Download Lectures on Biostatistics (1971). Corrected and searchable version of Google books edition
Download review of Lectures on Biostatistics (THES, 1973).
antoxidant
There is no topic more widely discussed than what one should eat in order to stay healthy. And there are few topics where there evidence is so lacking in quality. This post isn’t about quackery, but about something much more important. it is about the real science (if it merits that description) behind dietary advice. I’m not an expert in nutrition, but I do know a bit about the nature of evidence. I’m continually astonished by the weakness of the evidence for some things that have become received truths, and nowhere is that more true than in nutrition.
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The BMJ used my review of Gary Taube’s book, The Diet Delusion, to start off their new Round Table feature [full text link to BMJ]. The published version had some big cuts so I publish the original version here. Taubes was kind enough to send me a copy of the book after I’d mentioned his wonderful New York Times piece in my previous excursion into the murky world of diet and health, Diet and health. What can you believe: or does bacon kill you? |
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The biggest omission in the BMJ version was Taubes’ own ten point summary of his conclusions (on page 454).
"“As I emerge from this research, though, certain conclusions seem inescapable to me, based on existing knowledge
- Dietary fat, whether saturated or not, is not a cause of obesity, heart disease, or any other chronic disease of civilization
- The problem is the carbohydrates in the diet, their effect on insulin secretion, and thus the hormonal regulation of homeostasis – the entire harmonic ensemble of the human body. The more easily digestible and refined the carbohydrates, the greater the effect on our health, weight, and well-being.
- Sugars – sucrose and high-fructose corn syrup specifically – are particularly harmful, probably because the combination of fructose and glucose simultaneously elevates insulin levels while overloading the liver with carbohydrates.
- Through their direct effect on insulin and blood sugar, refined carbohydrates, starches, and sugars are the dietary cause of coronary heart disease and diabetes. They are the most likely dietary causes of cancer, Alzheimer’s disease, and the other chronic diseases of civilization.
- Obesity is a disorder of excess fat accumulation, not overeating, and not sedentary behaviour.
- Consuming excess calories does not cause us to grow fatter, any more than it causes a child to grow taller. Expending more energy than we consume does not lead to long-term weight loss; it leads to hunger.
- Fattening and obesity are caused by an imbalance – a disequilibrium – in the hormonal regulation of adipose tissue and fat metabolism. Fat synthesis and storage exceed the mobilization of fat from the adipose tissue and its subsequent oxidation. We become leaner when the hormonal regulation of the fat tissue reverses this balance.
- Insulin is the primary regulator of fat storage. When insulin levels are elevated – either chronically or after a meal – we accumulate fat in our fat tissue. When insulin levels fall, we release fat from our fat tissue and use it for fuel.
- By stimulating insulin secretion, carbohydrates make us fat and ultimately cause obesity. The fewer carbohydrates we consume, the leaner we will be.
- By driving fat accumulation, carbohydrates also increase hunger and decrease the amount of energy we expend in metabolism and physical activity.”
It is on these bases that Taubes suggests that the increase in obesity is, in part, a consequence of the recommendation of a low fat, and hence high sugar diet.
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The Diet Delusion [ pp 601] (published in the USA as Good Calories, Bad Calories) Gary Taubes 2008 There is no topic more widely discussed than what one should eat in order to stay healthy. And there are few topics where the evidence is so lacking in quality. It is also a topic that is besieged by gurus, cranks and supplement hucksters. You need to beware of misleading titles. Dietitians are good. Nutritionists are sometimes good. But titles like ‘nutritional therapist’ and ‘nutritional medicine’ are usually warning signs of alternative therapists and/or pill salespeople. Gary Taubes is a journalist, but he is quite an exceptional journalist. His account of the importance of randomisation for the establishment of causality is one of the best ever and it was published not in an academic journal, but in the New York Times [1]. His book, The Diet Delusion, is in the same mould. It is more complete and more scholarly than most professional scientists could manage. Not only does it cover the literature right back to Samuel Johnson, but it is also particularly good at unravelling what one might call the politics of science. And by politics I don’t mean the vast lobbying industry that has built up with the aim of selling you unnecessary supplements, but the politics of academia. Obesity sounds simple. If you are fat it is because you eat too much or exercise too little, right? Well no, it’s not as simple as that. For a start, it has been shown time and time again that low fat diets, and exercise, have small and temporary effects on weight. The problem with diet and health revolves round causality. The law of conservation of energy is an inevitable truth, but says nothing about causality. It could imply that you get fat because you eat too much, or equally the causal arrow could point the other way and “we eat more, move less and have less energy to expend because we are metabolically or hormonally driven to get fat”. The assumption that positive caloric balance is the cause of weight gain has predominated since the 1970s and “this simple misconception has led to a century of misguided obesity research”. At the heart of the problem is the paucity of randomised trials, which are the only way to establish causality. Those that there are have usually shown that diet does not matter as much as we are told. Taubes concludes
I think it can certainly be argued that the problem of causality has been greatly underestimated. We are warned constantly of the dangers of processed meat, on the basis of very unconvincing evidence [2]. This is one reason why we still know so little about the causes of obesity, diabetes and heart disease. For Taubes, a major villain was the US nutritionist Ancel Keys (1904 – 2004). His It is quite possible that there was rather more to be said for the Atkins diet than was apparent at the time. The fact that Atkins was not a university scientist, that his views were extreme and that he was so obviously out to make a lot of money from it, gave him all the appearance of being yet another profiteering diet guru. He was dismissed by the medical establishment as a quack. Taubes points out that conflict of interest cuts both ways. Atkins’ sternest critics at Harvard were funded by General Foods, Coca-Cola and the sugar industry. It adds up to a sorry story of a conflict of vested interests and scientific vanity. Taubes’ final judgement is harsh. He quotes Robert Merton’s description [4] of what science is, or should be.
He then comments
It took Taubes five years to write this book, and he has nothing to sell apart from his ideas. No wonder it is so much better than a scientist can produce. Such is the corruption of science by the cult of managerialism that no university would allow you to spend five years on a book [5]. I find all ten points in his summary convincing. But his most important conclusion is that you cannot have any certainty without randomised trials. The business of nutrition is greatly at fault for not having put more effort into organising randomised trials. Until they are done, we’ll never really know, and we shouldn’t pretend that we do. 1. Taubes G. Do we really know what makes us healthy? New York Times 2007 Sep 16.[full text link] [pdf file] 2. Colquhoun, D. (3 May 2009) Diet and health. What can you believe: or does bacon kill you?. 3. Greenberg, S.A.. 2009 How citation distortions create unfounded authority: analysis of a citation network. BMJ ;339:b2680 [pdf file]. 4. Merton, R. K. Behavior Patterns of Scientists . Leonardo, Vol.3 1970; 3(2):213-220. From Jstor [or pdf file] 5. Lawrence PA. The mismeasurement of science. Curr Biol 2007; 17(15):R583-R585.PM:17686424 [pdf file] [commentary] |
If length had allowed, there should certainly have been a reference here to Robert Lustig of UCSF. He is an academic nutritionist who supports the main thesis of Taubes’ book. See, for example, his 2005 review, Childhood obesity: behavioral aberration or biochemical drive? Reinterpreting the First Law of Thermodynamics [full
text link]. Lustig’s slide show, The Trouble with Fructose is available in the NIH web site.
There are a couple of other articles by Taubes that are well worth reading. The Scientist and the Stairmaster Why most of us believe that exercise makes us thinner—and why we’re wrong. Gary Taubes, in New York Magazine, and We can’t work it out, in the Guardian.
You can see Taubes in action on YouTube, for example in “on Cholesterol and Science Practices“, and “on Carbohydrates and Degenerative Diseases“. There is also a video of Taubes on medical grand rounds at Dartmouth-Hitchcock Medical Center in June 2009. You can see Robert Lustig on YouTube too: “Sugar: The Bitter Truth“.
Follow-up
22 December.2009, Unlike the serious questions dealt with in the Diet Delusion, this concerns merely another bit of the ubiquitous nutribollocks that crops up in the media, While writing this I was listening to the excellent early evening news programme, PM, run by Eddie Mair, when a diet-related topic came up, it was nonsense about how a cocktail made with vodka, cointreau, acai juice and pomegranate juice would not give you a hangover. I suppose it was meant as christmas fun but whenever I hear the words ‘antioxidant‘ or ‘superfood; I feel an email coming on. It seems that Eddie Mair liked the fact that the email contained the words ‘quack’ and ‘codswallop’ because the next thing I knew I was asked to give an interview on next day’s programme. The mp3 is here.
This post has been translated into Belorussian..
Chinese medicine and herbal medicine are in the news at the moment. There is a real risk that the government could endorse them by accepting the Pittilo report.
In my view traditional Chinese medicine endangers people. The proposed ‘regulation’ would do nothing to protect the public. Quite on the contrary, it would add to the dangers, by giving an official stamp of approval while doing nothing for safety.
The government’s idea of improving safety is to make sure that practitioners are ‘properly trained’. But it is the qualifications that cause the danger in the first place. The courses teach ideas that are plain wrong and often really dangerous.
Why have government (and some universities) not noticed this? That’s easy to see. Governments, quangos and university validation committees simply don’t look. They tick boxes but never ask what actually goes on. Here’s some examples of what goes on for them to think about. They show clearly the sort of dangerous rubbish that is taught on some of these ‘degrees’.
These particular slides are from the University of Westminster, but similar courses exist in only too many other places. Watch this space for more details on courses at Edinburgh Napier University, Middlesex University and the University of East London
Just a lot of old myths. Sheer gobbledygook,
SO much for a couple of centuries of physiology,
It gets worse.
Plain wrong.
Curious indeed. The fantasy gobbledygook gets worse.
Now it is getting utterly silly. Teaching students that the brain is made of marrow is not just absurd, but desperately dangerous for anyone unlucky (or stupid) enough to go to such a person when they are ill.
Here’s another herbal lecture., and this time the topic is serious. Cancer.
Herbal approaches for patients with cancer.
I’ve removed the name of the teacher to spare her the acute embarrassment of having these dangerous fantasies revealed. The fact that she probably believes them is not a sufficient excuse for endangering the public. There is certainly no excuse for the university allowing this stuff to be taught as part of a BSc (Hons).
First get them scared with some bad statistics.
No fuss there about distinguishing incidence, age-standardisation and death rates. And no reference. Perhaps a reference to the simple explanation of statistics at Cancer Research UK might help? Perhaps this slide would have been better (from CDC). Seems there is some mistake in slide 2.
Straight on to a truly disgraceful statement in slide 3
The is outrageous and very possibly illegal under the Cancer Act (1939). It certainly poses a huge danger to patients. It is a direct incentive to make illegal, and untrue claims by using weasel words in an attempt to stay just on the right side of the law. But that, of course, is standard practice in alternative medicine,
Slide 11 is mostly meaningless. “Strengthen vitality” sounds good but means nothing. And “enhancing the immune system” is what alternative medicine folks always say when they can think of nothing else. Its meaning is ill-defined and there is no reason to think that any herbs do it.
The idea of a ‘tonic’ was actually quite common in real medicine in the 1950s. The term slowly vanished as it was realised that it was a figment of the imagination. In the fantasy world of alternative medicine, it lives on.
Detoxification, a marketing term not a medical one, has been extensively debunked quite recently. The use of the word by The Prince of Wales’ company, Duchy Originals recently fell foul of the Advertising Standards Authority, and his herbal ‘remedies’ were zapped by the MHRA (Medicines and Health Regulatory Authority).
And of course the antioxidant myth is a long-disproved hypothesis that has become a mere marketing term.
“Inhibits the recurrence of cancer”! That sounds terrific. But if it is so good why is it not even mentioned in the two main resources for information about herbs?
In the UK we have the National Library for Health Complementary and Alternative Medicine Specialist Library (NeLCAM), now a part of NHS Evidence. It was launched in 2006. The clinical lead was none other than Peter Fisher, clinical director of the Royal London Homeopathic Hospital, and the Queen’s homeopathic physician. The library was developed with the School of Integrated Health at the University of Westminster (where this particular slide was shown to undergraduates). Nobody could accuse these people of being hostile to magic medicine,
It seems odd, then, that NeLCAM does not seem to thnk to think that Centella asiatica, is even worth mentioning.
In the USA we have the National Center for Alternative and Complementary Medicine (NCCAM), an organisation that is so friendly to alternative medicine that it has spent a billion dollars on research in the area, though it has produced not a single good treatment for that vast expenditure. But NCCAM too does not even mention Centella asiatica in its herb list. It does get a mention in Cochrane reviews but only as a cosmetic cream and as an unproven treatment for poor venous circulation in the legs.
What on earth is a “lymph remedy”. Just another marketing term?
“especially valuable in the treatment of breast, throat and uterus cancer.“
That is a very dramatic claim. It as as though the hapless students were being tutored in doublespeak. What is meant by “especially valuable in the treatment of”? Clearly a desperate patient would interpret those words as meaning that there was at least a chance of a cure. That would be a wicked deception because there isn’t the slightest reason to think it works. Once again there this wondrous cure is not even mentioned in either NELCAM or NCCAM. Phytolacca is mentioned, as Pokeweed, in Wikipedia but no claims are mentioned even there. And it isn’t mentioned in Cochrane reviews either. The dramatic claims are utterly unfounded.
Ah the mistletoe story, again.
NHS Evidence (NeLCAM) lists three completed assessments. One concludes that more research is needed. Another concludes that “Rigorous trials of mistletoe extracts fail to demonstrate efficacy of this therapy”, and the third says “The evidence from RCTs to support the view that the application of mistletoe extracts has impact on survival or leads to an improved ability to fight cancer or to withstand anticancer treatments is weak”.
NCCAM says of mistletoe
- More than 30 human studies using mistletoe to treat cancer have been done since the early 1960s, but major weaknesses in many of these have raised doubts about their findings (see Question 6).
- Very few bad side effects have been reported from the use of mistletoe extract, though mistletoe plants and berries are poisonous to humans (see Question 7).
- The U.S. Food and Drug Administration (FDA) has not approved mistletoe as a treatment for cancer or any other medical condition (see Question 8).
- The FDA does not allow injectable mistletoe to be imported, sold, or used except for clinical research (see Question 8).
Cochrane reviews lists several reviews of mistletoe with similar conclusions. For example “The evidence from RCTs to support the view that the application of mistletoe extracts has impact on survival or leads to an improved ability to fight cancer or to withstand anticancer treatments is weak”.
Anthroposophy is one of the highest grades of fantasy you can find. A post on that topic is in the works.
“Indicated for cancers . . . colon/rectal, uterine, breast, lung“. A cure for lung cancer? That, of course, depends on how you interpret the weasel words “indicated for”. Even Wikipedia makes no mention of any claims that Thuja benefits cancer. NHS Evidence (NeLCAM) doesn’t mention Thuja for any indication. Neither does NCCAM. Nor Cochrane reviews. That is not the impression the hapless students of this BSc lecture were given. In my view suggestions that you can cure lung cancer with this tree are just plain wicked.
Pure snake oil, and not even spelled correctly, Harry Hoxsey’s treatment centres in the USA were closed by court order in the 1950s.
At least this time it is stated that there is no hard evidence to support this brand of snake oil.
More unfounded claims when it says “treated successfully many cancer patients”. No references and no data to support the claim. It is utterly unfounded and claims to the contrary endanger the public.
Gerson therapy is one of the most notorious and unpleasant of the quack cancer treatments. The Gerson Institute is on San Diego, but their clinics are in Mexico and Hungary. It is illegal in the USA. According to the American Cancer Society you get “a strict low-salt, low-fat, vegetarian diet and drinking juice from about twenty pounds of fresh fruits and vegetables each day. One glass of juice is consumed each hour, thirteen times a day. In addition, patients are given several coffee enemas each day. Various supplements, such as potassium, vitamin B12, pancreatic enzymes, thyroid hormone, and liver extracts, are used to stimulate organ function, particularly of the liver and thyroid.”. At one time you also got several glasses of raw calf liver every day but after infections killed several people] carrot juice was given instead.
Cancer Research UK says “there is no evidence to show that Gerson therapy works as a cure for cancer”, and “The Gerson diet can cause some very serious side effects.” Nobody (except perhaps the Price of Wales) has any belief in this unpleasant, toxic and expensive folk-lore.
Again patients are endangered by teaching this sort of stuff.
And finally, the usual swipe at vaccines. It’s nothing to do with herbalism. but just about every alternative medicine advocate seems to subscribe to the anti-vaccination lobby.. It is almost as though they have an active preference for things that are known to be wrong. They seem to believe that medicine and science are part of an enormous conspiracy to kill everyone.
Perhaps this dangerous propaganda might have been ameliorated if the students had been shown this slide (from a talk by Melinda Wharton).
Click to enlarge
Left to people like this, we would still have smallpox, diphtheria. tetanus and rabies, Take a look at Vaccine-preventable diseases.
This is the sort of ‘education’ which the Pittilo report wants to make compulsory.
Smallpox in Baltimore, USA, 1939. This man was not vaccinated.
Conclusion
This selection of slides shows that much of the stuff taught in degrees in herbal medicine poses a real danger to public safety and to public health.
Pittilo’s idea that imposing this sort of miseducation will help safety is obviously and dangerously wrong. The Department of Health must reject the Pittilo recommendations on those grounds.
Follow-up
The Nutrition Society is the interim professional body for nutrition. It seems that, unlike so many ‘regulatory bodies’, it may actually take its responsibilities seriously. The following announcement has appeared on their web site.
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The UK Voluntary Register of Nutritionists acts to protect the public and the reputation the nutrition profession On March 4th 2009, a Fitness to Practice Panel was convened to consider an allegation against a registrant, Dr Ann Walker, that her fitness to practise was impaired. The panel considered whether the registrant, in advocating the use of a web based personal nutritional profiling service had complied with the Code of Ethics’ clause 3: This expects all registered nutritionists to “maintain the highest standards of professionalism and scientific integrity”. In particular, the panel considered whether the registrant showed “knowledge, skills and performance of high quality, up-to-date, and relevant to their field of practice”, in keeping with the Statement of Professional Conduct (para 9). The Panel accepted the allegation of impaired fitness to practice. Mindful of its duty to protect the public, it recommended that Dr Walker be removed from the register. Dr Walker has a right of appeal. |
Well. well, this must be none other than the Dr Ann Walker who caused UCL,and me, such trouble a few years ago. And just because I described her use of the word “blood cleanser” as gobbledygook. She has appeared a few times on this blog.
- Nutribollocks: antioxidants useless, some are dangerous
- Red clover, herbal spin and vested interests
- The fallout from DC’s de-excommunication
- So what is a “blood cleanser”? Quinion speaks.
- Herbal medicines fail test
- Nutriprofile: useful aid or sales scam?
- She even gets a brief mention at Boots reaches new level of dishonesty with CoQ10 promotion
Presumably the “web-based personal nutritional profiling service” that is referred to is Nutriprofile, on which, with the help of a dietition, we had a bit of fun a while ago. However ideal your diet it still recommended at the end of the questionnaire that you should buy some expensive supplements. Read about it at Nutriprofile: useful aid or sales scam?
I have no idea who lodged the complaint (but it wasn’t me).
It is interesting to compare the high standards of the Nutrition Society with the quite different standards of BANT (the British Association for Applied Nutrition and Nutritional Therapy). They bill themselves as the “Professional Body for Nutritional Therapists”. Nutritional therapists are those fantasists who believe you can cure any ill by buying some supplement pills. Their standards can be judged by, for example, BANT ethics code: BANT nutritional therapists are allowed to earn commission from selling pills and tests.
It seems Dr Ann Walker may have joined the wrong society.
Follow-up
Sense about Science have just produced a rather good pamphlet that exposes, yet again. the meaningless marketing slogan “detox”. You can download the pamphlet from their web site.
The pamphlet goes through the claims of eleven products. Needless to say, the claims are either meaningless, or simply untrue.
- Garnier Clean Detox Anti-Dullness Foaming Gel
“Detoxifies by cleansing the skin’s surface” - MG Detox Shampoo Trevor Sorbie
“Deep cleansing and clarifying shampoo” - Boots Detox Body Brush
“Ritualistic body brushing helps expel toxins through the skin” - Innocent Natural Detox Smoothie
“Helps neutralise nasty free radicals which can cause damage to your body’s cells” - Vitabiotics Detoxil 15 day support
“Helps the body cleanse itself of toxins and pollutants caused by the excesses of a busy life” - V-Water Detox
“Cleanse your system and whisk away the polluting nasties” - 4321 Shape Up and Detox
“To drain off water and toxins” and “purify the body” - Boots Detox 5 Day Plan
Works “in harmony with your body to flush away toxins” - Farmacia Spa Therapy Detox range
To “rid your body of these damaging toxins” - Crystal Spring Detox patches
“I’m the easy way to detox, just put me on one foot at night and take me off in the morning” - Fushi Holistic and Health Solutions Total Detox Patch
“it acts as a toxin sink and absorbs impurities through your feet”
One nice thing about the pamphlet is that each item is written by a young scientist (including my close neighbour, Daniella Muallem). They are all people at an early stage in their career, but they care enough to spend time dissecting the rubbish spread by companies in order to part you from your money.
Garnier, it’s true, is a cosmetics company, so one expects nothing but lies You won’t be disappointed on that score.
That least ethical of pharmaceutical companies, Boots, appears twice The Boots Detox Body Brush is reviewed by a young chemist, Tom Wells. It turns out (there’s a surprise) to be nothing more than an ordinary stiff brush. It seems that Boots’ definition of “detox”, for this purpose, is “removing dead skin cells” A totally shameless con, in other words.
The Boots Detox 5 day plan consists if 5 phials of apple or strawberry flavoured goo containing two vitamins and one mineral, mixed with glycerol. In this case the young investigator, Evelyn Harvey, elicited a quite remarkable response from Boots.
Well, have you tested the effects of that diet, with or without the detox product? Does the ‘goo’ stuff [the drink which forms part of the plan] add anything extra?
Well, it’s meant to kick start it.
But has is been tested like that?
No.
Ok, I’m thinking I’ll just try a healthy diet for a week, a bit more exercise, and not bother with buying the detox.
Yes, that sounds like a better idea, to be honest I’d never do this myself.
The media coverage
The Radio 4 Today programme interviewed Ben Goldacre and the managing director of yet another product “Detox in a box” (following their usual policy of equal time for the Flat Earth Society). Listen to the mp3. When Ben Goldacre asked the MD for evidence for the claim made on the web site of Detox in a box, that their diet could remove cadmium from the body, it was denied explicitly that any such claim had been made.
Not so.
But by 10.02 the site had already changed
So no apology for the mistake. Just a sneaky removal of a few words.
That seems to be the only change though. All the rest of the nutribollocks is still there. For example
There isn’t the slightest reason to believe that it will “improve our immune function”.
There isn’t the slightest reason to think that scavenging free radicals would do you any good, even if it happened.
There isn’t the slightest reason to think it will strengthen body’s fight against cancer cells (that looks like a breach of the Cancer Act to me).
“Cleansing mucous” doesn’t mean much, but whatever it is there isn’t any reason to think its true.
“Purify our blood”. Total meaningless bollocks. The words mean nothing at all. I’ve been here before.
Ben Goldacre’s own account is here “The barefaced cheek of these characters will never cease to amaze and delight me.”
The BBC web site does a good job too.
The Guardian gives an excellent account (James Randerson).
The Daily Mail writes “Detox diets to kick-start the New Year are a ‘total waste of money’ “.
Medical News Today write “Debunking The Detox Myth“.
The Daily Telegraph disgraces itself by not only failing to carry a decent account of the item, but it does run an article on “Detox holidays: New year, new you“. Mega-expensive holidays for the mega-stupid (not to mention the capital letter after the colon).
The Daily Mash provides a bit of cognate fun with “BRITAIN SIGNS UP FOR VORDERMAN’S 28-DAY PISS-DRINK DETOX“. That alludes to “Carol Vorderman’s 28-Day Detox Diet”. A woman who got an enormous salary for playing a parlour game on TV, and has done some good for maths education, is reduced to promoting nonsense for yet more money.
As Clive James pointed out, it’s a but like watching George Clooney advertising coffee for, of all unethical companies, Nestlé. They really look very silly.
Follow-up
Evening Standard 6th January. Nick Cohen writes “Give up detox – it’s bad for your health”
“Giving up on detox should not be painful, however. On the contrary, it should e a life-enhancing pleasure.”
The Times. rather later (January 18th) had a lovely one, “Detox
Debunked“, by the inimitable Ben Goldacre, His account of /detox; as a quasi-religious ‘cleansing ritual’, is spot on.
Jump to follow-up: Brian Kaplan
| Obama wins! Bush and Blair have gone. Could this mark the beginning of the end of the fashion for believing things that aren’t true? |
Trinity College Dublin: the Phil. “Creationism is a valid world view”
This is the 324th year of the Trinity College Philosophical Society (known locally as the ‘Phil’). Its former members include Bishop Berkeley, Dean Jonathan Swift, Oscar Wilde, Bram Stoker, Samuel Beckett, and E.T.S. Walton . It was founded for “discourse of philosophy, mathematics, and other polite literature ”, and is now a debating society.
The motion was Creationism is a Valid World view. At the dinner before the debate, the students all dutifully stood as one of them recited long graces in Latin both before and after eating. All very Oxbridge. So I wasn’t optimistic. However I hadn’t taken into account the conformist tendencies of undergraduates. Notwithstanding the Latin graces, the result of the debate was very clear indeed.
Result. The Creationists were totally wiped out. Almost the only vote for the motion was a young born-again student, who made a desperately sincere speech.
I don’t need to give the details of what happened, because the opposer of the motion, Bob Bloomfield (of the Natural History Museum) has given an excellent account (The Discovery Institute send big guns to Ireland but only manage to fire blanks) on the Beagle project blog. Two of the proposers were Americans, from the Discovery Institute, and they said what you’d expect: nothing that would impress anyone with any education. I’ll settle for Bloomfield’s description of me as “charmingly irascible”. Irascible, moi? Well it would make anyone mildly irritated to have to spend time arguing about creationism in 2008.
Religion, all religion, seems to me to be boring and not a thing worth wasting good time on thinking about, but the rise of barmy fundamentalism has made it essential, if only so that genetics can be taught without accusations of racism, I’m entirely with Dawkins, I can’t prove that there is no god, and I can’t guarantee
that the bottom of my garden is free of fairies. Both questions merit about the same amount of time, though if pressed, I’d go for the fairies. They are, allegedly, rather better behaved than gods.
The 24th president of the USA said, when asked for his thoughts on evolution, said
“of course like every other man of intelligence and education I do believe in organic evolution. It surprises me that at this late date such questions should be raised”.
Woodrow Wilson, 1922
That, of course, was from a president who has been described as ” leading intellectual of the Progressive Era”.
How things have changed in the time of Tony Blair, George Bush and Sarah Palin. Very few people had such barmy beliefs in 1960, never mind 1922. My thesis is much the same as that of Francis Wheen in “How mumbo-jumbo conquered the world” Sometime around 1980, with the conjunction of Thatcher, Reagan and Khomeini it came into fashion to believe things that aren’t true, just because you wished they were (actually I’d put it a bit earlier than Wheen: arguably it started when the Beatles went to that guru), It was after that when suddenly people started to believe in magic medicine, religious fundamentalism. weapons of mass destruction, and, ahem, that the market would make us rich if only we would remove all the regulations.
Tony Blair defended in parliament the Emmanuel School which is run by a young earth creationist and used car dealer, Peter Vardy. The head of the school, Nigel McQuoid, features strongly on the web site of the Christian Institute, This curious organisation seems to be devoted largely to creationism, homophobia and the virtue of beating children (a search of the site for “corporal punishment” gives 43 hits). An essay by Burns & McQuoid says
“There are those who argue that Science and Christianity can be harmoniously reconciled . ; ;. We cannot subscribe to this view”
The former head of science (yes, of science) at McQuoid’s school, Steven Layfield, had an article on the Christian Institute web site. It vanished as soon as it got some publicity but you can read it at http://www.darwinwars.com/lunatic/liars/layfield.html.
Try this quotation.
“Note every occasion when an evolutionary/old-earth paradigm (millions or billions of years) is explicitly mentioned or implied by a text-book, examination question or visitor and courteously point out the fallibility of the statement. Wherever possible, we must give the alternative (always better) Biblical explanation of the same data.”
| These guys are really at the fruit-cake end of the religious spectrum. In contrast, the young anglican chaplain of Trinity, Darren McCallig, spoke against creationism, eloquently and sensibly. His religiousness did seem at times to be diluted almost to homeopathic extremes, but all the better for that. He seems to have a sense of humour too, judging by the poster for his services. |  click to enlarge |
There is, of course, a very healthy opposition to creationists in the USA too, I like particularly Gerald Weissman’s article “The facts of evolution: fighting the Endarkenment” (it may have been the first time that I saw the wonderful word endarkenment, which describes so well the last 30 years). It starts thus.
“Those of us who practice experimental science are living in the best of times and the worst of times, and I’m not talking about A Tale of Two Cities, but a tale of two cultures. “
Here are a couple of pictures of the meeting.
Chris Stillman (geologist)
Berlinski (left) Luke Ryder (speaking), Bloomfield, DC, Stillman (right)
And some pictures of Dublin here
James Joyce, TCD quadrangle and Molly Malone. Click to view
UCL homeopathy debate
This was organised by the UCL students’ debating society. The Darwin Lecture theatre was surprisingly full for this debate, but they weren’t all students. As usual on these occasions, the homeopaths tried to pack the audience, but this time they failed. That tactic is fair enough I suppose, but it means that the vote failed to tell us anything much about the opinion of students, beyond the fact that not many of them opposed the motion.
There are a few though. To the horror of some of our pharmacology and neuroscience undergraduates, a student society devoted to medicines that don’t work has been started at UCL, for the first time ever. Luckily, it seems to be a rather small society. I was fascinated to see that they are going to hear about the evidence base for complementary therapies, from George Lewith. I had occasion a while ago to look at Dr Lewith’s attitude to evidence: see Lewith’s private clinic has curious standards.
| The proposers were Simon Singh and me. Simon is author of, among other things, Fermat’s Last Theorem and Trick or Treatment. I thought he did an excellent job. Singh pointed out that, contrary to the view propagated by quacks, science likes wacky ideas, as long as you can produce the evidence for them He cited dark matter as an example. |
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The main opposer was my old friend Peter Fisher, homeopathic physician to the Queen. It was a pleasure to show the video of Fisher agreeing with me that there is not enough science in homeopathy to justify a BSc degree in it. Fisher, in his papers, strikes me as one of the most honest of homeopaths. He was “very angry” when homeopaths were caught out recommending their sugar pills to prevent malaria. But is his speech, he struck me as less than honest. He cherry-picked the evidence quite shamelessly as usual. And his suggestion that there was an analogy between the ‘memory of water’ and a DVD was disposed of ably by a physics student who spoke from the floor.
The results were too close for comfort, 65 for, 53 against and an amazing 37 abstentions,
Sadly we’ll never know how the students voted, because of the imported homeopaths.
| Dr Brian Kaplan was there. He had given the meeting some advance publicity, in a web posting that also kindly gave publicity to our 2006 letter to the Times. He didn’t like the letter, which is unsurprising given that it turned out to be more effective than we could ever have hoped (see also here). |  |
On the second row, getting very excited, was homeopath Grace Da Silva-Hill and her husband, She runs the ‘Healing with Grace’ business. On her web site she makes the ludicrous claim that
“Homeopathy will treat the cause of your health problem, not just alleviate your symptom”
She also says, inter alia, that
“Homeopathy is effective in treating a wide range of conditions such as: asthma, . . . “
In contrast, the Cochrane review says
“There is not enough evidence to reliably assess the possible role of homeopathy in asthma. “
I have been sent her account of the debate (a reply to a query from the ubiquitous Dana Ullman).
“Hello Dana, The debate, on monday 20th Oct., organised by UCL debating society, was poorly managed, and biased, attended mostly by students, who appear to have gone there to practice their debating skills. The motion was lost by 12 (65 for and 53 against), with 37 abstentions. Peter Fisher put on a good show, and so did his second, in comparison with the rather stale and poor presentation of Simon and Qulquoun (sorry, can never spell this). My husband Ken did a rather
good caricature of him, unfortunately can’t share it here. Pity there were not more homeopaths/supporters there. Kind regards,”
Uhuh. Well, I guess she would say that.
You can judge the critical faculties of Mrs Da Silva-Hill from a comment she left on a piece in the Daily Telegraph, ‘Homeopathy putting lives at risk with claims’. I quote from it verbatim.
“The public does not care about the research available, the public care about having their health problem sorted, where conv. medicine has failed,”
(I apologise for attributing to Mrs Da Silva in the original post a quotation from the Telegraph that appeared above her name but was actually written by somebody else. I apologise also for using a picture of her without permission.)
On the way out of the debate, I walked back to Euston Road with another homeopath, William Alderson, who had come all the way from Kings Lynn to cast his vote. He was earnest and sincere, the conversation was amicable but his idea of evidence was so different from mine that no progress was made. You can read more about Alderson on Dr Aust’s blog.
It’s fascinating stuff.
Follow-up
Dr Brian Kaplan has posted some splenetic comments on this post. I suppose the paranoid tone is an indication that we are winning, but I do wish he’d be a bit more careful about the facts. Let me correct some of them.
(1)Neither the letter of May 2006, nor its follow up in May 2007, was written under the NHS letterhead. The follow-up letter of May 2007 contained the words
“If you have not already reviewed your own trust’s provision, you might find it useful to consider, in conjunction with your Director of Public Health, the paper that we have enclosed which, while not a full review of the scientific position, has been used by other trusts to promote evidence based commissioning.”
The enclosed form was a sample commissioning letter which reproduced the NHS logo with a notice saying “insert your NHS logo here”. The accompanying letter made it perfectly clear that the enclosed form was simply an example to help those who wanted to save money and not an official NHS communication.
(2) Kaplan says I accuse him of lying to his patients, but his reference is to (an old version of) my Dilemmas at the heart of alternative medicine. It says nothing of the sort. I have said many times that I believe homeopaths are perfectly sincere, but they are just deluded. The reference to lying in the ‘dilemmas’ concerns how to get the maximum placebo effect when you know it is a placebo. Homeopaths have not reached that stage yet.
All this information has been available since May 2007. He should have checked.
Today is a good day for anyone who deplores dangerous confidence tricksters. In particular it is a good day for Ben Goldacre, and for the Guardian which defended him at potentially enormous expense.
| Matthias Rath, the Dutch (or is it German) vitamin salesman has dropped his libel action against the Guardian. He is the man who is, without doubt, responsible for many deaths form AIDS in Africa, as a result of peddling vitamin pills as cures. The action was taken after Goldacre said, in the Guardian, that Rath aggressively sells his message to Aids victims in South Africa that Rath vitamin pills are better than medication”. |  |
Here is some of what has appeared already today
Fall of the doctor who said his vitamins would cure Aids – from The Guardian, with a video of the villain.
Goldacre’s Badscience blog article on his victory .
Profile of Zackie Achmat – from The Guardian, Mr Achmat is the founder of the Treatment Action Campaign , instrumental in exposing Rath.
Extract from witness statements from the defence in the trial .
And a lot of publicity from Gimpyblog (“Ben Goldacre and The Guardian triumph over murderous Matthias Rath”), Holfordwatch , Quackometer and jdc325 blogs.
Then more in the Guardian the next day, Chris McGreal investigates the Rath Foundation
Nutritional therapist?
Let’s be clear about what the words mean. Nutritional therapists are not like dietitians, and they are not like nutritionists. Nutritional therapists are solidly in the camp of alternative medicine practitioners, Don’t
take my word for it. They say so themselves.
“For nutritional therapists (who practise Complementary and Alternative Medicine) optimum nutrition encompasses individual prescriptions for diet and lifestyle in order to alleviate or prevent ailments and to promote optimal gene expression through all life stages. Recommendations may include guidance on natural detoxification, procedures to promote colon health, methods to support digestion and absorption, the avoidance of toxins or allergens and the appropriate use of supplementary nutrients, including phytonutrients.”
They love to use imaginary words like “detoxification”, and, much more dangerously, they love to pretend that they can cure diseases by changes in diet. As long as you buy from them a stack of expensive “supplement” pills, of course. That means they are selling medicines, but by pretending they are selling food supplements they manage to evade the law that requires medicines to be safe and effective. That will not be so easy under new legislation though, and we can look forward to a few prosecutions soon.
Guess who runs an “Honours BSc degree” in Nutritional Therapy. No prizes for realising it is the UK’s leading university purveyor of woo.
The University of Westminster
On their web site we learn that the Course Leader is Heather Rosa, and the Deputy Course Leader is Val Harvey. Harvey qualified in the subject at the Institute of Optimum Nutrition, the private college run by none other than the famous pill-peddler, Patrick Holford, about whom so very much has been written (try Holfordwatch, or the masterly chapter in Goldacre’s Bad Science)
We don’t know much about what is taught on the Nutritional Therapy course because the University of Westminster has refused repeated requests to say (but watch this space).. One can only assume that, whatever it is, they are not very proud of it. It seems a little unlikely that they will go as far as Matthias Rath and claim to cure AIDS -we’ll just have to wait and see. Meanwhile we can get an inkling by looking elsewhere.
Course leader, Heather Rosa, pops up for example, on the expert panel of a web site called Supplements Compared.com. “Supplements Compared is designed to help you find the best dietary supplement product for your health needs.” And what sort of advice do you find there? Try the page that compares 10 brands of CoQ10 (that is the stuff I wrote about recently, in “Boots reaches new level of dishonesty with CoQ10 promotion” – their advertising was deemed improper by the ASA ). It isn’t a recommended treatment for anything at all, but you certainly wouldn’t guess that from what is written by the ‘expert panel’. The winners are, according to the ‘expert panel’, Boots’ CoQ10 and Holland and Barrett’s CoQ10. Winners? Perhaps the explanation for that comes elsewhere, under “How are we funded?”. “Manufacturers who are awarded “best product” and “worth a look” are given the opportunity to promote this fact throughout the site for an additional fee.”. Well well.
Deputy Course leader, Val Harvey has her own web site and business (I do hope thar Westminster does not pay these people a full time salary too). What can we glean from there? It has the usual scare tactics “Why
you are at risk?“. Never fear; buy enough vitamin pills and you’ll be saved.
Her home page makes some pretty drastic claims.
“Potential health benefits of your nutritional programme
An appropriate Nutritional Programme can benefit many conditions including:
Allergies
Arthritis
Asthma
Bloating, indigestion
Chronic degenerative diseases
Chronic fatigue, ME
Constipation, diarrhoea
Cystitis
Depression, mood swings
Digestive or bowel problems
Eczema, psoriasis, other skin problems
Food sensitivities
Frequent infections
Hormone imbalanceHypertension or elevated cholesterol
Irritable bowel syndrome
Low energy
Menopausal symptoms
Migraines, headaches
Parasitic and fungal infections
Pre-conceptual issues
Premenstrual syndrome (PMS)
Sinus congestion
Stress
Thrush
Weight problems
and many others ….
These are just some of the wide range of health problems that may be helped by nutritional therapy. Even those who consider themselves well and healthy may be able to enhance their physical and mental health, as well as their performance, including athletic performance, by improving their nutrition.”
There is, in my view, not the slightest bit of good evidence that swallowing vitamin pills can benefit most of these conditions.
But at least the list doesn’t contain AIDS, so is all this really relevant to the case of Matthias Rath?
Yes, I believe it is. The University of Westminster may well not support the views of Matthias Rath (they won’t say), but we have heard no choruses of protests about him from any nutritional therapists, as far as I’m aware. There is no mention of him at all on the web site of the British Association of Nutritional Therapists (BANT), the UK club for these people. BANT, by the way, has a rather curious code of ethics. It allows its members to take undisclosed financial kickbacks for the pills they prescribe to patients. If doctors were caught doing that they’d be struck off the register.
It is the existence of degrees in subjects like “nutritional therapy” that gives the subject a spurious air of respectability which allows seriously dangerous people like Rath to flourish with very little criticism. In an indirect way, the vice-chancellors who allow it to flourish (and Universities UK who do nothing about it) must bear some small part of the responsibility for the deaths of thousands of people from AIDS.
It is about time they did something about it.
Follow-up
ANH. The first reaction from the supplement-peddling industry comes from the Alliance for Natural Health on 16th September. It contains not one word of condemnation for Rath’s murderous activities. It’s hard to believe how low they will sink.
The Prince’s Foundation for Integrated Health remains totally silent about Rath. HRH’s concern for health seems to dry up if things don’t suit his views.
The British Association of Nutritional Therapists shows it’s total irresponsibility after a letter was sent to them to ask about their reaction. Their answer , on jdc325’s weblog was “The association has no opinion to offer on Dr Raths vitamin trials.”.
There have been some really excellent books about quackery this year. This isn’t one of them, because
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Nice dedication uh? |
it is about a lot more than quackery It is about the scientific method in general. and in particular about how often it is misunderstood by journalists. Abuse of evidence by the pharmaceutical industry is treated just as harshly as abuse of evidence by homeopaths and you get the low-down on both.
“More importantly, you will also see how a health myth can be created, fostered and maintained by the alternative medicine industry using all the same tricks on you, the public, which big pharma uses on doctors. This is about something much bigger than homeopathy.” (p.28)
Sir Iain Chalmers, a founder of the Cochrane Collaboration , co-author of the best lay text on evidence says: “Bad Science introduces the basic scientific principles to help everyone become a more effective bullshit detector”. And there is no more invaluable skill than being a bullshit detector.
Chalmers says also “Ben Goldacre has succeeded where the ‘public engagement in science’ organisations have so signally failed.” That is exactly right. ‘Public engagement’ has rapidly become bureaucratised, and at its worst, is no better than a branch of the university’s marketing department. This sort of public engagement corrupts as much as it enlightens. Goldacre enlightens, and he also makes you laugh.
In the introduction, Goldacre says
“You cannot reason people out of positions that they didn’t reason themselves into.” (p xii)
It’s a nice point, but the rest of the book makes a magnificent attempt to do just that.
There is quite a lot about medicine, of course, that’s his job, after all. But it isn’t all quackery by a long chalk Quackery is merely a good hook to hang the arguments on about how you distinguish what’s true from what isn’t. That’s partly because quacks make every mistake known to mankind (sometimes through ignorance, sometimes just to boost sales), and partly just because it is a topic that interests people, and with which they are bombarded every day I feel exactly the same. If I were to talk about the statistics of single ion channels, nobody would read it (big mistake -it’s fascinating), but if one can use the case of honey versus cough medicine to explain the analysis of variance, there is a chance that someone might find it interesting.
As much as anything, Goldacre’s book is about C.P. Snow’s two cultures. The chapters on the distortion and trivialisation of science in the media are just terrific.
“My basic hypothesis is this: the people who run the media are humanities graduates with little understanding of science, who wear their ignorance as a badge of honour. Secretly, deep down, perhaps they resent the fact that they have denied themselves access to the most significant developments in the history of Western thought from the past two hundred years.” Chapter 11, p. 207
“.. . . here is the information I would like from a newspaper to help me make decisions about my health, when reporting on a risk: I want to know who you’re talking about (e.g. men in their fifties): I want to know what the baseline risk is (e.g. four men out of a hundred will have a heart attack over ten years); and I want to know what the increase in risk is , as a natural frequency [not as relative risk] (two extra men out of that hundred will have a heart attack over ten years). I also want to know exactly what’s causing that increase in risk -an occasional headache pill or a daily tub full of pain-relieving medication for arthritis. Then I will consider reading your newspapers again, instead of blogs which are written by people who understand research , and which link reliably back to the original academic paper, so that I can double check their précis when I wish. ” (p. 242)
I detect some ambiguity in references to things that aren’t true. Sometimes there is magnanimity. At other times he is a grade one kick-ass ninja. For example
I can very happily view posh cosmetics -and other forms of quackery -as a special, self-administered, voluntary tax on people who don’t understand science properly (p. 26)
Of course nobody wants to ban cosmetics, or even homeopathy. But a lot of bad consequences flow from being over-tolerant of lies if you take it too far (he doesn’t). The lying dilemma and the training dilemma are among them. Some unthinking doctors will refer troublesome patients to a reflexologist. That gets the worried-well out of their surgery but neglects the inevitable consequence that Human Resources box-ticking zombies will then insist on having courses that teach the big toe is connected to the kidney (or whatever) so that reflexologists can have an official qualification in mystical mumbo-jumbo.
Is there anything missing from the book? Well inevitably. There are plenty of villains among the peddlers of nutri-bollocks, and in the media. But there isn’t much about the people who seem to me to be in some ways even worse. What about the black-suited men and women in the Ministry of Health and in some vice-chancellors’ chairs who betray their institutions and betray the public through some unfathomable
mixture of political correctness, scientific ignorance and greed? What about the ludicrous behaviour of quangos like Skills for Health? You have to wait right to the end of the book to hear about universities. But when it comes, it is well worth the wait.
“I’m not surprised that there are people with odd ideas about medicine, or that they sell those ideas. But I am spectacularly, supremely, incandescently unimpressed when a a university starts to offer BSc science courses in them.” (p. 317)
It’s almost worth buying Ben Goldacre’s book for that sentence alone.
This book is a romp through the folly, greed and above all the ignorance of much in our society. It’s deeply educational. And it makes you laugh. What more could you want?
My original piece on Integrative Baloney@Yale was posted on May 16th, after I got back from a visit there. The talk I gave there included a short video. My movie, Integrative baloney@Yale, was made entirely from clips taken from Yale’s own YouTube movies which showed something approaching three hours of its “1st Annual Scientific [sic] symposium”, entitled “Complementary and Alternative Medicine: Evidence for Integration”. I had merely interspersed a few titles to show the worst scientific absurdities of that rather pathetic event. YouTube removed the movie last week.
You can download the movie here [15.8 Mb, wmv file].
It should soon reappear on YouTube (actually it took over a month and several reminders, but eventually they kept their word in the end).
Yale’s lawyers had written to YouTube, to have my movie removed. I guess if you have no evidence, all you can do is resort to law to suppress the views of those who have the temerity to point out that the emperor is naked. Last week it was New Zealand Chiropractors’ Association Inc. This week the rather more substantial Yale University. We live in interesting times.
This is what I got on 15th August.
| Dear Member
This is to notify you that we have removed or disabled access to the following material as a result of a third-party notification by Yale University, Yale School of Medicine (CME) claiming that this material is infringing: Integrative baloney@Yale: http://uk.youtube.com/watch?v=HEl2fhfGBdI Please Note: Repeated incidents of copyright infringement will result in the deletion of your account and all videos uploaded to that account. In order to prevent this from happening |
If you clicked on the link you saw
“This video is no longer available due to a copyright claim by Yale University, Yale School of Medicine (CME)”
It seems that Yale’s Continuing Medical Education (CME) department was responsible.
Of course Yale is correct. I expect they own the copyright of their original movies, but they are not what I posted. I would argue that selecting 6 minutes from a 3 hour original amounts to “fair quotation”, no different from when one cites a short passage from somebody else’s book or paper. Perhaps Yale was just a bit jealous that my movie was getting viewed a lot more times than theirs. Or perhaps they were a bit peeved that a Google search for “Yale Integrative Medicine” produced my movie as #2 (add the word movie and I was #1).
My movie seems to me to be fair comment from someone who is a pharmacologist by trade. Apparently it didn’t seem that way to the apparatchiks of Yale Medical School, who seem to think that academic arguments should be settled by paying lawyers to suppress views they don’t like, rather than by rational discussion.
It’s interesting that the three hours of Yale’s own movie have also vanished from YouTube. Could that be because they realise that the remarks made at the meeting are so embarrassing intellectually that it would be better not to make them public? Actually, no.
What does Yale CME say?
Rather than publishing this straight away, I thought it better to delve a bit further into what had happened. I lodged an appeal with YouTube and I wrote to Ronald J. Vender, MD (Associate Dean, YSM Clinical Affairs, CMO, Yale Medical Group, Medical Director, Yale CME ). The outcome was rather interesting.
First, it turned out that the original posting of the three hours of the symposium proceedings on YouTube was itself unauthorised, which is why it suffered the same fate as my movie.
Dr Vender told me that he is new to the job, and didn’t know about the incident. What’s more surprising, he said he “did not know an Integrative Program even existed at Yale”. That does seem a bit odd indeed for an Associate Dean of Clinical Affairs.
However, Dr Vender turned out to be a very reasonable man,.After some amiable correspondence over the weekend, it took him only a day and a half to sort the matter out. After talking to Yale’s attorney, he wrote on 19th August, thus
“The University attorney believes that there is in fact a difference between the initial unauthorized filming of an entire conference as opposed to quoting from that conference. Therefore, she has agreed to withdraw the injunction that has been imposed on your use of the material. YouTube will be contacted.”
That’s good for me, but it isn’t the main thing. The movie would doubtless have been seen by more people if Yale had tried to maintain the ban. Much more impressively, Dr Vender also said
“As for this particular program, I will be speaking with Dr Belitsky and the program directors to encourage them to adopt a more critical view of the scientific basis for claims made by proponents of CAM. They will also be encouraged to develop a future program that includes faculty who have opposing points of view.”
It remains to be seen what actually happens, but so far, so good.
What next?
The removal of the original videos of the meeting is understandable because they were pretty embarrassing to Yale. But can that be the real reason? I was told that it is simply because their posting was “unauthorised”. But Yale Continuing Medical Education still boasts about the meeting on their own web site. They describe the meeting as “successful”, but if they are so proud of it, why remove the video from YouTube whether it was authorised or not? We are told
“The symposium, accredited for 7.5 AMA PRA Category 1 Credits, began what is hoped to be a long tradition at the Yale School of Medicine.”
They give credits for such miseducation?
Dr Katz’s phrase “we need a more fluid concept of evidence” now gets about 148 hits in Google, since I first helped him to publicise it.
Two of the six “learning objectives” that Yale CME lists for this symposium are particularly revealing.
- Describe therapeutic benefits and recent scientific evidence supporting a wide range of safe and practical complementary treatments, including acupuncture, massage, yoga, meditation, nutrition and exercise
- Identify and discuss barriers to CAM use, practice and research, as well as propose ways of overcoming these barriers
‘Describe the evidence supporting complementary treatments’? But don’t on any account describe the much more substantial evidence that does not support them? A question (or “learning objective”) put in this loaded way is the very antithesis of education.
Equally the second ‘learning objective’ carries with it the assumption that CAM works, otherwise why would anyone want to overcome the barriers to it?
This is indoctrination, not education. It betrays everything that a university should stand for.
Let’s hope the new head of CME, the admirable Dr Vender, succeeds in doing something about it
Follow-up
Success!. Well I think it is success. On 26 November 2008, the admirable Dr Vender wrote to me as follows.
“I do not know if another CAM/Integrative Medicine program is planned at Yale. However, based on the new ACCME standards, this program does not fulfil the standards for receiving CME accreditation (by my interpretation of the standards). At least one of last year’s program directors has been notified already.”
The extent to which irrationality has become established in US Medicine is truly alarming I wrote about Quackademics in the USA and Canada on my last trip to the USA, and on my May trip I visited Yale, where I decided to try a full frontal attack. [download the poster]
Several US blogs have written about this phenomenon. For example the incomparable Orac at the The Academic Woo Aggregator , and Dr RW (R.W. Donnell) , see particularly his articles on How did pseudoscience get admitted to medical school? and What is happening to our medical schools? Abraham Flexner is turning over in his grave. Excellent US stuff too at Science-based Medicine (try this and this). There is also a good analysis of what’s happening at Yale by Sandy Szwarc at Junkfood Science.
Remember that the terms ‘integrative’ and ‘complementary’ are euphemisms coined by quacks to make their wares sound more respectable, There is no point integrating treatments that don’t work with treatments that do work.
‘Integrative Medicine’ at Yale says, like all the others on the roll of shame, says “we aim to improve awareness and access to the best in evidence-based, comprehensive medical care available worldwide”. They all pay lip service to being “evidence based”, but there is just one snag. It is untrue. In almost all cases, the evidence is either negative or absent. But this does not put them off for a moment. The whole process is simply dishonest.
The evidence
The evidence has been summarised in several books recently, The following books are particularly interesting because they are all ‘views from the inside. Edzard Ernst is the UK’s first Professor of Complementary Medicine. Barker Bausell was research director of an NIH funded Complementary and Alternative Medicine Specialized Research Center at the University of Maryland.
The first two books go through the evidence fairly and carefully. They show no bias against alternative treatments (if anything, I’d say they are rather generous in cases of doubt).
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For a first class US account try Barker Bausell’s Snake Oil Science
Bausell’s book gives an excellent account of how to test treatments properly, and of all the ways you can be fooled into thinking something works when it doesn’t. Bausell concludes
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| For an excellent account of how to find the truth, try Testing Treatments (Evans. Thornton and Chalmers). One of the authors, Iain Chalmers, is a founder of the Cochrane library and a world authotity on how to separate medical fact from medical myth. |  |
It can now be said with some certainty that the number of alternative treatments that have been shown to work better than placebo is very small, and quite possibly zero,
With that settled, what’s going on at Yale (and many others on the roll of shame)?
David L. Katz, MD, MPH, FACPM, FACP, is founder and director of the Integrative Medicine Center (IMC) at Griffin Hospital in Derby, Connecticut. He is also an associate professor, adjunct, of Public Health and director of the Prevention Research Center (PRC) at the Yale University School of Medicine in New Haven, Connecticut.
That sounds pretty respectable. But he is into not just good nutrition, exercise, relaxation and massage, but also utterly barmy and disproved things like homeopathy and ‘therapeutic touch’.
| Watch the movie
It so happens that Yale recently held an “Integrative Medicine Scientific Symposium”. Can we find the much vaunted evidence base there? That is easy to answer because three hours of this symposium have appeared on YouTube. So this is the public face of Yale medical school. There’s some interesting history and a great deal of bunkum and double-speak. To save you time, I’ve cut out about 6 minutes from the movies. |
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View or download the movie here > [18.5 Mb, flv file].
Dean of education Richard Belitsky and Dr David Katz
Pretty remarble uh? Dr Katz goes through several different trials, all of which come out negative. And what is his conclusion? You guessed.
His conclusion is not that the treatments don’t work but that we need a “more fluid concept of evidence” .
It’s equally bizarre to hear Richard Belitsky, Dean of Medical Education at Yale saying he is “very proud” of this betrayal of enlightenment values. If this is what Yale now considers to be education, it might be better to go somewhere else.
This is not science. It isn’t even common sense. It is a retreat to the dark ages of medicine when a physician felt free to guess the answer. In fact it’s worse. In the old days there was no evidence to assess. Now there is a fair amount of evidence, but Dr Katz feels free to ignore it and guess anyway. He refers to teaching about evidence as ‘indoctrination’, a pretty graphic illustration of his deeply anti-scientific approach to knowledge. And he makes a joke about having diverted a $1m grant from CDC, for much needed systematic reviews, into something that fits his aims better.
Katz asks, as one must, what should we do if there is no treatment that is known to help a patient. That is only too frequent a problem. The reasonable thing to say is “there is no treatment that is known to help”. But Dr Katz thinks it’s better to guess an answer. There is nothing wrong with placebo effects but there is everything wrong with trying to pretend that you are doing more than give placebos. Perhaps he should consider the dilemmas of alternative medicine.
You can read about more about Yale’s activities here and in interviews here. Dr Katz says “The founding approach—and I think Andrew Weil, MD, gets the lion’s share of credit for establishing the concept —is training conventional practitioners in complementary disciplines”. Let’s take a look at this hero. Try, for example, Arnold Relman’s “A trip to Stonesville“.
“According to Weil, many of his basic insights about the causes of disease and the nature of healing come from what he calls “stoned thinking,” that is, thoughts experienced while under the influence of psychedelic agents or during other states of “altered consciousness” induced by trances, ritual, magic, hypnosis, meditation, and the like.”
“To the best of my knowledge, Weil himself has published nothing in the peer-reviewed medical literature to document objectively his personal experiences with allegedly cured patients or to verify his claims for the effectiveness of any of the unorthodox remedies he uses.”
Here is the advertisment for Andrew Weil’s nutrition symposium.
Not only does this yet again propagate the great antioxidant myth, but a few moments with Google show that it is riddled with vested interests, as already pointed out on Quackademics in USA and Canada.
What has brought medical schools down to this level?
That isn’t hard to see, The main thing is simply money. Very few university administrators have the intellectual integrity to turn down money, whatever the level of dishonesty that is required by its acceptance. You can buy a lot of silence for $100m
The US Taxpayer has given almost a billion dollars, via NIH.
Wallace Sampson, MD says of NCCAM
“. . it has not proved effectiveness for any ‘alternative’ method. It has added evidence of ineffectiveness of some methods that we knew did not work before NCCAM was formed”
“Its major accomplishment has been to ensure the positions of medical school faculty who might become otherwise employed in more productive pursuits.”
“Special commercial interests and irrational, wishful thinking created NCCAM. It is the only entity in the NIH devoted to an ideological approach to health.”
NCCAM has given money from some very dubious trials too, Both Orac on Respectful Insolence and Dr RW (R.W. Donnell) have written recently about the NCCAM-funded trial of “chelation therapy”, as first exposed in a devastating article by Kimball C. Atwood IV, MD; Elizabeth Woeckner, AB, MA; Robert S. Baratz, MD, DDS, PhD; Wallace I. Sampson, MD on Medscape Today. This is a $30 million, 5-year, phase 3 Trial to Assess Chelation Therapy (TACT) for coronary artery disease.
“But how did such a crappy study ever come to be, much less be funded by the NIH to the tune of $30 million? The answer, not surprisingly, involves one of the foremost promoters of quackery in the federal government, Representative Dan Burton (R-IN).”
“We conclude that the TACT is unethical, dangerous, pointless, and wasteful. It should be abandoned.”
Orac comments
“TACT is not the only example of an unethical and scientifically worthless trial being funded not because the science is compelling but because powerful lobbies and legislators who are true believers in woo applied pressure to the NIH to do them”
The Bravewell Collaboration is the other major source of money. Forbes Business says “Bravewell is not some flaky New Age group”. Well dead wrong there, That is precisely what it is.
This group of ultra-rich people, according to its boss, Christy Mack, has a
So Bravewell is corrupting the search for real knowledge and real cures with big bucks. You can buy a lot of hokum for $100m. |
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The money comes from Morgan Stanley,
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Bravewell is run by his wife, Christy Mack (Mack-the-wife?) Vice-President, The C.J. Mack Foundation, Member, Board of Directors, The Bravewell Collaborative.
The Flexner report.
The story of Bravewell stands in chilling contrast to another case of philanthropy. Andrew Carnegie’s foundation financed the report by Abraham Flexner, “Medical Education in the United States and Canada” (1910) [download, 15 Mb] . That report was responsible for dragging medical education out of the dark ages
almost a century ago. It resulted in creation of some of the best medical schools anywhere (including Yale).
“By educational patriotism I mean this: a university has a mission greater than the formation of a large student body or the attainment of institutional completeness, namely, the duty of loyalty to the standards of common honesty, of intellectual sincerity, of scientific accuracy.”
“The tendency to build a system out of a few partially apprehended facts, deductive inference filling in the rest, has not indeed been limited to medicine, but it has nowhere else had more calamitous consequences.”
Flexner (1910).
Now another philanthropist is using big bucks to reverse the process and push medicine back into the 19th century.
Flexner would have thought it quite inconceivable that in 2007 medical schools would be offering Continuing Medical Education in homeopathy.
Why are Yale’s academics so quiet about this?
Perhaps they don’t even know it’s happening. If they say firmly that they don’t want it, it will go,
It’s been done before
Florida State University, allegedly under political pressure, proposed to set up a school of Chiropractic. That would have made it Florida State school of snake-oil salesmanship. What a sad fate. [ Science magazine comment] [comment form Paul Lee] [Comment in St Petersburg Times]
But the academics stopped it. An FSU professor, Albert Stiegman, predicted the future campus map.
According to FSUnews
“The Florida Board of Governors voted 10-3 Thursday to deny Florida State University’s request to build a chiropractic school.”
“However, the passage of the bill for the chiropractic school by the Legislature seemingly bypassed the Board of Governors.”
In the end, reason won. Let’s hope that Yale follows their example.
Follow up
The problem of Yale has been taken up with great eloquence by some US commentators
Dr RW (R.W, Donnell): “Quackademic Medicine at Yale”
“By the way, where’s the AAMC in all this? Aren’t they supposed to be guardians of integrity and professionalism in medical education? Are they asleep at the switch or is money silencing them too?”
Orac (Respectful Insolence): “Integrative” medicine at Yale: A more “fluid” concept of evidence?”
“after the Dean of the Yale School Medicine embarrassed himself in the introduction by saying he’s proud of how far this nonsense has come, Dr. Katz takes the stage and demonstrates the sort of hostile attitude towards science that, if allowed to take root will be the death of scientific medicine in any meaningful form at U.S. medical schools”
Junkfood Science. Sandy Szwarc on “Quote of the day: ;We need a more fluid concept of evidence’”
“Will healthcare professionals and consumers . . . . speak out against these wellness programs being enacted by government agencies, insurers and employers? Or is the money too good?”
Science-based Medicine. Steven Novella writes on “Changing the rules of evidence“. When alternative medicine people do not like the evidence, they change the rules to get the outcome that they want, as seen so graphically in this post. They have always done this, but it is only recently that this sort of behaviour has been endorsed by places like Yale.
The Macho Response, another US blog, comments bluntly, in “Yale wants a more fluid concept of evidence”
This is beyond embarrassing – it’s a fucking crime – and it’s happening at Yale University and many others.
If you’re in the medical profession (and I know many of my readers are) you need to go here – now.
Kiosque Médias writes as follows
Pour ceux qui s’intéressent à la médecine et à la santé, le blog de David Colquhoun vaut probablement le détour. Ce professeur-chercheur au département de neurosciences, de physiologie et de pharmacologie de l’University College London y décrypte les résultats d’études médicales, en mettant l’accent sur les médecines alternatives. Et il est rarement tendre!
James Randi Newsletter. The hit rate soars after a recommendation this piece by the amazing Randi.
Hokum-Balderdash Assay. Edwardson writes
“Yale University is going to the ducks. It now has an Integrative Medicine program and in April held its first annual Integrative Medicine Scientific Symposium. I think there must’ve been a typo there. They must’ve meant “Ist Annual I.M. Pseudoscientific Symposium.” There! Now we’ve done away with the oxymoron.”
Why is Yale so secretive about its quackery department?,
Most universities are only to keen to boast about their grant income. Not in this case though. When I asked how they funded their quackery, all I got was a letter that had very obviously been drafted by a lawyer.
“As a private institution, Yale University is not generally subject to the U.S. Freedom of Information Act. We therefore respectfully decline to compile and provide the information you have requested.”
So pretty clear signs of guiltiness there.
Dr David Katz, yes, he of the “fluid concept of evidence”, has posted an article, Health Hazards of rhe Blogoshere. If it quacks like a duck . . .
It seems that he has been a bit alarmed by the reaction of the bloggers. It starts, rather pompously, thus.
“Being well educated does not guarantee you’ll always be right, and it certainly doesn’t guarantee everyone will agree with you. But it still matters. Or at least it used to “
But the rest if it reads less like a defence than as an admission of guilt, thus prompting the next item.
Paul Hutchinson’s blog
| A quack who admits it picks out a quotation from Dr Katz’s response and turned into a cartoon, released to the public domain, So here it is. |  |
Respectful Insolence.
Orac comments too, in “Fluid evidence” strikes back: Dr. Katz versus the skeptical blogsophere”. He does a terrific job in taking apart the response from the hapless Dr Katz.
“No, Dr. Katz does not like his first encounter with the medical blogosphere at all. Indeed, he is so unhappy that apparently a few weeks ago he tried t answer the bloggers who had raked him over the coals for blatantly advocating “integrating” unscientific woo like homeopathy with scientific medicine. Unfortunately for him, he did not do a particularly good job of it. Indeed, what most stood out as I read his rejoinder was that he does not answer a single substantive criticism leveled at his comments. Not one. Instead, he does what pretty much all woo-meisters do when criticized for shifting goalposts and appealing to other ways of knowing besides science as a means of “proving” that their preferred fairy dust works; he wraps himself in the mantle of the brave iconoclast willing to challenge accepted dogma and whines about the peons who criticized him, heaping contempt on the bloggers who had the temerity to criticize his advocacy for pseudoscience because to him they have not earned the right to criticize his (at least in his opinion, apparently) greatness in comparison to him.”
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The Times published a letter from Edzard Ernst and Simon Singh on April 16th. In their forthcoming book, Trick or Treatment? Alternative Medicine on Trial, they go carefully through all the evidence for all sorts of ‘alternative’ treatments. They find some evidence that a handful of them work. For most the answer is ‘not enough evidence’, and for a number there is good evidence that many of them don’t work to any useful extent.
“Sir, For over two decades the Prince of Wales has been actively promoting alternative medicine and his Foundation for Integrated Health continues to encourage the use of treatments such as homoeopathy or reflexology.””In light of this “rigorous scientific evidence”, we strongly advise that the Prince of Wales and the Foundation for Integrated Health withdraw the publications Complementary Health Care: A Guide for Patients and the Smallwood report. They both contain numerous misleading and inaccurate claims concerning the supposed benefits of alternative medicine. The nation cannot be served by promoting ineffective and sometimes dangerous alternative treatments.”
Thank heavens that someone has the courage to say it as it is.
If only the ineffectual and ill-educated people in the Department of Health wouold do the same. But no, instead they gave £37 000 to the Prince of Wales Foundation to write their make-believe guides. And £900 000 to write nonsense for the Complementary and Natural Healthcare Council (also known as Ofquack), and Skills for Health,
The next day The Times ran an article by their science editor, Mark Henderson, Prince of Wales’s guide to alternative medicine ‘inaccurate’. Natasha Finlayson, of the Prince’s Foundation for Integrated Health, is quoted as saying “The foundation does not promote complementary therapies.”. That takes some beating for sheer bare-faced dishonesty.
Edzard Ernst appeared on the Today Program on 18th April. He was interveiwed by the formidable John Humphrys, along with Kim Lavely, Chief Executive, The Prince’s Foundation for Integrated Health (FIH). Ernst points out that the FIH guide suggests that chiropractic is effective in asthma, and that acupuncture is good for addiction, whereas the evidence says the opposite. Lavely retorts, rather lamely (OK I’m biassed).
Lavely: ” . . . we didn’t attempt to give detailed evidence on every therapy”. “We think they [the public] have the right to know and what doesn’t”
Humphrys: “Well isn’t that the whole point? the professor is saying here is that these things do not work, at least in terms of the claims that are made for them, such as homeopathy and chiropractic . . . ”
Lavely: “There are no claims made in this guide for what works and what doesn’t. What we have said is that some therapies are used for some things but we aren’t saying they are effective for those things . . . “
So, one might ask, what on earth is the use of a guide is it that offers no indication of effectiveness? Lavely’s second quotation contradicts directly her first. A pretty pathetic performance.
Listen to the interview [mp3 file]
The Sunday Times, on April 20th, pblished a pretty good review of Trick of Treatment?. “Their case against the folly, vanity and damage of HRH et al. is hard to argue with.”
Of course, the letters column drew the expected response from the quacks, most verging on the hilarious.
Another blow for the alternative industry came in the same week, The authoratitve Cochrane review confirmed earlier reports that vitamin supplements not only do not help you but some actually increase mortality. The antioxidant myth nevertheless rumbles on, and on, and on. There is too much money in it for it to die easily.
Predictably enough, the conclusions were denied by the Health Food Manufacturers’ Association (HFMA). They wheeled out several pop singers to say how wonderful their products are. Read about that pathetic defence on Holfordwatch.
Who is behind HFMA? Incidentally, HFMA are strangely reticent about the identity of their 120 members. They will not reveal who they are. Does anybody out there know the answer? I’ll buy a good dinner for anyone who can root this out. If it is anything like the ‘Health Supplements Information Service‘ it is likely to be backedby the very big pharmaceutical companies that the alternative industry loves to hate.
Take the test
Prince of Wales Guide
“Reflexologists work with a wide range of conditions including certain types of pain, particularly back and neck pain, migraine and headaches, chronic fatigue, sinusitis, arthritis, insomnia, digestive problems such as irritable bowel syndrome, and constipation, stress-related disorders and menopausal symptoms.”
Singh & Ernst
“The notion that reflexology can be used to diagnose health problems has been disproved and there is no convincing evidence that it is effective for any condition.”
Boots the Chemists have proved themselves dishonest before, over their promotion of homeopathy and of B Vitamins “for vitality”
In a press release dated 12 March 2008, they have hit a new low in ethical standards
| Boots help boost the nation’s energy levels in just one week “Health and beauty expert Boots has launched an exclusive energising vitamin supplement that helps boost depleted energy levels and maintain vitality. It is the first time that this exclusive form of CoQ10 has been made available on the high street.” ” . . .supplementation can help to supply higher levels of CoQ10 than are available in the diet. Boots Energy Super Strength CoQ10 containing natural Kaneka CoQ10 is a way of boosting energy levels that can help people who lack energy to see results in a week” |
You decide.
Last year there was an equally misleading press release about CoQ10 from Solgar/Boots Herbal. That one was headed “Need More Energy – Solgar’s Nutri Nano™ Uses Nanotechnology to Deliver Unprecedented Bioavailability of CoQ10”. Not only is the word ‘energy’ misused but notice that the trendy term ‘nanotechnology’ is worked in for extra sciencey effect. It turns out that all this means is that the preparation contains micelles. So nothing new there either. Micelles have been known for almost 100 years.
In contrast, the Boots online store is noticeably more restrained. Could that be because the Advertising Standards People can’t touch press releases, just as they can’t control what Boots Expert Team tell you face to face in the shop?
Boots PR contact is given as: Carrie Eames, PR Manager, Boots The Chemists, D90W WG14, Thane Road, Nottingham NG90 1BS. I’m not sure how Ms Eames sleeps at night. Perhaps you should write to her and let her know what you think.
You might point out to her Boots (anti) Social Corporate (ir)Responsibility Page. It says
| “So it’s part of our heritage to treat our customers fairly and act with integrity in everything we do, rather than seizing on the quickest and easiest way to turn a profit.” |
CoQ10 and “energy”
Coenzyme Q10 (also known as ubiquinone) is a relatively small molecule. It cooperates with cytochrome enzymes (big proteins) to synthesize a molecule called ATP. This is a chemical form of energy that can be used to do work, such as making a muscle fibre contract.
The word “energy ” here is used in the sense that a physicist would use it. It is measured in joules or in calories. The meaning of the word ‘energy‘ is described nicely in the Wikipedia entry. For example, when an electric current passes through a resistor (like a kettle) the electrical energy is converted to heat energy, and the energy used is potential difference (volts) X current (amps) X time. In other words energy is power (in watts) times time. So another unit for energy is kilowatt-hours (one kilowatt-hour is about 3.6 megajoules).
Energy in this sense has nothing whatsoever to do with the everyday use of ‘energy’ to indicate your vitality, or how lively you feel.
Furthermore there is not the slightest empirical reason to think that CoQ10 makes you feel more lively. None. The press release cites a sciencey-sounding reference (Ernster L, Dallner G. Biochemical, physiological and medical aspects of ubiquinone function. Biochim Biophys Acta. 1995 May 24;1271(1):195-204.). But this paper is just a review of the biochemistry, nothing whatsoever to do with feeling good.
CoQ10 and the supplement business
There is nothing new in this big push by Boots. CoQ10 has been a staple of supplement business for a long time now. All sorts of medical claims have been made for it. Everything from migraine, to Parkinson’s disease to cancer has been raised as possible benefits of the magic drug, oops, I mean ‘supplement’. This is quite improper of course, since it is being sold as a food not as a medicine, but it is standard practice among supplement hucksters, and so far they have been allowed to get away with it.
What’s interesting though is that until Boots PR machine swung into action, one thing that hadn’t been claimed much is that it made you feel more lively. That’s one they just invented.
CoQ10 and the press
It’s standard technique to get free advertising by hoping that journalists will dash off an article on the basis of a press release, with the hope that they will be in too much hurry to check the spin. Too often it works.
The Daily Mail has big coverage of the press release, under the title “Can a 60p pill from the chemist really add years to your life?“. This was written by Anna Hodgekiss and it’s not bad. It starts with a nice note of scepticism
“Forget vitamins C, E or even B12. The real wonder supplement is Coenzyme Q10 or CoQ10. That’s what Boots would have you believe, anyway. ”
“So should we all be taking this supplement?Not according to David Colquhoun, professor of pharmacology at University College London, who says Boots’ claims are “deliberately misleading customers”.
“Yes, CoQ10 helps the body convert glucose into energy, but it’s not the psychological get-up-and-go energy you feel day to day.
“The type of energy it does produce powers our muscles and cells – physical energy. They have confused the two here to promote a product that I’m not convinced would make any difference to how you actually feel at all.”
The article goes on
Among the other sceptics is Scott Marsden, a senior dietician at The London Clinic.
“There haven’t been enough trials to warrant us all taking CoQ10,” he says.
“It sounds boring, but if you are healthy and eating a balanced diet, you will get all the nutrients you need and shouldn’t have to take supplements.
“Not only could you be spending money unnecessarily, you could also be putting your health at risk. Buy some wholesome food instead.” “
Dr Clare Gerada, vice chairman of the Royal College of General Practitioners, is more forthright.
“While there is some evidence to suggest CoQ10 supplements may help patients with heart failure or severe respiratory disorders, more work is needed,” she says.
“This is just another example of normal health being medicalised, and it’s an issue that worries me.
“The human body is an amazing machine, and we have never been in better health. The fact that more people are living well into their 80s and 90s is proof.
“People need to stop looking for a wonder pill in their quest to live for ever.”
But guess who comes out fighting for Boots? None other than my old friend Dr Ann Walker. Little wonder then that my Nutriprofile result recommended a co Q10 supplement, because she is involved in that too.
Ann Walker’s colleague on the Nutriprofile project, Dr Sarah Brewer comments on CoQ10 on the Healthspan site, thus.
“As CoQ10 is vital for energy production in muscle cells, lack of CoQ10 is linked with lack of energy, physical fatigues, muscle aches and pains . . .”
It seems that she also can’t distinguish between energy in joules and energy as vitality,
Female First and Marie Claire also carry a story “Boots Sell ‘Life Extending’ Pill”
“A new pill that claims to add years to our lives is due to hit shelves in Boots stores this week but scientists say the drug is misleading.”
“Despite these claims Professor David Colquhoun told Marie Clare that he believes the drug is ‘deliberately misleading customers’: “Yes, CoQ10 helps the body convert glucose into energy, but it’s not the psychological get-up-and-go energy you feel day to day,” he said.”
(Funny, I never consciously spoke to Marie Claire but the quotation is OK.)
The Times, in contrast, carries an appalling column by their Dr Thomas Stuttaford, “A natural solution to tiredness“. There isn’t even a question mark in the title, and the content is totally uncritical. Private Eye has nicknamed the author ‘Dr Thomas Utterfraud’. How very cruel.
See also, excellent articles on CoQ10 by Ben Goldacre in the Guardian, and at badscience.net, and at Holfordwatch and Dr Aust’s Spleen
Aha Boots have repeated their mendacious claims in newspaper advertisements
This appeared in the Guardian on 18 March, and I’m told it was in the Mail too.
The small print says
“The new Boots Energy supplement contains Kaneka Q10 to help boost your energy levels throughout the day”
Here is what I just sent to the Advertising Standard Authority, or email new.complaints@asa.org.uk . Why not have a go yourself?
| “The words “boost your energy levels” and “still lacking energy” constitute a (presumably deliberate) confusion beteen ‘energy’ measured in joules and the everyday use of the word ‘energy’ to mean vitality. The former usage would be justified in viewof the role of Coenzyme Q10 in ATP production. There is neither theoretical justification nor any empirical evidence that CoQ10 helps your vitality or ‘energy’ in the latter sense.” |
A full size graphic to attach to your complaint can be downloaded here.
We are all interested in the relationship between our health and what we eat. What a pity that so little is known about it.
The problem, of course, is that it almost impossible to do randomised experiments, and quite impossible in most cases to make the experiments blind. Without randomisation there is no way to be sure about causality, and causality is all that matters. All you can do is measure “associations” and that sort of information is simply unreliable.
For example, if you simply observe that people who eat a lot of dark green vegetables are healthier than those who don’t, there is no reliable way to tell whether their health is caused by eating the vegetables. It is just as likely that, for example, rich people are healthier because the are rich, not because they eat more vegetables. The answer, though usually not known, is the only thing that matters for offering advice. The crucial problem is that, in the latter case, it will do no good at all to bully a poor person to eat more vegetables: their health will not improve because their bad health was caused by poverty, not by lack of vegetables.
It is precisely this difficulty that results in the constantly conflicting advice that we are given about diet. I can’t think of any single thing that does more harm to real science than the fact that one week we are told that red wine is bad and the next week we are told that red wine is good. No doubt both statements were based on a naive observational studies, the significance of which is vastly exaggerated by its authors (and often by their university’s media department too).
The first job of a scientist is to be able to say “I don’t know”. Under pressure from the government’s audit culture, and the HR apparatchiks who embrace it so eagerly, all that is forgotten only too easily. he lack of certain answers about diet leaves a vacuum into which not only naive scientists are sucked, but also it is a gift for hucksters who are eager to sell you expensive ‘supplements’, whether or not you need them. As always, it is a case of caveat emptor.
The questions are important to us all, so when sciencepunk pointed out to me a chance to check my own diet, I went for it. I try to keep pretty close to the current guidelines. Unreliable though they may be, they are the best we’ve got. So I went to the Nutriprofile site, and filled in the questionnaire, quite honestly (apart from saying I was 37 -I wish).
I eat plenty of fruit and oily fish every week so I though I’d do quite well. No such luck. I ended up being told I was deficient in iron and selenium, and at “risk of deficiency” in vitamin B5 (pantothenic acid), folate, vitamins D, E, K, magnesium, copper and potassium.
Uhuh, I must really be ill and I’d never realised it.
At the bottom of this analysis of all my deficiencies comes the sales pitch, “your personalised supplement recommendations”.”Strongly recommended” for me is Gold Standard A-Z Multivitamins (just click on the “buy now” button). I’m also “recommended” to buy Omega 3 1000mg capsules.
And then I’m invited to consider a whole list of other supplements
“The following products have been given a 1 star rating. This usually means they have been recommended to meet a specific issue raised by your NutriProfile. You should consider these supplements where you feel they could help if the issue is particularly important to you”
Here is the list.
- Selenium + A,C,E,
- Echinacea (“may help you maintain a healthy immune system”).
- OptiFive (antioxidant supplement)
- Co-enzyme Q10 (“may help you maintain energy levels” -look out for a forthcoming post on this scam)
- Memo Plus (“may help you maintain brain health and cognitive function”),
- Panax Ginseng (“may help you to maintain energy levels”
- Psyllium Husks
- Magnesium
- Vitamin D
- Ginkgo Biloba
- Probiotic
As always, there are lots of fantasies about “strengthening the immune system”. And the great antioxidant myth is exploited to the full.
Puzzled by this result, I got my wife to do the questionnaire, and also a particularly healthy and diet conscious colleague.
My wife was recommended to buy Omega 3 1000mg, Osteo Plus Bone health supplement (despite telling them that she already took calcium) and 50 Plus Multivitamins (“may help you address any deficiency in essential vitamins and minerals and may also help you maintain a healthy immune system and maintain energy levels. “). And then it may not.
My spectacularly healthy and diet conscious colleague got a strongly recommended (maximum 5 stars like me) for Gold Standard A-Z Multivitamins and for Omega 3 1000mg, as well as “recommended” for plant sterols, garlic and Opti-Omega 3.
Either I’m a lot unhealthier than I thought, or Nutriprofile is a sales scam.
You decide.
Is there anyone at all who does NOT need supplements?
By this stage I was getting suspicious so I sent the link to a professional dietitian, Catherine Collins of St George’s Hospital London. Unlike the people running the site, she has no financial interest in selling you pills. I asked her to fill in the questionnaire as a hypothetical person who had an ideal diet, based on current nutritional knowledge . Surely such a paragon of dietetic virtue would not need to buy pills too?
Don’t you believe it. At least she didn’t get any 5 star “strongly recommended”, but she did get “Recommended for you” Opti-Omega 3 (3.5 stars) and Gold Standard A-Z Multivitamins (3 stars). Plus, of course the whole list of “you may like to consider”, same as everyone seems to get.
So I asked Collins how it came about that everyone seems to end up being recommended to buy pills after going through all the questions. Here is what she said.
“Apparently my ratio of omega3:6 is unbalanced. not if you ate the amount of oily fish i’d put in, and used ‘vegetable’ oil which is mono-rich rapeseed. I think they’ve used the sunflower analysis to generate this distortion.
I disagree with absolute amounts of omega-3 per day. The amount I recorded meant I would easily exceed a daily intake of 500 mg of the important omega-3 fats, EPA and DHA
Low Vitamin B6 and folate – totally incorrect recommendation based on my entries
Potassium – the survey indicated concern that diet provided 200mg per day less potassium than recommended. This was incorrect, the flaw I assume being due to inability of the questionnaire to handle portion sizes. Should I have been worried even if this had been accurate? Of course not. Potassium is widespread across food groups, the most concentrated being fruit and vegetables. It is an essential nutrient, but its requirements are relative to sodium (‘salt’) intake.
Their omega-3 fat recommendation is double the FSA/ SACN suggestion of 450mg/d – they actually quote this in their supporting information but then say ‘experts say we need double’ [their experts are below]. This is highly misleading. We need a combination of omega-3 fats in our diet for health – not only the ‘fishy’ EPA and DHA, but also the readily available ALA, found in vegetable (rapeseed) oil
Omega 3:6 ratio -completely wrong based on the foods entered. Demonstrates a major flaws in the assumptions made about type and amount of foods in the diet.
Water recommendations. Totally inaccurate information based on the myth expounded by the health food industry and its workers that caffeine is a diuretic. This been extensively researched and proven to be not true ( Grandjeans excellent work). The only way in which a caffeinated beverage is ‘diuretic’ to someone who takes caffeinated drinks regularly is in the volume of drink consumed.
She concludes
“”This appears an elaborate pill-pushing exercise. Superficially reassuring in promoting the recognised FSA (Food Standards Agency] line – but then giving undue – and unjustifiable – support to the anecdotal ‘experts recommend’ to create what will be a powerful sell”
The comment about water intake stems from this bit of Collins’ Nutriprofile:
“Caffeinated drinks, fizzy drinks and alcohol do not count because, whilst they contain water, they are mild diuretics, ie. they boost urine output and therefore should only form a small part of your total fluid intake.”
This myth (aka nutribollocks) is quite contrary to what the real research (going back to 1928) says, Check “Laying the caffeine myth to rest” for the real story..
I’m told that Healthspan are now sending out the paper questionnaire in newspapers. Presumably this is to ensure that the poor, the elderly etc and others who that aren’t computer literate don’t miss their buying opportunity. How considerate of them.
Nutriprofile’s expert team
Who is the expert team behind Nutriprofile? Here they are.
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What do the real experts say about supplements?
The story you get is quite different when you ask somebody who is not trying to sell you something
The Food Standards Agency says
“Most people should be able to get all the nutrients they need by eating a varied and balanced diet. But if you choose to take supplements, it’s important to know that taking too much or taking them for too long can cause harmful effects.”
Harvard Men’s Health Watch says
“Harvard Men’s Health Watch suggests that the average man give up the multivitamin, at least until scientists solve the puzzle of folic acid and cancer.”
“If you eat a balanced diet that includes food from all the major groups, there should be no need to take vitamin supplements. The food you eat will provide you with all the vitamins and minerals you need. “
I guess we should not be surprised at the direct contradiction between this advice and that of the Nutriprofile questionnaire. After all, Nutriprofile was developed by a company, Healthspan, that is devoted to selling “supplements” with all the dubious claims and customer testimonials associated with the alternative health industry.
But this is what always happens when big business controls science.
Postscript
Oddly enough, Ann Walker’s experience seems to be much the same as ours. In an interview on the Healthspan site we read this.
Q: Which nutritional supplements do you choose to take?
A: I regularly take a multivitamin, vitamins C and E, fish oil, and a calcium and magnesium combination. I also take vitamin D during the winter and some herbs as and when they are needed.
Even if I have improved my diet, each time I complete the NutriProfile questionnaire my requirement for a multivitamin, calcium and magnesium, and a fish oil supplement are always thrown up.
Didn’t it occur to her to wonder why?
The sales pitch was followed up on 27 March the email arrived from Healthspan “Healthspan are offering you £5 to spend towards your recommended supplements”. One can’t say whether this offer goes to people who were not recommended supplements, because so far no such person has been found.
This is the third post based on a recent trip to North America (here are the first and second)
One aspect of the endarkenment, the Wal-Mart model of a university, is very much the same in the US as in the UK. At one US university, an excellent scientist offered the theory that an alien spacecraft had scattered spores across the land which developed into HR staff who appeared at first sight to be human, and who colonised academia.
The penetration of quackademics into US universities is a bit different from in the UK.
In the UK, the plague is restricted to sixteen or so ex-polytechnic universities which, to their great shame, actually offer Bachelor of Science degress in subjects like homeopathy. There are bits of quackery in good teaching hospitals (such as laying-on-of-hands at UCLH), but not very much.
In the USA and Canada, this sort of “vocational” training does not occur much in universities, but in separate colleges. The situation is worse there though, insofar as these colleges have been allowed to award titles like ‘doctor of naturopathic medicine (ND)’, for work that in no respect compares with what the rest of the world has to do to earn a doctorate. This prostitution of academic titles has not happened to anything like the same extent in the UK. How our own quacks would love it if they were allowed to call themselves ‘doctor’ and sport the initials ND (so easily mistaken for MD at first sight).
It is on the clinical side where the situation is far worse than in the UK. Almost every university hospital, including Harvard, Yale and Stanford, has departments devoted to fairy-tale medicine.
Quacks use a number of euphemisms to make themselves sound more respectable. First they became ‘alternative medicine’, then ‘complementary medicine’. Now the most-used euphemism is ‘integrative medicine’, which is favoured by most US universities (as well as by the Prince of Wales). Raymond Tallis pointed out that this seems to mean integration of treatments that don’t work with treatments that do work.
An official roll of shame for North American universities can be seen here (35 in USA and 4 in Canada). 
A bigger collection of 44 universities has been posted by the incomparable Orac at the The Academic Woo Aggregator. He’s had good support in the USA from DrRW (R.W. Donnell), see particularly his articles on How did pseudoscience get admitted to medical school? and What is happening to our medical schools? Abraham Flexner is turning over in his grave.
All these outfits have two things in common. They all claim to be scientific and evidence-based, and none has produced any real evidence that any of their treatments work.
Here are a few examples of what’s going on.
Yale University School of Medicine
The usual theme is expressed thus.
“Through open-minded exploration and rigorous scientific inquiry, we aim to improve awareness and access to the best in evidence-based, comprehensive medical care available worldwide, with the goal of optimizing health and healing for patients”
The driving force behind the woo seems to be a fourth year medical student, Rachel Friedman, so I wrote to her to ask what useful alternative treatments had been established by research at Yale. But she could not identify any. All I got was this.
“My best advice would be to do some medline searching of metaanalyses” there’s been enough research into some of these modalities to provide for a metaanalysis.”
So she was unable to produce nothing (and anyway. metanalyses, useful though they may be, are not research).. A glance at the Yale publications page shows why.
The Scripps Institute
Scripps Center for Integrative Medicine says
“In use at Scripps since 1993, Healing Touch is an energy-based, non-invasive treatment that restores and balances energy to help decrease pain and relieve associated anxiety.
Healing Touch is performed by registered nurses who recognize, manipulate and balance the electromagnetic fields surrounding the human body, thereby promoting healing and the well-being of body, mind and spirit.”
“Balances energy”?
“manipulate and balance the electromagnetic fields surrounding the human body”?
This is just meaningless baloney. And it come from the Scripps Institute.
The Oregon Health & Science University
OHSU is an excellent and well-respected research university where I have many friends. It was a pleasure to meet them recently.
But it also has a big department of “Complementary and alternative medicine” and an “Integrated medicine service”. There are some good bits of advice mixed up with a whole range of crazy stuff. Take their page on homeopathy.
“This therapy treats ailments with very small amounts of the same substance that causes the patient’s symptoms.”
WRONG. In most cases it is zero amount. To brush this fact under the carpet is simply dishonest (and perhaps a sign of guilt). Then comes this (my emphasis)..
Explanations for why homeopathy works range from the idea that homeopathic medicine stimulates the body’s own natural defenses to the idea that homeopathic medicine retains a “memory” of the original substance.
However, there is no factual explanation for why homeopathy works and more research is needed.”
WRONG. This statement carries (twice) the expicit message that homeopathy does work, quite contrary to a mountain of good evidence that it is merely a placebo. The statement is deceptive and dishonest. And it comes with the OHSU logo.
The University of Arizona
” Heal medicine”, “Transform the world?” Modest uh?
The University of Arizona Program in Integrative Medicine is certainly not modest in its claims, but its publications page shows that it doesn’t even attempt to find out if its “therapies” actually work.
Here is an example. They are advertising their Nutrition and Health conference
heavily.
There’s nothing wrong with good nutrition of course, but the ‘alternative’ approach is instantly revealed by the heavy reliance on the great antioxidant myth.
And look at the sponsors. The logo at the top is for Pistachio Health, a company that promotes pistachio nuts: “Delicious and good-for-you, pistachios are nature’s super heart-healthy snack. Nutrient dense, full of fiber and antioxidants, pistachios give you more bang per calories than any other nut.”.
The other advertisement is ‘POM Wonderful’, a company that sells and promotes pomegranate juice, “POM is the only pomegranate juice you can trust for real pomegranate health benefits”
No doubt pistachio nuts and pomegranate juice are perfectly good foods. But the health claims made for them are just marketing and have very little basis in fact.
Now let’s look at the speakers. Take, for example, Dr David Heber, MD., PhD. He is director of the UCLA Center for Human Nutrition at the University of California, Los Angeles, a professor of Medicine and Public Health, and the founding Chief of the Division of Clinical Nutrition in the Department of Medicine. He is the author of several books including “What Color is Your Diet” and the “L.A. Shape Diet.” With the possible exception of the books, you can’t sound like a more respectable and impartial source of advice than that.
But hang on. Dr Heber is to be seen in a video on the Pistachio Health web site doing what amounts to a commercial for pistachio nuts.
OK let’s take a look at one of Dr Heber’s papers. Here’s one about, guess what, pomegranate juice. “Pomegranate Juice Ellagitannin Metabolites Are Present in Human Plasma and Some Persist in Urine for Up to 48 Hours”. The work was “Supported by the Stewart and Lynda Resnick Revocable Trust and from the NIH/NCI grant P50AT00151”. So no problems there. Well not until you check POM Wonderful in Wikipedia, where you find out that Stewart and Lynda Resnick just happen to be founders of POM.
Of course none of these interesting facts proves that there is anything wrong with the work. But they certainly do show that the alternative nutrition business is at least as much hand-in-glove with big business as any other form of medicine. And we know the problems that that has caused.
So, if you want impartial advice on nutrition, sign up for the 6th Annual Nutrition and Health meeting. For “MD, DO, ND & other doctors”, it will cost you only $845 to register .
The meeting is being run by The University of Arizona College of Medicine and Columbia University’s College of Physicians and Surgeons.
The University of Arizona is, incidentally, also the home of the famous (or perhaps infamous) Gary Schwartz (see also, here). He “photographs” non-existent “energy fields” and claims to be able to communicate with the dead, and he is director of its Human Energy Systems Laboratory at the University of Arizona. He is also head of the inappropriately-named Veritas Research Program and “Centre for Frontier Medicine in Biofield Science”. All of these activities make homeopathy look sane, but he is nevertheless part of an otherwise respectable university. In fact he is He is Gary E. Schwartz, Ph.D. is professor of psychology, medicine, neurology, psychiatry and surgery at the University of Arizona. Even more incredibly, this gets NIH funding.
Columbia University, along with Cornell, also has its own “Complementary, alternative, and integrative medicine“, defined as “the use of treatments, such as homeopathic medicine, ayurveda, botanical dietary supplements”. And their “Integrative Therapies Program for Children” is intimately tied up with a company called Origins, which is more a cosmetics company, Origins” (with all the mendacity that implies). They say
“Origins understands the importance of addressing wellness through an integrative approach,” says Daria Myers, President of Origins Natural Resources. “With our recent Dr. Andrew Weil collaboration, Origins demonstrated its support for the integrative wellness concept. Now, with the introduction of the new Nourishing oil for body and massage, we hope to bring not only a moment of comfort but also a healthy future to children enduring the fight of their life.”
Andrew Weil is, of course, the promoter of the Arizona meeting.
The corruption of Universities by this sort of activity is truly amazing.
Two interesting papers. One shows popular anti-oxidant ‘supplements’, beta carotene, and vitamins A and D, far from making you live longer, have the opposite effect. Another shows that garlic does not lower cholesterol. And some publicity for Dan Hurley’s book, Natural Causes. An update looks at the activities of the supplements industry spokesperson. Dr Ann Walker, who seems sometimes to forget to declare her interests.
First let’s reiterate the myth of antioxidants
Nutribollocks: the antioxidant myth
“Nutritional supplements” are one of the most profitable scams (see, for example, Healthwatch, Quackwatch, and Holfordwatch).
There is a nice article by Lisa Melton on The Antioxidant Myth: a medical fairy tale in tne New Scientist (and see here), [download as pdf] . Here are some quotations.
| Cranberry capsules. Green tea extract. Effervescent vitamin C. Pomegranate concentrate. Beta carotene pills. Selenium. Grape seed extract. High-dose vitamin E. Pine bark extract. Bee spit.You name it, if it’s an antioxidant, we’ll swallow it. According to some estimates around half of US adults take antioxidant pills daily in the belief that they promote good health and stave off disease. . . . In 1992 researchers at the US National Cancer Institute set about testing beta carotene. The trial was set to run for 6 years, but two-thirds of the way through the researchers pulled the plug after discovering, to their surprise and horror, that those taking supplements were doing worse than the controls. They had developed 28 per cent more cases of lung cancer, and their overall death rate was 17 per cent higher. It’s a similar story with the world’s most popular antioxidant. Vitamin E shot to fame in the early 1990s, after two large studies involving more than 127,000 people in total found that those with a diet high in vitamin E were significantly less likely to suffer cardiovascular disease. Use of vitamin E supplements soared. In 1990, almost nobody took vitamin E; by the end of the decade an estimated 23 million US citizens were knocking back daily doses. |
“Treatment with beta carotene, vitamin A, and vitamin E may increase mortality”
That is the conclusion of a recent paper in the Journal of the American Medical Association, “Mortality in Randomized Trials of Antioxidant Supplements for Primary and Secondary Prevention” Systematic Review and Meta-analysis”, [Get the full text].
This isn’t original research, but a meta analysis that attempts to collate existing data taking into account the reliability of each source. The aim was to analyze the effects of antioxidant supplements (beta carotene, vitamins A and E, vitamin C [ascorbic acid], and selenium) on deaths (from any cause) in adults. The analysis seems to have been done well, and the results are startling. They aren’t just a waste of money, but some of them are actually bad for you. In 47 low-bias trials with 180 938 participants, beta carotene increased death rates by 7 per cent, vitamin A by 16 per cent, and vitamin E by 4 per cent (when taken separately). Vitamin C gave contradictory results and selenium showed no detectable effect.
This work got an excellent write-up in The Times, by their health correspondent, Nigel Hawkes. This was followed by a predictably silly defence of nutribollocks by the Times’ Dr Thomas Stuttaford (known in Private Eye as Dr Utterfraud). Luckily, this was neutralised by a second piece on the same page by Nigel Hawkes, “Phooey. Sensible balanced diet is the best investment”:
“ In nutrition, a plausible idea and a little bit of evidence are all that is needed to create a market. And such is the megaphone of marketing and the influence of countless “healthy eating” articles that these ideas, even the half-baked ones, can lodge very firmly in the national psyche.”
It’s a nice coincidence that this study came out while I was reading Dan Hurley’s book, Natural Causes (see below). This book sets out dramatically the harm, sometimes serious harm, that untested “supplements” have done to some individuals. But for me the most interesting part is the revelation of the political lobbying by this $20 billion supplement industry, with the aim (largely successful) of undermining the FDA and escaping from any effective regulation of its absurd, but exceedingly profitable, claims. The supplements industry puts the Prince of Wales in the shade when it comes to subverting common sense and good science.
The Health Supplements Information Service (HSIS)
Needless to say, the supplements industry has already organised vilification of this excellent bit of work.
According to their web site,
“HSIS is funded by The Boots Company PLC, Bayer PLC, Perrigo, Seven Seas Ltd and Wyeth Consumer Healthcare. The campaign is co-ordinated by PAGB (Proprietary Association of Great Britain)”.
So it’s no surprise that their spokesperson. Dr Ann Walker, immediately tried to discredit the study, saying “The results of these mixed-sample metaanalyses are worthless” (The Times).
This same Ann Walker recently wrote and editorial in the British Journal of General Practice (January 2007). The editorial concludes “Although still considered to be controversial by some, taking a daily multinutrient supplement would bridge the gap between intake and requirements and ensure that nutrient target intakes are met.” But in this editorial her affiliation is given as Senior Lecturer in Human Nutrition, University of Reading. No mention at all of her role as spokesperson for the Supplements industry. Tut tut.
Patrick Holford too
Needless to say, supplement salesman Patrick Holford has weighed into the vilification. His objections have been dealt with nicely on the cutely named web site stopholfordtalkingrubbish.blogspot.com. Find the answers here.
Holford is the man who, in the BMJ said “Competing interests: none declared”, when promoting his supplements.
No interests? Holford himself has said
“any product, be it a publication, seminar, food or supplement, that is authored/invented by me has my name on it and earns me a royalty/payment. That is how I live and fund my research.”
So what about the galaxy of supplements being sold at “Health products for Life”? They say “we only supply supplements, foods and drinks that are recommended by nutrition expert, Patrick Holford.” And at the bottom of the page it says “©Copyright 2007 Holford and Associates. All Rights Reserved”. Companies House lists the sole shareholder in ‘Health Products for Life’ as P.J. Holford.
Garlic is no good either
Another interesting recent paper has appeared in Archives of Internal Medicine
Garlic is widely promoted as a cholesterol-lowering agent, but the evidence so far has been lousy. In this trial, 192 adults with low-density lipoprotein cholesterol (LDL-C) concentrations of 130 to 190 mg/dL (3.36-4.91 mmol/L) were randomly assigned to one of the following four treatment arms: raw garlic, powdered garlic supplement, aged garlic extract supplement, or placebo.
“Conclusions None of the forms of garlic used in this study, including raw garlic, when given at an approximate dose of a 4-g clove per day, 6 d/wk for 6 months, had statistically or clinically significant effects on LDL-C or other plasma lipid concentrations in adults with moderate hypercholesterolemia.”