Sunday, January 27, 2013

Dr. Oz, Dr. Block and Donuts. Can You Trust Them?

To paraphrase an old English saying, "You can trust a man by the company he keeps." If we accept this notion, then it must also be fair to say a man can be judged trustworthy by considering those in whom they implicitly trust.

On his show last week, Dr. Oz said he "implicitly" trusts Rovenia Brock, a nutritionist with a PhD from Howard University. He made these comments in response to Dr. Brock's statement that it was okay to consume a sweet for breakfast in order to lose weight. She claimed she based her statement on studies that supported her.  In fact, she offered a donut as an example of a sweet that could be consumed and Dr. Oz said he trusted her judgment. (Let's not forget this is the same Dr. Oz who says people should eat regular ice cream. See my previous blog on the topic.)

Before we tackle the question of which study or studies, if any, support this statement, let's analyze the substance of donuts for a moment.  Donuts come in different shapes, sizes, and flavors. There are glazed donuts, cream filled donuts, sugar-coated donuts, etc. Donuts are often fried.  Most donuts have somewhere between 200 and 400 calories with fat often comprising half of the calories. Dr. Brock made no distinction between the type of donut she was recommending and Dr. Oz asked for no clarification. He simply stated he trusted her.

Now let's look at the science.  In the journal Steroids, a paper was published based on research done in Israel that included 193 obese (BMI 32.2±1.0kg/m(2)), sedentary non diabetic adult men and women (47±7years) who were randomized to a low carbohydrate breakfast (LCb) or an isocaloric diet with high carbohydrate and protein breakfast (HCPb). (To read about the study, cut and paste this url: Meal timing and composition influence ghrelin levels, appetite scores and weight loss maintenance in overweight and obese adults.)

During the study, both groups of subjects consumed the same amount of total daily calories, except one group consumed more calories during breakfast than during other meals. These calories came from both proteins and carbohydrates.  This loading of mixed calories to breakfast resulted in subsequent greater weight loss than those who balanced out calories during the day.

Carbohydrates come in several forms. There are simple and complex carbohydrates and there is soluble and insoluble fiber. A whole grain cereal can be high in both carbohydrates and fiber.  Fiber can be expected to increase a sense of fullness. In fact, a previous study showed that consuming cereal for breakfast results in greater net weight loss. (To read about the study, cut and paste this url:  Dietary intake of whole and refined grain breakfast cereals and weight gain in men.)

So the question is how did Dr. Brock and Dr. Oz make the leap from the Israeli study (which is the only study available to show such results) to declaring on national television that it is okay to consume a donut for breakfast if you want to lose weight.

By the way, at no time did he or she add that doing so required less calorie consumption later in the day. Rather, they implied that doing so would result in less calorie consumption during the day, a fact not supported by the study that required specific adherence to a strict calorie count. The study did show that a larger breakfast with protein and carbohydrates increased satiety for the rest of the day. Wow, imagine that. Eating a big breakfast may make you less hungry later in the day. Where's the news in that? Nevertheless, the study never said you should use fatty donuts as a source of your carbohydrates, so don't.

Furthermore, the researchers did not study what results would be obtained if the breakfast only included protein without carbohydrate. A recent study done in England and published in the European Journal of Nutrition showed that, in fact, consuming protein for breakfast offered more satiety than carbohydrates (in the form of a croissant and orange juice), with ingesting the protein alone resulting in lower subsequent calorie consumption during lunch and dinner. (To read about the study, cut and paste this url: Variation in the effects of three different breakfast meals on subjective satiety and subsequent intake of energy at lunch and evening meal.)

So why did Dr. Brock and Dr. Oz use donuts as an example.  In my opinion, it's TV ratings, pure and simply.  If they had said you should eat more whole grain cereal as a source of carbohydrate, no one would notice. But say you can eat a donut for breakfast to lose weight and that becomes newsworthy and sensationalistic; people take note.

One can only wonder how many Dr. Oz disciples hastened to follow the show's advice and will now add a donut to their breakfast routine. Poor, misguided souls.

So to answer the question posed in the title, should you trust Dr. Oz and Dr. Brock, I say no. You cannot trust their advice on donuts, and once you can't trust one thing they say, you make the decision regarding what you can trust.

If you want to include carbohydrates in your breakfast meal and want to satisfy your sweet tooth, then include a naturally sweetened, healthy, non-preservative muesli and leave the donuts to mortals foolish enough to take advice from doctors who have sold out to celebrity and TV ratings.

Saturday, January 26, 2013

Do Homeopathy and Botanicals Work? That Depends On How One Defines Work.

Virtually every day, I meet new patients who swear by their supplements. Oftentimes, they are conventional pills such as multivitamins, Vitamin D, fish oil, probiotics, etc. Once in a while, patients bring in products that I have never encountered.  This week it happened twice.  In each case, the patients conveyed a story about the effectiveness of the product in solving a problem that traditional medication could not, or that the product solved the problem with less side effects.

The two products this week were Rhus Tox and Ambrotose. Unfamiliar with these products, I immediately initiated research, in particular, looking for scientific evidence to support their efficacy and safety.

Rhus Tox (short for Rhus Toxicodendron), I was surprised to learn, is a homeopathic tincture derived from Poison Ivy. My initial reaction was sheer amazement that a product could actually be made from Poison Ivy, which is a scourge to human skin. But the real question was did it work?  After a thorough search, I could find only one reliable study ever done to determine if the product offered any benefits over placebo. In a paper published in 1983 in Lancet, the British Journal, the results were unequivocal. Rhus Tox offers no benefits over placebo. (

Yet, my patient insisted that the product worked for her husband and allowed him to stop taking Tylenol for his arthritic pain. Confronted by such self-reported efficacy of products scientifically proven to not live up to their hype, I am always challenged by what to say to the patient. Should they be educated that the product offers no scientifically validated benefits and deprive them of the placebo effect they have been enjoying, or should good enough be left alone with recognition that homeopathic remedies are almost always harmless because they are super-diluted tinctures with virtually no trace of the original substance.  For me, although the choice is clear, it still always gives me pause. I feel that people who come to a doctor looking for answers deserve the truth and I make no exception.

The second product, Ambrotose, is a glycoprotein marketed by a multilevel marketing company called Mannatech. This product was presented to me by a very intelligent and articulate gentleman who claimed that the product boosted his immune system and kept him generally healthy.

He are some notes about glycoproteins copied from Wikipedia.

"Independent commentary

The opinion of independent glycobiologists is that the body cannot digest Ambrotose, as it lacks the enzymes needed.[9] Prominent glycobiologist Dr. Ronald Schnaar, PhD of Johns Hopkins School of Medicine[11] told 20/20 in a June 1, 2007 interview, "All of the sugar building blocks that we need in our body are made from the most common foods we eat."[12]
Hudson Freeze, PhD, leading glycobiologist at the Sanford-Burnham Medical Research Institute[13] said this about glyconutrients: "There are authentic, scientific studies that have looked at people drinking these kinds of materials, and it doesn't really do anything except increase flatulence."[12] Dr. Freeze is a member of the editorial board of Glycobiology, whose current editor-in-chief is Dr. Schnaar.[14] Schnaar and Freeze published a critique of Mannatech's products in Glycobiology in 2008, describing the lack of published clinical benefits of the "partially purified polydisperse plant polysaccharides" found in "Ambrotose Complex."[15]
In Glycobiology, another article described the potential for the public to be misled about the science of glycobiology by the nebulous "glyconutrient" term.[16] The authors' concern was that the public would be susceptible to the "scientific-sounding label" of glyconutrient, which may "generate a feeling of security and credibility...despite the lack of acceptance among many glycobiologists of the term." In November 2007, Science published an article in its "News Focus" section detailing the scientific controversy surrounding Mannatech.[17] It included criticisms and comments from glycobiologists, including Ajit Varki, Raymond Dwek, Gerald Hart, James Paulson, Hudson Freeze, and Ronald Schnaar."

I actually read these comments to the patient; he was surprised by the gravity of the criticism leveled against his favorite product. It will be interesting to follow if he discontinues its use. I hope so.

On another note, today I came across an organization called the Association for the Advancement of Restorative Medicine (AARM). Their tagline reads, "Restoring patient wellness. Building physician practices." By building physician practices, I presume they mean adding a new revenue stream to physician's pockets.  That tagline alone would give me hesitation to trust anything they say. Nevertheless, I noted on their website that they had published their first issue of a magazine they call "Journal of Restorative Medicine."  An extensive perusal of the first issue reveals mostly review articles about the clinical effectiveness of multiple botanical products in treating mainstream diseases. There were no original randomized controlled studies. No groundbreaking new studies. Just the same old dribble about how botanical products may be good substitutes for conventional medications.

I get it. Many botanical products have real medicinal benefits.  But when they do, don't you want to know the proper dosing, side effects, and contraindications just like with any other medication.  The problem is that very few of these products are ever subjected to rigorous scientific inquiry and validation. Accordingly, we shouldn't dismiss using such products out of hand when traditional medicine offers no real benefits or benefits that come at a high cost due to side-effects. However, we should not be inclined to trust anecdotal evidence or the common rephrase that "it's been used for centuries by Chinese practitioners." We need clinical evidence! Is that too much to ask? 

The continuing economic pressures on a physician's income are leading many to consider practice enhancers to embellish their livelihoods.  These enhancers, almost never subject to government regulations, are therefore poorly regulated.  Financial incentives can skew good decision-making even among honest practitioners. Therefore, I always caution my patients, blog readership and listening audiences to be wary of doctors who offer additional fee for service products and services not typically covered by insurance.  There's often, but not always, a good reason why insurance will not pay for something. It's often because it doesn't actually confer any benefit. 

Don't get me wrong. I'm not defending reimbursement decisions made by insurance companies. They are also often driven by financial concerns and don't always look out for their customers best interests. But most Americans don't expect the same morality from an insurance company as they do from a physician. Physicians should be held to a higher standard. However, unfortunately this problem is increasing. Eager to spruce up their income, many doctors are embracing products related to anti-aging, regenerative, restorative, and functional medicine, still largely unproven fields, and these same physicians sell related products without the same scientific validation they were taught to confirm in medical school.  Although I don't know the statistic, I wonder how many of these doctors personally use and share with family members the same unregulated products they peddle to their patients.  So next time a doctor offers to sell you a product, ask him or her if all of their children also use the product.  Although it would not prove anything, exposing their own children would be a pretty good testament.

Otherwise, Caveat Emptor, (Latin for let the buyer beware).