Category Archives: Medical Information: Good and Bad Sources

Marketing Medicine, Changing Practice, And Groping Watchmen at the American College of Cardiology Meetings

In March, the skeptical cardiologist attended the annual Scientific Sessions of his professional organization, the American College of Cardiology. This year’s meeting was held in Orlando, a city which, for me, holds little allure beyond milder March temperatures than St. Louis.

The meetings are termed Scientific Sessions because lots of science is presented and discussed. The results of the latest, most important and “practice-changing” studies on cardiovascular drugs, devices, and diseases are released to much ballyhoo.

They take place in massive soul and leg muscle-sucking convention centers, where one typically has to hike several thousand meters to get from one presentation to another.

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The Orange County Convention Center-the second largest in the U.S., offering 7,000,000 sq. ft. of space, wifi everywhere, and the opportunity to garner 10,000 steps going from one room to another.

Medical science is best when not adulterated by commercial interest, but the ACC meeting is blanketed by advertisements for the latest (consequentially most expensive) and greatest (hopefully) life-saving drugs and devices.

A feature of these meetings is the draping of the escalators with drug marketing material. Look! Repatha now approved for a new indication!

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I used an app provided by the ACC to find sessions I was interested in, plan my itinerary and to interact with presenters. Quite irritatingly, every time I opened the app, I was presented with a commercial for, you guessed it, Repatha, one of two new (and really expensive) PCSK9 inhibitors.img_1022

I was so irritated by this advertising intrusion into my app use that I totally failed to find out what the new indication for Repatha was. (It was to prevent heart attacks and strokes, something the FDA decided in December, 2017, after reviewing the outcomes data from the FOURIER trial presented at the ACC last year (I listed this as #3 of my top cardiology stories of 2017).

Booth 1807 was in the sprawling “Expo” area of the conference, where drugmakers and device makers compete for the attention of cardiologists by offering espresso-based beverages, free nitrogen ice cream, made to order cannolis (the definite favorite of the Eternal Fiancee’, herself working the Expo for Scimage) and occasional kitsch, like rubber bouncy balls that light up when they hit a hard surface.

Typically, I avoid the cannoli and cappuccino but seek out the oddest opportunity to be seduced by the dark side.

One day I ventured into the Expo area to explore how companies were promoting their products in 2018 and before I knew it I was inside a heart,  grasping a left atrial appendage occluder.

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The skeptical cardiologist standing on the interventricular septum while occluding the left atrial appendage. This is how I ACC!

The Watchman device I was grasping has been approved for preventing stroke in patients with atrial fibrillation who are at high risk and can’t, or won’t, take blood thinners. Boston Scientific has been flying cardiologists to various cities for the last year to wine and dine them and fill them full of reasons to send their patients for the device. Thus far I have avoided going on such a boondoggle. (Read John Mandrola’s skeptical take on Watchman here).

If you didn’t get the message about Repatha from the app or the escalators, there were frequent presentations from investigators at various sites in the Expo floor.

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A lipid expert explaining why cardiologists should be prescribing cholesterol lowering PCSK9 inhibitors. Note the towering graphic “High LDL. Prior CV Event? Time to Act!”

The presenters are typically experts in the field, but are handsomely compensated for their time. Consequently, one cannot rely on this being unbiased information, so I avoid these like the plague. To the ACC’s credit, such presentations do not qualify for CME credit, and are labeled as industry-sponsored.

Despite my irritation with constant marketing and advertisements, and the bias these things introduce into cardiology practice, I get a lot out of attending the ACC sessions.

Full participation allows me to accumulate 34 hours of continuing medical education (CME), hours which I need to maintain certification in the various fields I specialize in, such as echocardiography, nuclear cardiology, vascular imaging, and coronary CT angiography.

I usually find several presentations which advance my knowledge base or change my viewpoint, and how I practice cardiology. This is ultimately good for my patients. I wrote about three of these for Medpage Today here. Consider reading the article, if only to experience the wonder that is the new and large photo of the skeptical cardiologist.

I’ll share some other thoughts from the meetings as time allows. Until then I remain

Skeptically Yours,

-ACP

 

 

 

The Bad Food Bible: A Well-Written, Sensible and Science-Based Approach To Diet

The skeptical cardiologist has been searching for some time for a book on diet that he can recommend to his patients. While I can find books which have a lot of useful content, usually the books mix in some totally unsubstantiated advice with which I disagree.

I recently discovered a food/diet/nutrition book which with I almost completely agree. The author is Aaron Carroll,  a pediatrician, blogger on health care research (The incidental Economist) and a Professor of Pediatrics and Associate Dean for Research Mentoring at Indiana University School of Medicine.

He writes a regular column for the New York Times and covers various topics in health care. His articles are interesting,  very well written and researched and he often challenges accepted dogma.

Like the skeptical cardiologist, he approaches his topics from an unbiased perspective and utilizes a good understanding of the scientific technique along with a research background to bring fresh perspective to health-related topics.

Last last year he wrote a column, within which I found the following:

Studies of diets show that many of them succeed at first. But results slow, and often reverse over time. No one diet substantially outperforms another. The evidence does not favor any one greatly over any other.

That has not slowed experts from declaring otherwise. Doctors, weight-loss gurus, personal trainers and bloggers all push radically different opinions about what we should be eating, and why. We should eat the way cave men did. We should avoid gluten completely. We should eat only organic. No dairy. No fats. No meat. These different waves of advice push us in one direction, then another. More often than not, we end up right where we started, but with thinner wallets and thicker waistlines.

I couldn’t agree more with this assessment and as I surveyed the top diet books on Amazon recently, I saw one gimmicky, pseudoscientific  diet after another. From the Whole30 approach (which illogically  completely eliminates any beans and legumes, dairy products,  alcohol, all grains, and starchy vegetables like potatoes (see how absurd this diet is here)) to Dr. Gundry’s Plant Paradox (aka lectin is the new gluten (see here for James Hambling’s wonderful Atlantic article on the huckster’s latest attempt to scare you into buying his useless supplements).

It turns out Carroll published a useful book recently, The Bad Food Bible which critically examines diet and I agree with the vast majority of what is in it.

The first three chapters are on butter, meat, eggs and salt. His conclusions on how we should approach these 4 are similar to ones I have reached and written about on this site (see here for dairy, here for meat, here for eggs and here for salt).  Essentially, the message is that the dangers of these four foods have been exaggerated or nonexistent, and that consuming them in moderation is fine.

The remaining chapters cover topics I have pondered extensively,  but have not written about: including gluten, GMOs, alcohol, coffee, diet-soda and non-organic foods.

I agree with his assessments on these topics. Below, I’ll present his viewpoint along with some of my own thoughts in these areas.

Gluten

Carroll does a good job of providing a scientific, but lay-person friendly background to understanding the infrequent (1 of 141 Americans), but quite serious gluten-related disorder, celiac disease.

However, surveys show that up to one-third of Americans, the vast majority of whom don’t have celiac disease, are seeking “gluten-free” foods, convinced that this is a healthier way of eating. Carroll points out that there is little scientific support for this; there are some individuals who are sensitive to wheat/gluten, but these are rare.

He concludes:

“If you have celiac disease, you need to be on a gluten-free diet. If you have a proven wheat allergy, you need to avoid wheat. But if you think you have gluten sensitivity? You’d probably be better off putting your energy and your dollars toward a different diet. Simply put, most people who think they have gluten sensitivity just don’t.

I do agree with him that the “gluten-free” explosion of foods (gluten-free sales have doubled from 2010 to 2014) is not justified.

However, I must point out that my 92 year old father has recently discovered that he has something that resembles gluten sensitivity. About a year ago, he noted that about one hour after eating a sandwich he would feel very weak and develop abdominal discomfort/bloating. He began suspecting these symptoms were due to the bread and experimented with different bread types without any symptom relief.

Finally, he tried gluten-free bread and the symptoms resolved.

If you have engaged in this type of observation and experimentation on your self, and noted improved symptoms when not consuming gluten, then I think you’re justified in diagnosing gluten sensitivity, and by all means consider minimizing/avoiding wheat.

GMOS

Carroll begins his chapter on genetically modified organisms (GMOs) with a description of the droughts that plagued India in the 1960s and the efforts of Norman Borlaug to breed strains of wheat that were resistant to fungus and yielded more grain. By crossbreeding various strains of wheat he was able to develop a “semi-dwarf” strain that increased what was produced in Mexico by six-fold.

Despite the fact that numerous scientific and health organizations around the world have examined the evidence regarding the safety of genetically modified organisms (GMOs) and found them to be completely safe, there remains a public controversy on this topic. In fact a Pew Poll found that while 88% of AAAS scientists believe that GMOs are safe for human consumption, only 37% of the public do – a 51% gap, the largest in the survey.

This gap is largely due to an aggressive anti-GMO propaganda campaign by certain environmental groups and the organic food industry, a competitor which stands to profit from anti-GMO sentiments. There is also a certain amount of generic discomfort with a new and complex technology involving our food.

The National Academy of Sciences analyzed in detail the health effects of GMOs in 2016. Their report concludes:

While recognizing the inherent difficulty of detecting subtle or long-term effects in health or the environment, the study committee found no substantiated evidence of a difference in risks to human health between currently commercialized genetically engi-neered (GE) crops and conventionally bred crops, nor did it find conclusive cause-and-effect evidence of environmental problems from the GE crops. GE crops have generally had favorable economic outcomes for producers in early years of adoption, but enduring and widespread gains will depend on institutional support and access to profitable local and global markets, especially for resource-poor farmers

Carroll does a good job of looking at the GMO issue from all sides. He touches on environmental downsides related to herbicide-resistant GMO crops and the problems created by patenting GMO seeds, but asserts that “these are the result of imperfect farming and the laws that regular agribusiness, not of GMOS themselves.”

Ultimately, despite these concerns, I agree with Carroll’s conclusion that:

“Foods that contain GMOs aren’t inherently unhealthy, any more are  than foods that don’t contain them. The companies that are trying to see you foods by declaring them ‘GMO-free” are using the absence of GMOs to their advantage–not yours.”

Alcohol, Coffee, and Diet-Soda

Carroll does a good job of summarizing and analyzing the research for these three topics and reaches the same conclusions I have reached in regard to coffee, alcohol and diet-soda:

-alcohol in moderation lowers your risk of  dying, primarily by reducing cardiovascular death

-coffee, although widely perceived as unhealthy, is actually good for the vast majority of people

For those seeking more details a few quotes


on alcohol:

“Taken together, all of this evidence points to a few conclusions. First, the majority of the research suggests that moderate alcohol consumption is associated with decreased rates of cardiovascular disease, diabetes, and death. Second, it also seems to be associated with increased rates of some cancers (especially breast cancer), cirrhosis, chronic pancreatitis, and accidents, although this negative impact from alcohol seems to be smaller than its positive impact on cardiovascular health. Indeed, the gains in cardiovascular disease seem to outweigh the losses in all the other diseases combined. The most recent report of the USDA Scientific Advisory Panel agrees that “moderate alcohol consumption can be incorporated into the calorie limits of most healthy eating patterns.”

Keep in mind that moderate consumption is up to one drink per day for women, and two drinks for men (my apologies to women in general and the Eternal Fiancee’ of the Skeptical Cardiologist in particular) and be aware of what constitutes “one drink.”

Also keep in mind that any alcohol consumption raises the risk of atrial fibrillation (see here) and that if you have a cardiomyopathy caused by alcohol you should avoid it altogether.


on coffee:

“It’s time people stopped viewing coffee as something to be limited or avoided. It’s a completely reasonable part of a healthy diet, and it appears to have more potential benefits than almost any other beverage we consume.
Coffee is more than my favorite breakfast drink; it’s usually my breakfast, period. And I feel better about that now than ever before. It’s time we started treating coffee as the wonderful elixir it is, not the witch’s brew that C. W. Post made it out to be.”

Strangely enough, coffee is usually my breakfast as well (although I recommend against adding titanium oxide to your morning java).  Why am I not compelled to consume food in the morning?  Because breakfast is not the most important meal of the day and I don’t eat until I’m hungry.


on diet-soda:

Carroll notes that many Americans are convinced that artificial sweeteners are highly toxic:

“no article I’ve written has been met with as much anger and vitriol as the first piece I wrote on this subject for the New York Times, in July 2015, in which I admitted, “My wife and I limit our children’s consumption of soda to around four to five times a week. When we let them have soda, it’s . . . almost always sugar-free.”

He notes, as I have done, that added sugar is the real public enemy number one in our diets. He reviews the scientific studies that look at toxicity of the various artificial sweeteners and finds that they don’t convincingly prove any significant health effects in humans.

Some believe that artificial sweeteners contribute to obesity, but the only evidence supporting this idea comes from observational studies. For many reasons, we should not highly value observational studies but one factor, “reverse causation,” is highly likely to be present in studies of diet sodas. If diet soda consumption is associated with obesity, is it the cause, or do those who are obese tend to drink diet soda. Observational studies cannot answer this question but randomized studies can.

Carroll points out that:

the randomized controlled trials (which are almost always better and can show causality) showed that diet drinks significantly reduced weight, BMI, fat, and waist circumference.”

Simple Rules For Healthy Eating

Carroll concludes with some overall advice for healthy eating:

-Get as much of your nutrition as possible from a variety of completely unprocessed foods

-Eat lightly processed foods less often

-Eat heavily processed foods even less often

-Eat as much home-cooked food as possible, preparing it according to rules 1, 2, and 3

-Use salt and fats, including butter and oil, as needed in food preparation

-When you do eat out, try to eat at restaurants that follow the same rules

-Drink mostly water, but some alcohol, coffee, and other beverages are fine

-Treat all calorie-containing beverages as you would alcohol

-Eat with other people, especially people you care about, as often as possible

These are solid, albeit not shocking or book-selling, rules that  correspond closely to what I have adopted in my own diet.

In comparison to the bizarre advice from nutrition books which dominate the best-selling diet books, I found The Bad Food Bible to be a consistent, well-written, extensively researched, scientifically-based, unbiased guide to diet and can highly recommend it to my readers and patients.

Semibiblically Yours,

-ACP

Do Statins Cause Memory Loss? The Science, The Media, The Statin-Denialist Cult, and The Nocebo Effect

The Skeptical Cardiologist was recently contacted by a television reporter  working on a segment about statins. and looking for a cardiologist to interview who “is concerned about the cognitive side effects of these drugs.”

Since I regularly prescribe statin drugs to my patients to reduce their risk of heart attack and stroke,  I am very concerned about any possible side effects from them, cognitive or otherwise. However, in treating hundreds of patients with statins, I have not observed a consistent significant effect on brain function.

When the U.S. Food and Drug Administration (FDA) issued a statement in 2012 regarding rare postmarketing reports of ill-defined cognitive impairment associated with statin use it came as quite a surprise to most cardiologists.

The FDA made a change in the patient information on all statin drugs which stated:

Memory loss and confusion have been reported with statin use. These reported events were generally not serious and went away once the drug was no longer being taken

This FDA statement was surprising because prior observational and randomized controlled trials had suggested that patients who took statins were less likely to have cognitive dysfunction than those who didn’t.

Early studies implied that statins might actually protect against Alzheimer’s disease.

In fact these signals triggered two studies testing if statins could slow cognitive decline in patients with established Alzheimer’s disease  One study used 80 mg atorvastatin versus placebo and a second 40 mg simvastatin versus placebo and both showed no effect on the decline of cognitive function over 18 months.

More recently, multiple reviews and meta-analyses have examined the data and concluded that there is no significant effect of statins on cognitive function. Importantly, these have been written by reputable physician-scientists with no financial ties to the pharmaceutical industry.

 

Data Show No Evidence of Causality Despite Case Reports

The FDA added the warning to statin patient information based on case reports  Occasional reports of patients developing memory loss on a statin do not prove that statins are a significant cause of cognitive dysfunction.

Case reports have to  be viewed in the context of all the other scientific studies indicating no consistent evidence of negative effects of the statins. Case reports are suspect for several reasons:

First, patients receiving statins are at increased risk for memory loss because of associated risk factors for atherosclerosis and advancing age. A certain percentage of such patients are going to notice memory loss independent of any medications.

Second. The nocebo effect: If a patient taking a statin is told that the drug will cause a particular side effect,that patient will be more likely to notice and report that particular side effect.

A recent study in The Lancet looked at reported side effects in patients taking atorvastatin versus placebo and found substantial evidence for the nocebo effect.

Analysis of the trial data revealed that when patients were unaware whether they were taking a statin or a placebo, the number of side effects reported was similar in those taking the statin and those taking placebo. However, if patients knew they were taking statins, reports of muscle-related side effects in particular increased dramatically, by up to 41 per cent.

Third, a review of the FDA post-marketing surveillance data showed the rate of memory loss with statins is not significantly higher than for other non-statin cardiovascular medications (1.9 per million prescriptions for statins , 1.6 per million prescriptions for losartan) and clopidogrel (1.9 per million prescriptions for clopidogrel.)

What Most Media Prefer: Controversy And Victims

I thought my experience and perspective on statins and cognitive function might be useful for a wider audience of patients to hear so I agreed to be interviewed. After I expressed interest the  reporter responded:

I would like to interview you and also a person who has experienced memory and/or thinking problems that they attribute to statin use.  
 I responded with “let me see what I can find,”  although I was concerned that  this reporter was searching for a cardiologist to support attention-grabbing claims of  severe side effects of statins rather than seeking a balanced, unbiased perspective from a knowledgeable and experienced cardiologist.
If I produced a “victim” of statin-related memory loss this would boost ratings.
I then began racking my brain to come up with a patient who had clearly had statin-related memory loss or thinking problems. I asked my wonderful MA Jenny (who remembers details about patients that I don’t) if she could recall any cases. Ultimately, we both came up without any patients for the interview. (Any patient of mine reading this with definite statin memory loss please let me know and I will amend my post. However, I won’t be posting anecdotes outside of my practice.)
I have had a few patients relate to me that they feel like their memory is not as good as it was and wonder if it could be from a medication they are on.  Invariably, the patient has been influenced by one of the  statin fear-mongering sites on the internet (or a friend/relative who has been influenced by such a site.)
I wrote about one such site in response to a patient question a while back:
The link appears to be a promotional piece for a book by Michael Cutler, MD. Cutler’s website appears to engage in fear-mongering with respect to statins for the purpose of selling his books and promoting his “integrative” practice. I would refer you to my post entitled “functional medicine is fake medicine”. Integrative medicine is another code word for pseudoscientific medicine and practitioners should be assiduously avoided.
The piece starts with describing the case of Duane Graveline, a vey troubled man who spent the latter part of his life attempting to scare patients from taking statins. Here is his NY Times obituary.
You can judge for yourself if you want to base decisions on his recommendations.
There is no scientific evidence to suggest statins cause dementia.
An Internet-Driven Cult With Deadly Consequences
Steve Nissen recently wrote an eloquent article which accuses statin deniers of  being  an “internet–driven cult with deadly consequences.”  Nissen has done extremely important research helping us better understand atherosclerosis  and is known for being a patient advocate: calling out drug companies when they are promoting unsafe drugs.
I have immense respect for his honesty, lack of bias, and his courage to be outspoken .  He writes:

“Statins have developed a bad reputation with the public, a phenomenon driven largely by proliferation on the Internet of bizarre and unscientific but seemingly persuasive criticism of these drugs. Typing the term statin benefits into a popular Internet search en- gine yields 655 000 results. A similar search using the term statin risks yields 3 530 000 results. One of the highest-ranking search results links to an article titled “The Grave Dangers of Statin Drugs—and the Surprising Benefits of Cholesterol”. We are losing the battle for the hearts and minds of our patients to Web sites de- veloped by people with little or no scientific expertise, who often pedal “natural” or “drug-free” remedies for elevated cholesterol levels. These sites rely heavily on 2 arguments: statin denial, the proposition that cholesterol is not related to heart disease, and statin fear, the notion that lowering serum cholesterol levels will cause serious adverse effects, such as muscle or hepatic toxicity— or even worse, dementia.”

He goes on to point out that this misinformation is contributing to a low rate of compliance with taking statins. Observational studies suggest that noncompliance with statins significantly raises the risk of death from heart attack.

The reasons for patient noncompliance, Nissen goes on to say, can be related to the promotion of totally unproven supplements and fad diets as somehow safer and more effective than statin therapy:

“The widespread advocacy of unproven alternative cholesterol-lowering therapies traces its origins to the passage of the Dietary Supplement Health and Education Act of 1994 (DSHEA). Incredibly, this law places the responsibility for ensuring the truthfulness of dietary supplement advertising with the Federal Trade Commission, not the U.S. Food and Drug Administra-tion. The bill’s principal sponsors were congressional representatives from states where many of the companies selling supplements are headquartered. Nearly 2 decades after the DSHEA was passed, the array of worthless or harmful dietary supplements on the market is staggering, amounting to more than $30 billion in yearly sales. Manufacturers of these products commonly imply benefits that have never been confirmed in formal clinical studies.”

Dealing With Statin Side Effects In My Practice

When a patient tells me they believe they are having a side effect from the statin they are taking (and this applies to any medication they believe is causing them side effects), I take their concerns very seriously. After 30 years of practice, I’ve concluded that in any individual patient, it is possible for any drug to cause  side effects.  And, chances are that if we don’t address the side effects the patient won’t take the medication.

If the side effect is significant I will generally tell the patient to stop the statin and report to me how they feel after two to four weeks.

If there is no improvement I have the patient resume the medication and we generally reach a consensus that the side effect was not due to the medication.

If there is a significant improvement, I accept the possibility that the side effect could be from the drug. This doesn’t prove it, because it is entirely possible that the side effect resolved for other reasons coincidentally with stopping the statin. Muscle and joint aches are extremely common and they often randomly come and go.

At this point, I will generally recommend a trial at low dose of another statin (typically rosuvastatin or livalo.)  If the patient was experiencing muscle aches and they return we are most likely dealing with a patient with statin related myalgias. However, most patients are able to tolerate low dose and less frequent administration of rosuvastatin or Livalo.

For all other symptoms, it is extremely unusual to see a return on rechallenge with statin and so we continue statin long term therapy.

Today a patient told me he thought the rosuvastatin we started 4 weeks ago was causing him to have more diarrhea. I informed him that there is no evidence that rosuvastatin causes diarrhea more often than a placebo and had no reason based on its chemistry to suspect it would. (Although I’m sure there is a forum somewhere on the internet where patients have reported this). Fortunately he accepted my expert opinion and will continue taking the drug.

If the symptoms persist and the patient continue to believe it is due to the statin, we will go through the process I described above. And, since every patient is unique, it is possible that my patient is having a unique or idiosyncratic reaction to the statin that only occurs in one out of a million patients and thus is impossible to determine causality.

Since statins are our most effective and best tolerated weapon in the war against our biggest killer, it behooves both patients and physicians to have a high threshold  for stopping them altogether. Having such a high threshold means filtering out the noise from attention-seeking media and the internet-driven denials cult thus minimizing the nocebo effect

Antinocebonically Yours

-ACP

N.B. It turns out the reporter had an open mind about the issue of statin-related memory loss. We had a good discussion  and at some point you may see the skeptical cardiologist on TV being interviewed on the topic.

I could bring to the interview one of  my many patients who since starting to take statins have  not had a heart attack or stroke and who have taken statins for decades without side effects.

Now that would make for some compelling and exciting TV!

For a nice discussion of Nissen’s article see Larry Husten’s excellent piece at Cardiobrief.org here (/nissen-calls-statin-denialism-a-deadly-internet-driven-cult/)

 

Quackery Promotion By Mainstream Media: Part I, Reader’s Digest and Naturopathy

As the skeptical cardiologist surveys the heart health information available to his patients and the lay public, he sees two broad categories of misinformation.

First we have the quacks and snake oil salesman. These are primarily characterized by a goal of selling more of their useless stuff online.

I’ve described this as the #1 red flag of quackery. Usually I’m inspired to investigate these charlatans because a patient asks me about one of their useless supplements.

The second category is more insidious: the magazine or internet news site seems to have as its legitimate goal, promoting the health of its readers. There is no clear connection to a product.

Web MD, which I wrote about here, is an example of this second type.  Hard copy versions of these types of media frequently make it into doctor’s waiting rooms: not because doctor’s have read and approved what is in them. These companies send their useless and misleading magazines for free to doctor’s offices, and the staff believe it to be legitimate.

How does glaringly inaccurate and often dangerous information get into media that ostensibly has as its goal promoting its readers health? Most likely, it is a result of media’s need  to constantly produce new and interesting ways for readers to improve their health.

Clearly, readers will not continue subscribing, clicking and reading such sources of information if there isn’t something new and exciting that might prolong their lives: gimmicks, miracles cures, and “natural” remedies are more alluring than the well-known advice to exercise more, watch your weight, stop smoking and get a good night’s sleep.

Reader’s Digest and Stealth Quackery

A patient recently brought in a printout of Reader’s Digest’s “40 things cardiologists do to protect their heart” which is typical of the second category.

Reader’s Digest was a staple of my childhood. My parents subscribed to it consistently and I would read parts of it. It was small and enticing. Allegedly its articles were crafted so that they could be read in their entirety during a session in the bathroom.

To this day it has a wide circulation. Per Wikipedia”

The magazine was founded in 1920, by DeWitt Wallace and Lila Bell Wallace. For many years, Reader’s Digest was the best-selling consumer magazine in the United States; it lost the distinction in 2009 to Better Homes and Gardens. According to Mediamark Research (2006), Reader’s Digest reaches more readers with household incomes of $100,000+ than Fortune, The Wall Street Journal, Business Week, and Inc. combined.[2]

Global editions of Reader’s Digest reach an additional 40 million people in more than 70 countries, via 49 editions in 21 languages. The periodical has a global circulation of 10.5 million, making it the largest paid circulation magazine in the world.

Reader’s Digest used to run a recurring educational feature on the various body parts and organs of Joe and Jane which intrigued me.

Here’s the first paragraph of “I am Joe’s heart:”

I am certainly no beauty. I weigh 340 grams, am red-brown in color and have an unimpressive shape. I am the dedicated slave of Joe. I am Joe’s heart.

The health information in this series was generally accurate but the presentation lacks the kind of sizzle that apparently attracts today’s readers.

The article my patient brought to my attention is typical of the mix of good and bad information and fluff that mainstream media can produce to attract followers:

Not So Bad But Not Clearly True Medical Advice

#1. I keep a gratitude journal. An internist “at NYU” is quoted as saying: “Studies have recently shown that expressing gratitude may have a significant positive impact on heart health.”

Fact Check: following the links provided provides no evidence to support this claim.

#2  I get 8 hours of sleep a night, every night.  This cardiologist seems to have been misquoted, because her comment is actually “getting a good night sleep is essential. I make a point of getting seven to eight hours of sleep every night…Poor sleep is linked to higher blood pressure.”

Fact Check. One review noted that:

Too little or too much sleep are associated with adverse health outcomes, including total mortality, type 2 diabetes, hypertensionand respiratory disorders, obesity in both children and adults, and poor self-rated health.

Another broke down mortality according to number of hours of sleep.

A J-shaped association between sleep duration and all-cause mortality was present: compared with 7 h of sleep (reference for 24-h sleep duration), both shortened and prolonged sleep durations were associated with increased risk of all-cause mortality (4 h: relative risk [RR] = 1.05; 95% confidence interval [CI] = 1.02–1.07; 5 h: RR = 1.06; 95% CI = 1.03–1.09; 6 h: RR = 1.04; 95% CI = 1.03–1.06; 8 h: RR = 1.03; 95% CI = 1.02–1.05; 9 h: RR = 1.13; 95% CI = 1.10–1.16; 10 h: RR = 1.25; 95% CI = 1.22–1.28; 11 h: RR = 1.38; 95% CI = 1.33–1.44; n = 29; P < 0.01 for non-linear test)

Thus, in comparison to those who sleep 7 hours, those who sleep 5 hours have a 5% increase in mortality and those who sleep 11 hours have a 38% increase in mortality.

These data are based entirely on observational studies so it is impossible to know if the shortened sleep is responsible for the increased mortality or if some other (confounding) factor is causing both.

My advice: Some people do fine with 6 hours and 45 minutes of sleep. Some require 8 hours 15 minutes for optimal function. Rather than obsessing about getting a specific amount of sleep time, it makes more sense to find our through your own careful observations what sleep time works best for you and adjust your schedule and night time patterns accordingly.

#3. I do CrossFit.

Fact Check. There is nothing to support CrossFit as more heart healthy than regular aerobic exercise (which the vast majority of cardiologists recommend and perform).

#4. I meditate. “Negative thoughts and feelings of sadness can be detrimental to the heart. Stress can cause catecholamine release that can lead to heart failure and heart attacks.”

Fact Check. There is a general consensus that stress has adverse consequences for the cardiovascular system. Evidence of meditation improving cardiovascular outcomes is very weak.

A recent review

Participation in meditation practices has been shown to reduce depression, anxiety, and negative mood and thus may have an indirect positive effect on CV health and well-being. This possibility has led the American Heart Association to classify TM as a class IIb, level of evidence B alternative approach to lowering BP.32

Non randomized, non blinded studies with small numbers of participants have suggested a reduction in CV death in those performing regular TM.

However, we need better and larger studies before concluding there is a definite benefit compared to optimal medical therapy.

Thus far, the recommendations have been pretty mundane: exercise, stress reduction and a good night’s sleep is good advice for all, thus boring.

Seriously Bad Advice From Quacks Mixed In With Reasonable Advice

In order to keep reader’s interest (and reach 45 things) Reader’s Digest is going to need to add seriously bad advice.

My patient had circled #34. “I mix magnesium powder into my water. If sufficient magnesium is present in the body, cholesterol will not be produced in excess.”

This bizarre and totally unsubstantiated practice was recommended by Carolyn Dean MD, ND.

What do we know about Dr. Dean?

-She was declared unfit to practice medicine and her registration revoked by the College of Physicians and Surgeons of Ontario in 1995. From quackwatch.org :

  • After being notified in 1993 that a disciplinary hearing would be held, Dean relocated to New York and did not contest the charges against her.
  • Dean had used unscientific methods of testing such as hair analysis, Vega and Interro testing, iridology and reflexology as well as treatment not medically indicated and of unproven value, such as homeopathy, colonic irrigations, coffee enemas, and rotation diets.

-The initials after her name (ND, doctor of naturopathy) should be considered the second red flag of quackery. See quackwatch.org (here) and rational wiki (here) and the confessions of a former naturopath  (here ) for discussions of naturopathy. As noted at science-based medicine:

Naturopathy is a cornucopia of almost every quackery you can think of. Be it homeopathy, traditional Chinese medicine, Ayurvedic medicine, applied kinesiology, anthroposophical medicine, reflexology, craniosacral therapy, Bowen Technique, and pretty much any other form of unscientific or prescientific medicine that you can imagine, it’s hard to think of a single form of pseudoscientific medicine and quackery that naturopathy doesn’t embrace or at least tolerate.

-She has a website (Dr. Carolyn Dean, MD,ND, The Doctor of The Future) where she incessantly promotes magnesium as the cure for all ills.

-She has written a book called “The Magnesium Miracle” (hmm. wonder what that’s about).

-She sells her own (really special!) type of magnesium (see red flag #1 of quackery).

-She writes for the Huffington Post (I’m considering making this a red flag of quackery).

-She is on the medical advisory board of the Nutritional Magnesium Association (an organization devoted to hyping magnesium as the cure for all ills and featuring all manner of magnesium quacks).

Prevention Magazine 

Reader’s Digest is not alone in allowing the advice of pseudoscience practitioners to stand side by side with legitimate sources.

For example, Prevention Magazine in its August 2017 issue highlights “35 All-Time Favorite Natural Remedies” with the subheading

“Go ahead, try them at home: Experts swear by these nondrug cures for back pain, nausea, hot flashes, and other common ailments.”

Who are these “experts”? Let the reader beware because the first quote comes from “Amy Rothenberg, past president of the Massachusetts Society of Naturopathic Doctors.”

Finding The Truth

It’s getting harder and harder for the lay public to sort out real from fake health stories and advice.

When seemingly legitimate news media and widely followed sources like Reader’s Digest and Prevention Magazine  either consciously or inadvertently promote quackery, the truth becomes even more illusive.

Readers should avoid any source of information which

  1. Profits from selling vitamins and supplements.
  2. Utilizes or promotes  naturopaths or other obvious quacks as experts in health advice.

IamJoesfootingly Yours,

-ACP

“Your Paper Really Attract Us”: Do Fake Scientific Journals Represent The Biggest Threat To Science Since the Inquisition?

When I was doing research in the field of echocardiography, and writing and publishing lots of research papers, there were only a few important cardiology journals that I wanted my papers published in.

It wasn’t easy getting my research published; after the paper was submitted, it was sent to two reviewers who critiqued it extensively and gave it  a thumbs up or down. Often, to satisfy the reviewers, I had to revise the manuscript multiple times, a process which could take months and months.

I knew once my work was published, however, that this heavy vetting process guaranteed that my paper appeared in a medium that was highly respected alongside similar important and well-vetted scientific work.

For the eighty-plus  papers that I published between 1987 and 1998, I paid not a dime, but I spent innumerable post-work hours reading, writing, and analyzing data.

In those years prior to the interweb, the process of researching a topic was laborious and time-consuming; I would spend hours in the medical libraries of various hospitals searching through the stacks of hard-bound medical journals for relevant articles. Once found, the very heavy tome containing the paper I needed would be lugged to a “Xerox” machine and copied.

I cannot recall one circumstance where a journal wrote to me asking me to submit a paper to them. The journals I published in were overwhelmed with high quality submissions from important scientists and only accepted a low percentage for publication.

The Rise of Open Access and Fake Scientific Journals

Unfortunately, we are now in an era of what I would term “fake scientific journals,” and in such journals it is quite easy to publish if one simply pays the asking price: somewhere between 150$ and 500$.

Publishers of these journals prey on scientists who are desperate to have their research published in order to survive in academia.

Jeffrey Beall, an academic librarian at the University of Colorado, Denver, noted the rise of this practice in 2008 and began researching what he termed “predatory journals.”  In a paper published in 2010 he wrote:

“These publishers are predatory because their mission is not to promote, preserve, and make available scholarship; instead, their mission is to exploit the author-pays, Open-Access model for their own profit.”

In 2012, Beall began listing (Beall’s list) predatory publishers and journals, and offered critical commentary on scholarly open-access publishing in a blog entitled  Scholarly Open Access.

Predatory journals have arisen in parallel with a change from print-only subscriptions to digitally available and free scientific publications.

It is important but often difficult to differentiate legitimate “open access” scientific journals from these profit-motivated sleazy journals.

A brief history of scientific publishing and the rationale for moving to open access publishing from Bowman:

Nature was first published in 1869, Science in 1880, and subsequently scientific journal publishing has increased to the point of a new paper being published every 20 seconds.1 In 2000, the future of scientific publishing was changed by the debut of PubMed Central and the Public Library of Science (PLoS). The next year, thousands of scientists called for a boycott of journals that would not allow free access on PubMed within 6 months. In 2002, for-profit Biomed Central began charging authors $500 to publish. In 2003, PLoS Biology was launched, charging authors $1500. By 2006, PLoS initiated the non-profit PLoS One, charged a $2500 author fee, and reviewed articles by placing scientific rigor over importance. In 2008, NIH mandated that papers published as a result of its funding be made free to the public within 12 months, and in 2009, the US Congress permanently required that all funded investigators submit electronic versions of their manuscripts to the National Library of Medicine’s PubMed Central.2 By 2010, PLoS generated revenues greater than costs and PLoS One became the world’s largest scientific publisher by volume.

My Brush With Fake Scientific Journals

From time to time since my days of research in academia, I have collaborated with medical residents at my hospital in writing what are termed “case reports.” These are descriptions of interesting patient cases and most prominent journals are not interested in publishing them.

However, I’ve noticed that with increasing frequency, I am receiving solicitations from journals I’ve never heard of based on my having published these types of papers.

Here’s my latest invitation. The editors of this journal (American Journal of Clinical and Experimental Medicine) first bizarrely ask me “how is everything going?”  then state that:

Your paper entitled Coronary Artery Fistula?\\Associated Endocarditis: Report of?Two Cases and a Review of the Literature from Echocardiography really attract us.
Are you interested in interested in sharing some other papers in this field?
If we may have the honor, we would like to publish your other papers in our journal.

Two weeks later they sent me a similar email with the verbiage slightly modified, but still horribly mangled:

We have learnt your paper entitled Coronary Artery Fistula?\\Associated Endocarditis: Report of?Two Cases and a Review of the Literature from Echocardiography, and are very attracted by its topic.
If you would like to publish other papers in the related subjects, you may consider to publish them in our journal

Both emails invited me to become a member of the editorial board!

How Can You Know Which Journals Are Fake?

Beginning in 2012, these types of journals were tracked by Beall’s list. In January 2017, Beall, “facing intense pressure from my employer, the University of Colorado Denver, and fearing for my job,” removed all of the blog contents from the internet.

(For a fascinating history of Beall’s work in this area see his article published here).

I found his list of predatory publishers resurrected  here.

Science Publishing Group, the publisher of  the journal that keeps emailing me is on the list.

A brief look at the website for Science Publishing Group does not reveal immediately that it is a predatory publisher. There are 80 scientific journals listed and they all have legitimate sounding names. However, I have never heard of any of them.

I searched in vain through the cardiology journals listed to find a paper that was the least bit interesting or important. Most of the listed editorial board members and authors were from third world countries. When I researched an American editorial board member  of one journal I found that he was a medical student.

Sting Operations on Fake Journals

Sting operations by academics have shown that papers that are composed of meaningless gobbledygook are often accepted by these types of journals as long as the publication fee is paid. The New Yorker has a great article describing such operations.

The Bohannon sting in Science two years ago found that 45% of a sample of publishers included in the directory of Open Access Journals accepted a bogus paper submitted for publication.

A recent sting operation also showed how anyone can become an editor or even “editor-in-chief” of one of these journals. From The NY times :

The applicant’s nom de plume was not exactly subtle, if you know Polish. The middle initial and surname of the author, Anna O. Szust, mean “fraudster.” Her publications were fake and her degrees were fake. The book chapters she listed among her publications could not be found, but perhaps that should not have been a surprise because the book publishers were fake, too.

Yet, when Dr. Fraud applied to 360 randomly selected open-access academic journals asking to be an editor, 48 accepted her and four made her editor in chief. She got two offers to start a new journal and be its editor. One journal sent her an email saying, “It’s our pleasure to add your name as our editor in chief for the journal with no responsibilities.”

Fake Conferences

Adding insult to scientific injury is the rise of fake scientific conferences.

I’ve been invited to lots of these important sounding conferences just based on publishing one case report. These emails are typically poorly written. If I didn’t know they were complete BS I would be flattered by the complements:

To ensure that you do not miss out, we extend our invitation to you again to express our sincere wish for your participation in BIT’s 9th Annual Congress of Cardiology-2017 (ICC-2017) with the theme of “Bridging Excellence in Cardiology and Clinical Aspects” will be held on 15-17 November 2017 in Singapore.

For your brilliant achievements and precious experience in the field of cardiology, on behalf of the organizing committee, we cordially welcome you to join us and give a presentation about Coronary Artery Fistula-Associated Endocarditis: Report of Two Cases and a Review of the Literature… at this congress.

I think I have had some brilliant achievements and my experiences are quite precious, but I’m definitely not  going to your ridiculous conference.

The Threat to Real Science

All of these fake and predatory scientific journals, editors and conferences could be dismissed as amusing if it weren’t for the fact that they are further contributing to the inability of the public to determine what is real science.

As Beall said

“predatory and low-quality journals are granting the imprimatur of science to basically any idea for which the author is willing to write an article and pay the author fees. This is polluting the scientific record with junk science”

This process is helping to fuel the rise of complementary and alternative medicine (CAM) which I have termed “fake medicine.” I’ve included below a long quote from Beall’s recent article which details this problem which he feels poses “the biggest threat to science since the Inquisition.”

Inquisitionally Yours,

-ACP

For your enjoyment, Beall’s full comments on the threat to science:

I think predatory publishers pose the biggest threat to science since the Inquisition. They threaten research by failing to demarcate authentic science from methodologically unsound science, by allowing for counterfeit science, such as complementary and alternative medicine (CAM) to parade as if it were authentic science, and by enabling the publication of activist science.

Because they aim to generate profits for their owners, gold (author-pays) open-access journals have a strong conflict-of-interest when it comes to peer review. They always want to earn money, and rejecting a paper means rejecting revenue. This conflict is at the heart of the ongoing downfall of scholarly publishing. Increasingly, the consumers of scholarly publishers’ services are the authors, not the readers, and not academic libraries. Businesses naturally always want to keep their customers content, for they want the revenue streams to continue and grow larger, as they add new services – such as more easy-acceptance journals – to their offerings.

Many of the larger predatory publishers, especially those based in Western Europe, offer a niche business. Their businesses are set up to publish manuscripts rejected by the top publishers, that is, papers rejected by Elsevier, Wiley, Sage, Taylor & Francis, Oxford University Press, and several others. They function something like a lender of last resort – they provide a publishing opportunity when no other publisher will, becoming, essentially, a Salon des Refusés for scholarly articles. However, the market is so lopsided now that there are more “publishers of last resort” than there are authentic ones, and they’re all competing with each other for subpar manuscripts.

Like counterfeit science itself, these publishers go through the motions of being a legitimate publisher. Some open-access publishers, even though they are not based in England, hire spokesmen with strong British accents to attend scientific conferences and other meetings and talk up the publisher, often renting a booth in the exhibit hall and even co-sponsoring some of the smaller meetings. They join publisher associations, make a show of donating to open-access causes, and manage to convince one or two aged Nobel Laureates to agree to serve on one of their editorial boards, no work required.

CAM is really taking off, and it’s being largely fuelled by pay-to-publish journals, though a few subscription journals have gotten in on the action as well. Predatory journals and even journals from legitimate publishers are legitimatizing this unscientific medical research in the public’s eye. Acupuncture and homeopathy are thriving, and numerous “studies” are being published each year to back up their effectiveness claims. In medicine, demarcation is failing, and there’s no longer a clear line where legitimate medical research ends and unsound medical research begins (5). More questionable medical research is being published now than ever before in history, including bogus research promoting fake medicines and nutraceuticals. There’s no longer a clear separation between the authentic and counterfeit medical research, even though medical research is the most important research for humankind today. Indeed, of all human endeavours, what surpasses medical research in importance, value, and universal benefit?

How To Spot a Quack Health Site: Red Flag #1, Primary Goal Is Selling Supplements

During the process of compiling the Cardiology Quackery Hall of Shame, the skeptical cardiologist has recognized that the #1 red flag of quackery is the constant promotion of useless supplements.

Such supplements typically:

-consist of “natural” ingredients

-are a proprietary blend of ingredients or a uniquely prepared single ingredient, and are only available through the quack

-have thousands of individuals who have had dramatic improvement on the supplement and enthusiastically record their testimonial to its power

-have no scientific support of efficacy or safety

-despite the lack of scientific data, the quack is able to list a series of seemingly valid supportive “studies”

-aren’t checked by the FDA

-apparently cure everything from heart disease to lassitude

I received an email today from a reader complimenting me on my post on the lack of science behind Dr. Esselstyn’s plant-based diet. The writer thought I would be interested in the work of a  Dr. Gundry.

I found on Dr. Gundry’s website an immediate and aggressive attempt to sell lots of supplements with features similar to what I describe above.

Dr. Gundry’s bio states “I left my former position at California’s Loma Linda University Medical Center, and founded The Center for Restorative Medicine. I have spent the last 14 years studying the human microbiome – and developing the principles of Holobiotics that have since changed the lives of countless men and women.”

Need I mention that “holobiotics” is (?are) not real.

Bonohibotically Yours,

-ACP

After writing this, I googled “red flag of quackery” images in the foolish hope that I might find a useable image. Lo and behold the image I featured in this post turned up courtesy of sci-ence.org. Here it is in all its glory, courtesy of Maki

2012-01-09-redflags2-682x1024

 

 

 

WebMD: Purveyor of Bad Health Information And Snake Oil

Part of my motivation for writing this blog is to provide a source for reliable cardiovascular health information patients can access online.

It’s not easy to get reliable health information and even media organizations that might normally be perceived as trustworthy are often corrupted, inaccurate and potentially dangerous to patients.

WebMD is such an organization.

WebMD’s motto is  WebMD – Better information. Better health..

A stack of magazines produced by WebMD appeared on my office desk for some reason recently and I decided to look closely at what might be sitting in my patient waiting room amongst the 5 year old Architectural Digests and Car and Driver magazines.

I think it is particularly important to closely vet any health advice magazine that appears in the waiting room because our patient’s will assume we agree  with what is within the pages.

First off, recognize that this magazine, like most health magazines exists primarily to serve as an advertising vehicle: by my count 48 out of its 92 pages are ads of one sort or another.

Dominated by Direct-To-Consumer Advertisements

A lot of these ads are direct to consumer (DTC) ads for expensive and/or new medicatons that doctors apparently haven’t recognized the value of. There are new diabetic medications, new multiple sclerosis medications, new weight loss pills and new asthma inhaler medications guaranteed to cost more than the ones your doctor currently has you on.

For example, the weight loss drug, Belviq, helped increase the number of obese individuals  who were able to lose 5% of their body weight. However, before you take it you might want to read the page which lists  the  potentially serious adverse effects which include:

  • valvular heart disease
  • slowing your thinking
  • hallucinations
  • depression/suicide
  • slow heart beat

Also, be aware this is a federally controlled substance because it may lead to abuse or drug dependence.

There are even DTC ads for medications that treat diseases I have never heard of.  Take Nuvigil (armodafinil) which Teva is promoting for Shift Work Disorder. “Take Note:” the headline announces “excessive sleepiness due to shift work disorder may be burning out your wakefulness.”

We can debate the value of DTC advertising but at least the big Pharma DTC ads are promoting medications approved by the FDA.

This is not the case for the majority of products being advertised in the Web MD magazine. The vast majority of ads are for useless and ineffective snake oil products.

Snake Oil Ads

First out of the snake oil box: Sambucol black elderberry extract, promoted for “immune support.” A recent review of this stuff concluded that more studies were needed before concluding that it had any benefit on reducing flu duration.

Second up: Zyflamend, “Discover an herbal approach to pain relief after exercise:”Ten pure herbs, One potent formula. ” I’m not sure why they picked “pain relief after exercise” as their target here, the compound has not been shown to treat anything. New Chapter, the purveyor of this uselessness promotes a wide variety of snake oil supplements along with fish oil, the mainstream snake oil.

Next snake oil contender:ZZquil:Sleep Like You Got Upgraded. The non-habit forming sleep aid.ZZquil contains diphenhydramine (benadryl) a sedating antihistamine. There’s no reason to buy this forulation of benhydramine. If you feel the need to sedate yourself with a relatively benign drug, just buy generic diphenhydramine pills. Try 25 to 50 mg which cost less than 5 cents a pill.. Put the container back in the medicine cabinet when you’re done and you will have it available next time, unlike the ZZquil which you are bound to throw out after a while,.

Meaningless Celebrity Fluff Articles, Inaccurate Diet and Fitness Blurbs

The only significant original content in the magazine is  two celebrity fluff articles: one on the shoulder injury of NBA player Kevin Love, the other an interview with Olivia Munn (“We talk to the actor about her versatility and how she learned self-acceptance”)

In between the DTC ads and the snake oil ads are one-page blurbs full of misinformation on weight loss, fitness, and diet.

Screen Shot 2016-02-07 at 6.32.29 AM For example, the fitness blurb takes recommendations from a celebrity fitness trainer which seems to emphasize doing Burpees or Burpee-like activities a potentially dangerous activity I have discussed  here.

Screen Shot 2016-02-07 at 6.34.12 AMThe crowning achievement of this “magazine” has to be the heart health quiz which asks the question if men or women have a higher risk of heart attack and gives the wrong answer.

The scientifically accurate answer is that men  have a much higher risk of heart attack or risk at any given age than women.

 

 

After encountering this horribly inaccurate quiz I was entering intoIMG_6140 male asdvd
my ASCVD risk calculator app, the numbers
for a 69 year old female patient I was seeing. Her 10 year risk for heart attack and stroke was 7.9%. When I changed the gender parameter to male, the risk jumped to 15.2%.

Basically, for any set of risk parameters, if you enter male versus female, the 10 year risk of heart attack and stroke nearly doubles.

Thus, WebMD, the magazine,  is a useless and potentially harmful combination of:

  • DTC ads promoting expensive, marginally beneficial medications
  • Snake oil products with no benefit and potential risk
  • Celebrity fluff pieces with no useful medical information
  • Brief, often inaccurate blurbs on diet, exercise, weight loss.

This magazine, although free, should not be in doctor’s waiting rooms.

Given this production from WebMD I would also advise patients to avoid the WEbMD website as it cannot be considered  a trusted source of medical information and, like the print format, primarily exists as  an advertising vehicle.

Serenity Now,

-ACP