing in that processing that would make them less healthful, or natural. Tallow and lard when sold commercially are purified as well. A lot of stuff that is natural can be good for you, but a lot of stuff can also be bad for you. Many people advocate for the use of herbal remedies (natural, right?) and in fact many plants do have physiologic effects that can treat symptoms and diseases. Some have been the basis of commercially-produced medicines, e.g., aspirin from willow bark, digitalis from foxglove, colchicine from autumn crocus (Drug prices and corporate greed: there may be limits to our gullibility, December 27, 2015). Even in these cases the standardization of dose is much better in commercially produced drugs (and I am no fan of pharmaceutical companies or their practices, especially advertising and pricing). How many leaves of foxglove is good for your heart and how much is going to kill you (digitalis has a very narrow therapeutic:toxic ratio)? And there are many other natural things that are not good for you…I do not recommend rubbing poison ivy on your skin! Tobacco is a natural product, and Native people used it to treat wounds, as well as smoked it. Respecting those traditions and putting it on wounds, or especially smoking it, may not be the best thing for your health.

One thing that is sometimes cited as an indication of what natural things are good is the behavior of other animals. This is worth observing, but it is also worth noting that people are not the same as other animals, and the fact that they like something doesn’t mean it is god for people (or even for them!):

‘Mathaus Myga, 37, who owns a German takeout restaurant in Wisconsin, started frying his pork and chicken schnitzel in locally sourced beef tallow a year and a half ago….When Mr. Myga returns home after a day of frying with tallow, his two dogs lick his fingers. “They would never do that with rapeseed oil,” Mr. Myga said, referring to a common vegetable oil. “These are animals that have natural instincts.”’

I don’t know about Mr. Myga’s dogs, but the things my dogs’ natural instincts lead them to eat are not always things I’d recommend to people. Horse droppings are one of their favorites!

You can believe whatever you want. You can act on those beliefs in living your life (as long as they don’t hurt others). You can prepare your food based on those beliefs. But this does not necessarily make what you believe true. Finding “an article” by a reputable researcher that supports your belief is not a legitimate scientific approach, it is cherry-picking. To know what the science actually says, you have to form your belief based upon the overwhelming consensus of the research.

Of course, that is not a problem if you don’t believe in science.

Jane Brody, Dietary fat and carbohydrate, Vitamin D and really assessing the evidence

I admit that, as I write this, it is hard to think of anything else as important when Vladimir Putin has invaded Ukraine in an action that, in addition to its obvious direct impact on that country, had led to as great a threat to nuclear war and human extinction as we have seen in two generations. That a deranged power-mad autocrat can do this is even more terrifying when we look at the number of psycho autocrats that have gained power in the world, including recently (and hopefully not in the future) in the US. But I am not going to write about it, for three reasons:

--It is not the topic of this blog, which is Medicine and Social Justice

--There remain a lot of things that urgently need discussion in regard to American healthcare, mired as it is not only in the evils of for-profit capitalism but incredible inefficiency and incompetence, and

--These issues actually matter on a day-to-day, week-to-week, year-to-year basis for the American people.

First, I will start a good thing, or at least a mixed one. The less-good part is that Jane Brody, the health columnist in the New York Times, has written her last column. The good part is lauding her for the incredible contributions she has made to our understanding of the issues of our health over the decades (since 1976) that she has been writing it. We all have (or should have) learned much from her, about diet, and exercise, and dealing with illness and even death. In her last column she points out some areas where her advice has been incorrect, based on the science of the time, when new evidence has disproven it. I believe that an ability to acknowledge that you were wrong, whether because (as usually true for her) the scientific knowledge has changed, or because you wanted to believe something and so were previously unwilling to actually examine the evidence adequately. A particular area of health that she has been associated with is diet (she has written several cookbooks), and this is the area in which her admission of error is most incomplete and thus disappointing. While she notes that ‘One of the most significant shifts has concerned dietary fats,’ her emphasis is on how the recommendations in the ‘70s to shift away from animal fats missed the dangers of vegetable-based trans fats. She cautiously says ‘But time will tell whether specific dietary fats, or the much vaunted Mediterranean diet currently embraced by many doctors, will fall prey to future findings.’ 

But that’s it. There is no mention whatever of the problems with carbohydrates in the diet, particularly simple carbohydrates like sugars, on people’s health. This is a major lapse. Without getting into a discussion about the benefits of a very-low-overall carbohydrate diet (e.g., Atkins, paleo, etc.), there can be no question that large amounts of sugar (and possibly even small amounts of sugar) in the diet is deleterious, non-nutritious, and causes not only obesity but a great many other health problems, and that no reasonable diet today can fail to feature this fact. Moreover, it completely avoids the evidence that the campaign against dietary fat, carried on by organizations such as the American Dietetic Association (now the Academy of Dietetic and Nutrition, AND) and many others, for decades was funded by the sugar industry and the manufacturers of high-sugar foods such as soda pop (addressed in several blog posts, including Gangster capitalism and our health: In the US and in the World Jan1, 2019, The AAFP, Coca-Cola, and Ethics: Serving the public interest? Aug 20, 2010, and others). The lack of any mention of this in Ms. Brody’s column is concerning; does she still believe that fat is a bigger dietary problem that sugar? This is not an academic question; go to your grocery store and look at the labels on “low fat” or “fat free” products and see what is in them. My personal favorite is “fat-free half-and-half”, which is almost an oxymoron because fat is the basis of half-and-half: half whole milk (4% fat) and half cream (about 20%) for a total of about 12%. How can half-and-half be fat free? Read the label! It is full of sugars. Indeed, almost all foods with such labels are high in calories an high in carbohydrates, especially sugar (commonly in the form of ‘high-fructose corn syrup’).

Another undying health claim, promoted by some doctors and many non-medical professionals and non-scientists for several decades is vitamin D (not an issue which Ms. Brody, in this final column, addresses). Fifteen years ago, endocrinologists were promoting vitamin D deficiency as a major endemic problem, claiming deficiency at blood levels then (and now) considered normal. While most have backed away from the idea that it is a panacea, some have not and fed an ongoing commitment to taking more of this vitamin, an idea that flourishes on, of course, the Internet. With the onset of the COVID-19 pandemic, enthusiasts have found this to be the newest “indication” for it (Vitamin D, false nostrums, and conspiracy theories: The world has enough real problems, Jan 28, 2021). In an excellent – and brief and easy to read --Commentary on Medscape® (Feb 17, 2022), John Mandrola asks ‘Why Is Vitamin D Hype So Impervious to Evidence?’. His emphasis is on critical appraisal of the scientific research, on the quality, breadth, and significance of the studies done. He emphasizes that there are many, many randomized controlled trials that do not show that taking Vitamin D decreases the risk of any condition (other than true vitamin D deficiency, which occurs at quite low levels.) Among the many important points he makes is that association (many people with chronic disease have lower vitamin D levels) does not show causation (it was the low vitamin D levels that caused the disease), because often ill-health causes the lower levels, and still less that administration of vitamin D will cure it. Indeed, he discusses the many large, well-designed studies that prove that it does not.

So why is this issue so impervious to evidence? The answer, it appears, is rooted more in psychology than science, in how people choose to believe what they believe and seek out evidence that supports it (if, indeed, they seek evidence at all). There are always experts who espouse their (and almost any) position. Even when they are a small minority, there are 330 million Americans and 8 billion people in the world, so a small minority can be a lot of people. Almost all people (scientists are a very small minority) do not have the training or the skill to read and assess the scientific literature, and it is uncommon that they even try. Instead, they seek (or have sent to them) articles by people that seem to be reputable that support their position. Mandrola focuses also on how even scientific papers engage in “spin”, pointing out how often they emphasize minor, secondary, and non-significant results even when the main point that they were trying to prove (that vitamin D cures or prevents something) is not shown by their research. Indeed, such minor things are pounced on by a public that wants to see what isn’t there; he gives this example:

the authors of the VITAL trial, which found that vitamin D supplements had no effect on the primary endpoint of invasive cancer or cardiovascular disease, published a secondary analysis of the trial looking at a different endpoint: a composite incidence of metastatic and fatal invasive total cancer. They reported a 0.4% lower rate for the vitamin D group, a difference that barely made statistical significance at a P value of .04. 

But everyone [he says; I think he means physicians and scientists] knows the dangers of reanalyzing data with a new endpoint after you have seen the data. What's more, even if this were a reasonable post hoc analysis, the results are neither clinically meaningful nor statistically robust.  Yet the fatally flawed paper has been viewed 60,000 times and picked up by 48 news outlets. [emphasis mine].

Think about that. It is not what is proven to be true that gets the most coverage, it is what is most provocative. And clearly, this is not just about vitamin D. COVID and the COVID vaccines are common and prevalent examples of people choosing to believe something and then picking and choosing research that supports it; they even call this “doing their own research”. Some of this is the result of religious-like devotion to a position or point of view, some is purposely malicious, some is conspiracy theory, and some is honestly being overwhelmed by data that they do not understand. But it sure can be very dangerous. You deciding that COVID is not a risk anymore (if ever) and you don’t need to be vaccinated and don’t need to wear a mask is dangerous to me!

If over 95% of climate scientists agree that human activity, especially the burning of fossil fuels, is the cause of global warming, but many people do not believe it, why would we think the kinds of foods we eat, the benefits (or not) of taking high doses of a vitamin, the risk of a pandemic virus, the benefit of vaccination, would not be controversial? I would like to agree with Dr. Mandrola that there is hope, but I am sometimes not sure.

In the meantime, get vaccinated, eat very little sugar, and do not overdose on vitamin D, which can absolutely happen.

 

The Texas Abortion Law is contrary to women, to science, and to human values

The new Texas abortion law and the Supreme Court tacit endorsement of it is the latest (as of this writing – there will be more!) assault on science, medicine, and the will of the people, in an almost unbroken string of such actions. Another example of this process is the effort to spread COVID by opposing mandates for masking, vaccination, or social distancing, under the pretense of “individual liberty”, by a variety of jurisdictions, mostly at the state level and mostly in Republican-controlled states.

First, a quick review: the Texas law prohibits abortions after 6 weeks without exceptions for anything, including rape and incest, or ability of the fetus to survive outside the womb. It employs a cute (in the sense that the term “cute” can be applied to, say, a giant, mean, ugly, evil, violent ogre) trick to try to get around potential lawsuits that would be based on fact that the Roe v. Wade decision gives women a Constitutional right to abortion. The law does not mandate that state officials enforce it. Instead, anyone, from any state, is empowered to be a “whistleblower” and turn in anyone enabling the abortion (doctor, nurse, counselor, taxi driver) with the potential reward of $10,000 (from the state, of course) if successful.

Neat, huh? The Supreme Court majority thought so too, and, using another trick (called the “shadow docket”) declined to invalidate it. This method obviates the need for a hearing, presentation of arguments on either side, questions from the justices, and thought-out opinions which present the reasoning of the majority and the dissenters. It thus does not require the identification of those voting in the majority (we only know in this case that it was 5-4 and who the 5 and 4 were because each of the 4 issued their own dissenting statement). It also does not allow the lower courts to know what the reasons and arguments were, resulting in inconsistent interpretation of the decision by those courts. This, of course, was on purpose. Justice Sotomayor (one of the 4) put it succinctly “The court has rewarded the state’s effort to delay federal review of a plainly unconstitutional statute, enacted in disregard of the court’s precedents, through procedural entanglements of the state’s own creation.”

Several of the justices who created this problem have defended their action, and Justice Alito, in a speech at Notre Dame, not only defended the shadow docket but portrayed himself and the other members as the actual victims. This is another neat trick, which has been employed by the right, including former president Trump, and billionaires and corporations who have been criticized for such things as underpaying their workers and not paying taxes. The best defense, it is said, is a good offense.

 Let’s review the science:

1.      a large percentage of pregnant women do not even know that they are pregnant, particularly if they usually have irregular periods, before 6 weeks,

2.      the assertion in the Texas law that the fetus has a heartbeat at 6 weeks, thus why they chose that timeframe, is incorrect. In fact, the embryo is not even a fetus at 6 weeks.

There is in fact a lot more relevant science, but let’s move on, since the science is only an issue for those of us who believe in it.

The reason for the restrictive abortion law in Texas (and all the other states’) is not in the least because they have any respect for science or medicine. For different individuals, of course, there are different reasons. For some it is because of their religious beliefs, Catholic or otherwise, that all life is sacred and thus abortion is murder. That this may result in the death of the mother, or that it should then require the same level of commitment to helping the parents ensure that children have a reasonable chance at life (housing, food, clothing, education) may be positions supported by some Catholics, including the current Pope, but is not a corollary of opposition to abortion for most of these people. This is important, because in the case of taking a human life by say, murdering them with a gun, the public is not empowered to sue anyone who might have enabled them, like the gun dealers or manufacturers.

For others, the abortion restrictions are, explicitly or not, about restricting the rights of women and relegating them to their place. This is so essentially the results of such laws and policies that denial of it is virtually always disingenuous. Even those who take the “life is life” Catholic anti-abortion position find themselves in this situation (arguably, this position on women is part of the justification by an entirely male-run church). None of these laws or policies create any penalty or responsibility for the male whose role in creating the pregnancy was central. And 100% of unintended pregnancies are directly caused by men.

Finally, the reason for these laws is political. They garner support for a generally right-wing, pro-corporate political agenda from those who would not support it as such. This trend has always been part of US politics, but more explicitly so since Richard Nixon. Ultimately, of course, whatever the ostensible position of any individual is, the issue is essentially about politics. You put together a coalition, and then you implement the laws you want to. Make no mistake, this is what it is about. Nationally, a large majority of Americans oppose overturning Roe v. Wade (about 60%). In individual states, it may differ. A good history of the right-wing of the GOP looking for an issue that would mobilize the evangelical community in support of them, and their segregationist, pro-corporate agenda, is found in a recent issue of Politico. Abortion turned out to work after other issues didn’t, despite evangelical ambivalence on the issue at the time.

For nearly two decades, [right-wing activist and segregationist Paul] Weyrich, by his own account, had been trying out different issues, hoping one might pique evangelical interest: pornography, prayer in schools, the proposed Equal Rights Amendment to the Constitution, even abortion. “I was trying to get these people interested in those issues and I utterly failed.”

To the extent that the Texas anti-abortion law is about a rejection of science to achieve a political or religious or misogynist agenda, it is not entirely a separate issue from COVID and opposition to mask or vaccination or distancing mandates. The politicians want what they want – mainly power – and are willing to pander to whoever to get it, even fomenting anti-science agendas. Truth no longer matters, and it has gotten beyond an abstract concept to the point where people are dying, and yet others are still unwilling to believe in the cause-and-effect. A recent article in Rolling Stone notes that in parts of Oklahoma, hospitals are not only full of people with COVID and its complications but with people who are overdosing on ivermectin, an anti-parasitic drug that has widely -- and falsely – been promoted as a treatment for COVID. Since ivermectin requires a prescription for people (and it is indicated for certain kinds of worm infestations and actually does work to treat scabies), people are buying it at feed stores where it is sold for deworming horses! If the RS article is correct, many of these hospitals are even too full for gunshot victims!

COVID is a virus, and one that mutates and evolves (whether you believe in evolution or not) and can create more dangerous strains like the Delta variant. It is infectious. Immunization offers great, if not perfect protection; while it is possible to get infected after being immunized, it is less likely and, more important, it is much less likely that you will be hospitalized, ventilated, and die. This is  a fate reserved almost exclusively for the unvaccinated. Masks do help, although they are better at protecting others from being infected by you than protecting you from others – this is why OTHER people wearing masks makes a difference. This is science. On abortion – a “6 week” pregnancy is measured since the last menstrual period, which could easily mean 4 weeks since ovulation, 2-3 weeks since fertilization, and less since implantation, not to mention a positive pregnancy test. A very high percent of women don’t yet know that they are pregnant.

Scientific answers are arrived at through experimentation and re-experimentation; “truth” changes as more information becomes available. It is messy, not simple and easy to understand like a “belief”, or something you read on the internet. If it is one-dimensional and simple it is probably wrong.

But more important, it is usually out there to accomplish another agenda.