I Just Don't Know

Today's blog has two parts and thought-trains.

Part 1

I typically don't read Glamour Magazine. However knowing my penchant for all things related to vitamins, my youngest daughter was delighted to share an article she came across in the magazine. The gist of the article were the responses from three experts to a question regarding the appropriateness of taking multivitamins after recent studies have suggested they may be harmful.

The first response came from a PhD who works at the Fred Hutchinson Cancer Research Center whose response was basically no, they are not needed. The second response came from a MD and professor of prevention at a Harvard teaching hospital who basically said no except in specific cases like folate during pregnancy shown to avoid birth defects. The third response came from Dr. Michael Roizen, the Chief Wellness Officer of the Cleveland Clinic who basically said yes because people don't eat good diets.

I was infuriated that he answered as he did. I met the man a little over a year ago when I visited the Cleveland Clinic in Ohio. The purposes of the trip was to explore partnership with him and the Clinic regarding my new prevention initiative. (For full disclosure, there were a number of subsequent conversations and correspondences after the trip as I vigorously pursued the opportunity. Eventually, however, I walked away because I found their terms of partnership to be highly lopsided.)

Notwithstanding, during the trip, I had an opportunity to speak to Dr. Roizen in privacy. During that time, which was relatively early in my auditing the field of prevention, I asked Dr. Roizen which dietary supplements he believed stood out among all others and that he would personally recommend for daily consumption. His list included baby aspirin, fish oil, probiotics, Vitamin D, and turmeric.

On the surface, it's not a bad list. Under the right set of circumstances, the first four have clear benefits. However, he did not know my medical history and therefore it was probably imprudent to him to make such specific recommendations, but then again I asked and he was happy to oblige. (Read more about this in part 2 of this blog.) 

For example, aspirin can prevent platelet aggregation (thereby decreasing blood clots) and some studies show some benefit in preventing colon cancer, but aspirin can also increase gastric bleeding and can lead to the development of macular degeneration. Given my history of gastric ulcer, aspirin is a tough choice.

One of my recent blogs dealt with fish oil at length, so just to summarize, its not the panacea everyone has made it out to be and given the option, eating fish like Wild Alaskan Salmon beats it hands-down.

Another one of my blogs dealt with probiotics and an extensive body of research supports my assertion that probiotics have no benefit if you have a generally healthy gut. They can be beneficial when taking antibiotics and when dealing with inflammation of the bowels, but they are not useful routinely.

Many people are apparently (I say apparently because no one knows for sure) Vitamin D deficient because of lack of sun exposure. However, treating anything on presumption, I believe is a mistake. First of all, many foods are fortified with Vitamin D so even though one does not get much sun exposure one is not necessarily deficient. Second, it is easy enough to check for a Vitamin D deficiency and by doing so the result will indicate if you there is a need to supplement and also how much should be taken.

So viewed in their entirety, the first four suggestions from Dr. Roizen were not outlandish as they generally do not cause harm (except for aspirin.) and may be beneficial at times. Tumeric, however, is another story.

Dr. Roizen told me that tumeric prevents Alzheimer's and is good for brain health. Based on Dr. Roizen's suggestion that day (and my hearing him repeat the same advice a few days later on the Retirement  Living TV channel), I naively purchased tumeric and began to add it regularly to my food.

Unfortunately, the highly staining substance turned my teeth bright yellow.  After this disconcerting turn of events, I began intensively researching tumeric and discovered two disturbing facts. First, tumeric has little validated science to support its use for the indications Dr. Roizen asserted. Second, I discovered that in the absence of a black pepper called piperine, tumeric is very poorly absorbed by normal ingestion and so adding it to my food was an effort in futility, except if turning my teeth yellow was my endgame. (By the way, I had to go to a dentist to get rid of the stain.)

Despite these five recommendations, I should have been even more wary of Dr. Roizen's advice when he also practically whispered to me, as to share a well-kept secret, that a certain statin drug had also been shown to decrease the development of Alzheimer's. The whispering should have been the giveaway. All statins are now widely accepted to have no efficacy for such purposes, but I suppose he was depending on some source of information to make his claim.

So now you know why it was disturbing for me to read about Dr. Roizen confidently disseminating advice about multivitamins.

Part 2

After reading Dr. Roizen's comments, I became curious about his background and read his bio available online. I find his credentials to be excellent.  I started thinking why a person like him would spew out what I believe is basically worthless, if not harmful advice, with such certainty. I also started thinking about Dr. Oz, a close friend of Dr. Roizen, (they've authored a number of books together and Dr. Roizen is an adviser to the Dr. Oz Show). Like Roizen, Oz's credentials are also top-notch.

Why, I asked myself, are such erudite men propagating such apparently bad advice about dietary supplements?  Why were they either ignoring or reaching different conclusions that I do from the numerous studies now widely available that show the dangers of dietary supplementation?

So let's assume for a moment that I am reaching the more valid conclusions. If so, what causes them to support the industry? Your first instinct may be to say money, but I dismiss money as the main motivator because I suspect they have already accumulated enough to live quite comfortably and I don't believe that for such distinguished and successful clinicians, it is the end to end all.

So what's the answer? I thought back to a recent episode of The Dr. Oz Show. The guest was a cryptographer (hand-writing expert). As part of the show, the expert analyzed a writing sample from Dr. Oz. His conclusion based on how Dr. Oz forms a wide-open at the bottom scripted 's.' was that this demonstrates that Dr. Oz is very susceptible to the opinion of others. Basically, he concluded that Dr. Oz's popularity stems from his genuine desire to please others. I think most people would agree that this is a pretty good trait to possess.

Let me preface my next comments by stating I have basically no training in psychotherapy. All that follows is conjecture. If you are interested, allow me to speculate why I think this trait of wanting to please others can be problematic especially for physicians in the limelight.

Most physicians are highly intelligent and possess a great deal of accumulated knowledge. Patients know this and expect doctors to be able to routinely answer their questions. However, the body of clinical knowledge, which continues to grow daily, is already far beyond anyone's grasp and that is why there are many specialties and sub-specialties in medicine.

For doctors in the limelight, however, they work hard to create a persona of all-knowing. They want to be viewed as saviors of sorts, able to help both small and wide audiences alike. They never want to disappoint by saying I don't know or I'm not sure.

This realization has caused me to think about my own approach. Until a few weeks ago, I grew more confident in my assertions and more provocative in my conclusions. Then a funny thing happened which I wrote about in another blog. During one of my lectures, an audience member challenged my statements virtually one by one. This forced me to recalibrate and make sure that everything I was saying was defensible. I think my conclusions were generally accurate, but generally was no longer good enough.  I realized after that talk that I was falling into the same trap that I think many before me have fallen into.  I realized that because almost nothing in regards to science can be said with absolute certainty, that it is not fair for someone who can get up and comfortably speak to an audience to assert otherwise.  A speaker should not be expected to always please his or her audience out of expediency if it is the truth that the audience needs and wants.

I believe that many of the doctors like Hyman, Oz, Roizen, etc, say what they say not because it will make them even more money; rather, because it will make their audiences like them more as they offer simple solutions to complicated problems. Some problems require the audience to work hard to accomplish effective solutions and promising quick fixes may be dangerous and inappropriate.

I promise to keep Mark Twain's words close to heart whenever I speak and write. Twain said "it's not what you know that gets you into trouble, it's what you know for sure that does."  Accordingly, as I continue to learn more about dietary supplements, I will work hard to report the facts (if they can be called as much), not my biases. I promise to answer "I just don't know" when that is the most appropriate answer. I think my patients and audiences deserve no less. What do you think?

Playing With Our Minds: The Placebo Effect

When I was in Spain last summer, I came across a chain of stores called Happy Pills. The store sold candy in prescription like bottles with cute sayings affixed. I learned from store management that they had 4 stores and I happened across two of them which seemed to be busy. Not a fan of candy, I wondered what would be a better replacement. Placebos came to mind. Of course, most placebos are in fact inert sugar pills so nutritionally they are no better than candy, but when it comes to medical studies, that's a whole different story.

It wasn't their taste, look, or nutritional content that piqued my curiosity about using placebos. It's the fact that I come across numerous randomized double blind controlled studies that use a placebo pill, injection, or sham procedure as the control and that actually show symptom improvement for both groups of subjects, including those receiving the placebo.

Three interesting studies comes to mind. One involved the use of placebo against counseling for the treatment of Irritable Bowel Syndrome (IBS). Performed by the Program for Placebo Studies at Harvard, fascinatingly, the placebo users who were told they were being given a placebo still showed marked improvement in their IBS related symptoms.

In a second Harvard study, placebo was compared against saw palmetto for prostate symptoms and the saw palmetto reduced symptoms by 30% while placebo reduced symptoms by 31%.

In a third study looking at the effects of Human Chorionic Gonadotropin (HCG), the weight loss drug, placebo was administered in the form of injections. Both parties showed identical weight loss due to the accompanying low calorie diets.

So placebos clealry have clinical effectiveness. Why? Our minds are very susceptible to suggestion. The word placebo is a Latin word which means "I shall please." How apropos as that is what it seems to often do. In fact in 1811, placebos were defined as "any medicine adapted more to please than to benefit the patient."    

One could write a book about the placebo effect and in fact, Henry Beecher did in 1955 titled The Powerful Placebo. Since that time, there have been numerous studies, including a Cochrane Review of their effects.  They seem to be most effective in illnesses that are thought to involve some psychological elements such as pain, depression, chronic fatigue syndrome, and gastric disturbances. There is disagreement if placebos work for everyone and that debate rages on.  There are also medical ethical questions regarding their use, but even here there is no clear consensus. Sometimes the ingredients in a placebo, which are meant to be inert, can actually be responsible for negative effects which is called nocebo.  Some women even demonstrated withdrawal symptoms when taken off placebo for a hormone replacement trial.

There can be no doubt that the placebo effect is real in terms of subjective patient reporting of improved symptoms and therefore placebo use can be reasonably claimed to sometimes provide real clinical benefit under the right circumstances. Other times, placebos have shown no effect, particularly as related to objective measurements such as blood pressure.

Some doctors have been known to use placebos to fend off unreasonable requests from patients. For example, a doctor sees a patient with what he diagnoses to be a viral illness that will not respond to antibiotics.  The patient nevertheless insists on taking antibiotics. It has been reported that some doctors have resorted to using placebos in such a case. The ethics of doing so can be reasonably debated but such practice has been reported as high as 60% in some countries.

One of the biggest arguments used by supplement marketers is that even if supplements provide no physiological benefit, then perhaps they still provide some psychological benefit. This may be true, but I think it is a dangerous premise. Supplements are usually used in a preventive nature--to prevent disease.  Relying on supplements can lead one not to take proper care of one's health and therefor such logic can lead to dire consequences. Some describe this as the licensing effect in which the belief that supplements are protective leads one to engage in otherwise unhealthy behaviors such as eating poorly or excessively.

I think placebos have their place, but it's a case by case basis. I suspect they will be around for a long time and will continue to be widely used in medical studies. I'm also sure that someday, someone will open a retail shop specializing in placebos and will make lot of money off of unwary or bemused shoppers. That person will not be me.