Tag Archives: statins

Cholesterol: zero shades of grey or, Oceania has always been at war with Eastasia

The thing about quacks and quackery shills is that they don’t do nuance. Medicine = bad, natural = good because duh obvious. This simplistic thinking is absent in science, of course, but it makes for some pretty comical content in WDDTY. Consider LDL. The starting premise here is that statins – sorry, statin drugs, mustn’t forget to label them as products of big pharma – are evil. But they provably lower levels of LDL cholesterol. Therefore LDL cholesterol must be good, right? So WDDTY expends significant effort persuading its readers that LDL cholesterol is beneficial.

LDL cholesterol isn’t the ‘bad guy’ after all As we’ve been saying for years now, LDL isn’t the ‘bad’ cholesterol responsible for heart disease and blocked arteries-and now  scientists are proving it. Although it’s the target of statin drugs, LDL doesn’t cause fatty deposits in the arteries, but prevents them.

Saying for years. Hmmm.

  • April 2008 p10: “The diet can also reduce LDL, or ‘bad’, cholesterol levels“.
  • Oct 2011 p18: “After 40 days, all doses of cinnamon significantly reduced blood glucose, triglycerides, and LDL (‘bad’) and total cholesterol levels“.
  • Aug 2012 p4: “The antioxidant is found in almost all fruits, including peaches and oranges, lots of vegetables and Brazil nuts, and appears to have the same protective effect as a statin drug, which promotes the ‘good’ HDL (high-density lipoprotein) cholesterol while lowering levels of ‘bad’ LDL (low-density lipoprotein) cholesterol” .

Those are just a sample of the many hits for “LDL cholesterol” in WDDTY back issues, the vast majority of which talk about “natural” ways to reduce LDL without taking those statins. Sorry, statin DRUGS!!!! Oceania has always been at war with Eastasia.

The ‘good/bad’ cholesterol theory, which launched the multibillion-pound statin drugs industry, has claimed that oxidized LDL (low-density lipoprotein) cholesterol infiltrates the arterial walls and engorges them with cholesterol. ln time, cholesterol turns into plaque, blocking the artery or sending clots into the bloodstream, causing heart attacks and strokes.

This is “claimed” on the basis of good biomedical evidence. But, you know, science self-corrects. In matters of complex biochemistry new findings can overturn old ones. That’s one of the ways science is different from quackery – no homeopathic remedy has ever been discarded on the basis that it’s subsequently found not to work, no cancer quack has ever shut down after trials show their treatment to be bogus.

Statin drugs target LDL cholesterol while allowing the ‘good’ HDL cholesterol to flourish. But scientists for a while now have been finding that the theory just isn’t true. Results from human and animal studies show LDL cholesterol isn’t the ‘bad guy’ after all.

Current consensus seems to be that LDL may have beneficial effects as well as harmful ones. Which is hardly a surprise. Observational data shows that raised levels of LDL are a risk for heart attack and stroke, but what constitutes raised may vary according to the patient and their other risk factors. Or as Dr. Goldacre might say: I think you’ll find it’s a bit more complicated than that. Here’s a handy table that explains what that means:

Markers indicating a need for LDL-C Reduction (Per 2004 United States Government Minimum Guidelines)
 If the patient’s cardiac risk is…  then the patient should consider LDL-C reduction if the count in mg/dL is over… and LDL-C reduction is indicated if the count in mg/dL is over…
 High, meaning a 20% or greater risk of heart attack within 10 years, or an extreme risk factor  70 100
 moderately high, meaning a 10-20% risk of heart attack within 10 years and more than 2 heart attack risk factors  100 130
 moderate, meaning a 10% risk of heart attack within 10 years and more than 2 heart attack risk factors  130 160
 low, meaning less than 10% risk of heart attack within 10 years and 1 or 0 heart attack risk factors  160 190

Of course there’s no way WDDTY could know this, as it’s drawn from secret sources: the US National Institutes for Health and the American Board of Clinical Lipidology.

Researchers at the University of Kentucky are becoming increasingly convinced by the evidence. “Our research … seems to indicate that oxidized LDL might, in fact, be a ‘good guy’ in the process,” said lead researcher Jason Meyer.

You can read the reality-based take on this at Science Daily. The full quote (not from an interview with WDDTY, by the way, as their story rather implies):

“Oxidized LDL moves rapidly into arterial walls and engorges them with cholesterol,” Meyer said. “Cholesterol ultimately converts into plaque, blocking the arteries or, in a worst case scenario, rupturing and sending clots into the bloodstream, causing heart attacks and/or strokes.” However, more recent studies in animals and humans have brought that assumption into question, and the oxidized LDL theory is currently the subject of lively debate. “Though in its very early stages, our research will add considerably to that controversy,” Meyer said, “because it seems to indicate that oxidized LDL might, in fact, be a ‘good guy’ in the process.”

So: partially oxidised LDL may have a role in reducing the effects of cholesterol, which is still the bad guy. See how that’s different from WDDTY’s spin?

Their research has shown that LDL cholesterol actually prevents the increase of cholesterol-laden foam cells in artery walls, making it a protective mechanism against the development of heart disease and atherosclerosis (hardened and obstructed arteries).

Or, as Science Daily puts it, “If it is demonstrated that oxidized LDL actually has a preventive effect on the accumulation of cholesterol in arterial walls, it may be possible to create a medicine from oxidized LDL to help prevent or treat this killer disease” “There is still much work to do because this project is very early in development and has not been tested in animals, but the results we have so far are very promising.” So, this is a preliminary finding in an area subject to active dispute, but the consensus view has not yet changed – and might never change, there would first need to be some accounting for the observational data that shows elevated risk in patients with elevated LDL cholesterol. So unlike WDDTY to rewrite history, spin scientific findings and present tentative early findings as the slam dunk evidence that their nonsensical anti-medicine agenda is somehow evidence based. I say unlike, I mean, of course, entirely characteristic. Oh, do read the Wikipedia article on LDL. It makes a lot more sense of the apparently conflicting information than anything published by the Ministry of Truth WDDTY.

Paying the Piper

(Reblogged with permission from Majikthyse. Please go there to comment)

That guardian of all that’s self-righteous about quackery, the magazine and website What Doctors Don’t Tell You, has its ire well stoked this week. The editors reveal that the famous Clinical Trials Service Unit (CTSU) at Oxford University is funded by the pharmaceutical industry. This apparently is the result of tireless investigation by`nutritionist and wholefood campaigner’ Zoë Harcombe. Not you will note a dietician, but a nutritionist, a title that almost anyone seems qualified to hold these days. I can boil an egg, so I’m a nutritionist. “You got an ology?” But enough of flippancy.

I feel duty bound to explain that Ms Harcombe is a writer who mainly sells books on obesity. Her dedication to the truth might be judged by her false claim to the Daily Mail in 2011 that she was studying for a PhD, as reported by my good friend Ben Goldacre. But we all make mistakes. In Ms Harcombe’s case, a further mistake was not realising what the CTSU actually is.

Presumably she has not heard of contract research organisations (CROs). Most of these are commercial companies to whom health care companies contract out a large part of their research, mainly in clinical trials. They have existed for at least 30 years, and some of them are enormous. The usual modus operandi is for the sponsor to engage the CRO to carry out a clinical trial, providing entire or partial functions. So if the contract is `full service’, the CRO will do everything from writing the protocol to writing the final report. The bits in between would include obtaining all the approvals (regulatory, ethics etc), designing the data capture and processing tools, analysing the data, as well as recruiting all the trial sites and investigators and managing the logistics (eg drug and equipment supplies).

However a lot of these contracts are not full service, and in particular data capture and analysis might well not be contracted out at all, or may be delegated to a different contractor. A lot of sponsors run their own data repositories and insist on CROs feeding data into those. Lots of them do their own analysis, and employ armies of statisticians. So what is the CTSU?

It is in fact a CRO, but more so. Rather than rely on what the CTSU claims (“they would say that wouldn’t they?”), let’s look at what the independent Science Media Centre says. The relevant bit is right at the end:

The CTSU conducts, analyses and interprets its clinical trials and other research independently of industry and other funders, with the datasets held by the CTSU rather than by the funders.

Now I’m sure that text came straight from the CTSU, but some credibility is added by its appearance on an independent and respected site. The point though is that the CTSU goes way beyond the probity of a conventional CRO, by erecting a Chinese wall between sponsor and data. The people paying the piper do not call the tune, because they don’t know what the tune is until it’s played at the end of the whole project. Not only that, but the CTSU has a rigorous policy on payments to individuals. Read it and make up your own mind.

What about the funding issue? Look again at the Science Media Centre page. It’s a list of trials, with sponsors and how much they paid. It is baffling as to why anyone should be surprised or indignant about this. The CTSU is a CRO, albeit academically based (and better for that), with a more than usually rigorous policy on independence from financial bias. The CTSU exists to do trials, it has a world-class reputation for that, and companies will pay for that expertise.

WDDTY is full of righteous indignation because Merck & Co, a major statin manufacturer, is also a major funder of the CTSU. Look at the trials Merck has sponsored. Apart from relatively small amounts unrelated to particular trials, Merck provided £63.9 million for statin trials, but £149 million for trials of other drugs unrelated to statins. Yet WDDTY states (my bold):

Over the past 20 years, the two research bodies* have received £268m donations, including £217m from Merck, a major manufacturer of statins.

(*CTSU and its subsidiary The Cholesterol Treatment Trialists Collaboration)

It is a lie to say this funding comprised `donations’ – it was not. It was perfectly normal business and scientific practice, whereby the CTSU was compensated for carrying out research commissioned to it. There is nothing unusual or suspicious about that.

I am not going to get into detail about whatever the CTSU’s director Sir Rory Collins said about the discredited papers in the BMJ, which grossly overstated the side effects of statins, or about what he said about his sources of funds. I haven’t reviewed the whole saga in detail, but as the CTSU’s funding is so transparent I can’t see how he could have forgotten about most of it.

Regarding the retraction of papers, the Science Media Centre provides some useful sound bites on its news page. I am not sure whether WDDTY is simply careless and incompetent, or deliberately distorts the truth – I suspect the latter. But whatever the motivation, the editors have got it wrong yet again. They say that an independent panel refused to retract the papers that quoted the incorrect data, which is not true. The truth is that the authors of the erroneous studies agreed that they were wrong. What the panel declined to retract were two other papers that referred to the original ones. As you can see from the comments from various experts, opinions are divided as to whether there was a need to retract the derivative papers, although they are pretty much unanimous that statins are very useful drugs that have saved many lives.

WDDTY has studiously avoided saying anything about the research which shows statins to be better tolerated than previously thought. Instead the editors make invalid connections between unrelated facts, and indulge in selective reporting and distortion. A drug company would be quite rightly castigated for such behaviour, but in 40 years I have never come across one that tried anything as bad as this.


Addendum: This is the full post as it appeared on WDDTY’s website on 21st August 2014.


‘Independent’ statin research group funded by drugs industry

A research unit that influenced wider statin use in the UK was all the time being funded by drug companies, including £217m from Merck, one of the largest producers of the cholesterol-lowering drug.
The Cholesterol Treatment Trialists Collaboration (CTT), based at Oxford University and headed by Sir Rory Collins, has been very influential in shifting UK health policy, which this year started to recommend statin use for all over-60s.
The new guidelines, issued by NICE (National Institute for Health and Care Excellence), followed the publication of ‘independent’ studies from CTT that maintained that statins had few side effects but many major benefits. Sir Rory was also highly critical of studies published in the British Medical Journal that claimed the drugs caused side effects in 22 per cent of users. He demanded that the papers were retracted, which an independent review panel refused to do.
All along, Sir Rory claimed that he and the CTT were independent, and that any funding came from charitable sources such as the British Heart Foundation and Cancer Research UK. Even as recently as last March, Sir Rory repeated in an email to the BMJ that the British Heart Foundation was a major funder, and demanded to know who had funded the critical research he wanted withdrawn.
But these have been minor funders of CTT and its parent body, the Clinical Trial Service Unit (CTSU). Over the past 20 years, the two research bodies have received £268m donations, including £217m from Merck, a major manufacturer of statins.
The true picture came to light only after nutritionist and wholefood campaigner Zoe Harcombe uncovered the original documents that outline the CTSU’s funders.

 

 

100 ways to live to 100: 10 bits of medical advice you should question

 

Part of a series on WDDTY’s “free” advertorial report “100 ways to live to 100

10 bits of medical advice you should question

In general, it’s always fair to ask for the evidence supporting any proposed medical intervention.

In general, WDDTY does this for you by quote-mining and cherry-picking to suit its anti-medicine agenda.

What WDDTY does not do is to provide any actual evidence that this information is anything other than a routine part of the normal process of informed consent, especially in the UK. For example, discussion of radical prostatectomy is dominated by a test that has been deprecated in the UK for over twenty years and an operation that never reached a quarter of its peak level in the USA.

81 Lower your blood cholesterol levels

The theory that high-fat foods—like meat and dairy—build up fat in our arteries has never actually been proven. After people eating high-fat diets were followed for 10 years and not one suffered a heart attack, researchers concluded that “the evidence is not there” to support a high fats–heart disease connection.48 In fact, high levels of the ‘bad’ LDL cholesterol may actually be good for us, especially as we get older.49

Reference 48: Nutr Metab Cardiovasc Dis, 2012; 22: 1039–45 Biomarkers of dairy intake and the risk of heart disease. Aslibekyan S, Campos H, Baylin A.

Reference 49: J Gerontol A Biol Sci Med Sci; 2007; 62: 1164–71 Statins and dietary and serum cholesterol are associated with increased lean mass following resistance training. Riechman SE, Andrews RD, Maclean DA, Sheather S.

The first reference is specific to dairy, noting:

Dairy product intake as assessed by adipose tissue 15:0, 17:0, and by FFQ is not associated with a linear increase in the risk of MI in the study population. It is possible that the adverse effect of saturated fat in dairy products on cardiovascular health is offset by presence of beneficial nutrients.

This is a great point against WDDTY’s anti-dairy agenda, but not really a point for the argument that cholesterolW is good for you. The second source finds:

These data suggest that dietary and serum cholesterol contribute to the skeletal muscles’ response to RET in this generally healthy older population and that some statins may improve this response.

A great point against WDDTY’s anti-statin agenda, but not much of a hit for the promotion of cholesterol either since this applies to people undergoing “12 weeks of high intensity resistance exercise training (RET) with post-exercise protein supplementation”. Few 60-69-year-olds do this, and the overall evidence is taken from the largely sedentary general population not from atypical sub-populations like this.

WDDTY seems to be disputing the lipid hypothesisW but without actually tackling it head on, still less addressing the evidence base behind it. In fact both the lipid and the chronic endothelial injury hypothesisW are converging over time to a single hypothesis which puts LDL front and centre in the mechanism of hypertension.

The Centers for Disease ControlW are blunt: “Having high cholesterol puts you at risk of developing heart disease, the leading cause of death in the United States”.

82 The mercury in your fillings is permanently locked in and harmless

Dentists have been saying this for years, but the European Commission’s BIO Intelligence Service (BIS) begs to disagree. The group recommends that a total ban on amalgam fillings be fully implemented in five years’ time, and the use of mercury fillings virtually eliminated throughout the EU.

No, the EU does not say that your fillings are a problem. It has a rather technical document detailing measures to reduce usage and pollution from mercury in the environment. It puts the report by Bio Intelligence Service S.A. (which is,a s the name suggests, a commercial entity and not an EU body) into context. Its principal argument is that dental use of mercury represents an environmental, not a toxicological, problem.

The report does not say that amalgam fillings in-place are a significant source of concern, instead it discusses the pollution caused by the mixing and installation of amalgam, and the disposal of amalgam after teeth are extracted or the patient dies.

Overall, you’re probably fine as long as you don’t heavily chew nicotine chewing gum. A controversy that has raged for a century without any consensus forming or any concrete and damning evidence of significant biological effect – a “smoking gun” – is evidence of philosophical differences, not provable harm.

83 Go for angioplasty

Balloon angioplasty and stents were to be medicine’s ‘miracle’ treatments for blocked arteries, but around one in 10 heart patients returns to hospital for emergency treatment following the procedures, and nearly a third of non-emergency ‘drug-eluting’ stents are also likely to cause potentially fatal harm.50 Patients given a cocktail of generic heart drugs instead do just as well .51

Reference 50: Arch Intern Med, 2012; 172: 112–7 Factors associated with 30-day readmission rates after percutaneous coronary intervention. Khawaja FJ et. al.

Reference 50b: N Engl J Med, 2007; 356: 1009–19 Long-Term Outcomes with Drug-Eluting Stents versus Bare-Metal Stents in Sweden Bo Lagerqvist et. al.

Reference 51:  N Engl J Med, 2007; 356: 1503–16 Optimal Medical Therapy with or without PCI for Stable Coronary Disease William E. Boden et. al.

This is a particularly pernicious piece of misinformation. It is very easy to find cases where people are readmitted not long after surgery for coronary heart disease: the reason they have had the surgery is often because they are very sick. Unsurprisingly, they are a poor surgical risk and a high risk for post-surgical complications. In other words, even with surgery, doctors may not be able to save them. That’s a great reason for keeping your heart in good shape and a truly terrible reason for refusing heart surgery if it’s indicated.

WDDTY say that nearly a third of drug eluting stents are likely to cause potentially fatal harm. The source absolutely does not support this.

Drug-eluting stents were associated with an increased rate of death, as compared with bare-metal stents. This trend appeared after 6 months, when the risk of death was 0.5 percentage point higher and a composite of death or myocardial infarction was 0.5 to 1.0 percentage point higher per year. The long-term safety of drug-eluting stents needs to be ascertained in large, randomized trials. (emphasis added)

 WDDTY have been caught before confusing relative and absolute risks, but rarely this blatantly.

The final study also doesn’t support WDDTY’s statement:

As an initial management strategy in patients with stable coronary artery disease, PCI did not reduce the risk of death, myocardial infarction, or other major cardiovascular events when added to optimal medical therapy.

WDDTY recommending intensive pharmacologic therapy. That’s a turn-up for the books.

84 You don’t need your womb anymore

A University of California committee of gynaecologists once concluded that three-quarters of all hysterectomies done are not necessary.52 Except for genuine indications like uterine cancer and life-threatening bleeding during childbirth, some 90 per cent of referrals for hysterectomies can be treated with conservative surgery, medication, alternative medicine, nutritional supplementation or just waiting until menopause.

Reference 52: Obstet Gynecol, 2000; 95: 199–205 The Appropriateness of Recommendations for Hysterectomy, Michael S Broder et. al.

This is an US study. One in three US women will undergo hysterectomy, compared with one in five in the UK. The US removes ovaries in 73% of cases, the UK in 20%.

WDDTY editor Lynne McTaggart is American. Sometimes she forgets which side of the pond she’s living.

Sometimes she also forgets that the anecdotal claims of quacks to “cure” endometriosis, fibroids and the like are a long way short of being evidence that they actually can do this.

85 Have ‘catch it early’ surgery for prostate cancer

Men in the early stages of the disease are often offered radical prostatectomy, where the entire gland is removed. At best, it’s a trade-off, mostly because of the high risk of permanent impotence and incontinence. Unless you’re under 55, you’re more likely to die with the disease than from it.

That’s why the standard of care for indolent prostate cancer is “watchful waiting”. Who are these doctors who supposedly “don’t tell you” this? I suspect they may be American again, though even there it’s been in decline since the early 1990s. The UK has deprecated screening since the 1990s and the UK’s rate of radical prostatectomy never reached 10 per 100,000, a quarter of the peak rate in the US.

Bottom line: if your doctor recommends radical prostatectomy, it’s probably the conservative option.

86 Have a radical mastectomy to ‘catch it all’

This mutilating operation involves removing the breast, the chest wall, the lymph nodes and much of the skin, but it confers no advantage over other, less aggressive forms of mastectomy, including the simple removal of the lump with radiotherapy.53 Also, some 70 per cent of double mastectomies—where both breasts are removed following a diagnosis of breast cancer—are unnecessary as the cancer was never likely to have spread, say researchers.54

Reference 53: Ann Surg, 1986; 204: 136–47 Treatment of primary breast cancer without mastectomy. The Los Angeles community experience and review of the literature.

Reference 54: J Clin Oncol 30, 2012; suppl 34: abstr 26 [Medline does not find this reference]

This advice is literally decades out of date. Radical mastectomy no longer involves routine axillary clearance, instead the lymph nodes are staged, often in real time. Prophylactic mastectomies will only be advised for women who already have cancer, or who, like Angelina Jolie, have both genetic and family history indications.

WDDTY were among the strident chorus of natural-woo promoters who denounced Jolie for her decision. Jolie showed grace and fortitude in the face of this torrent of bullshit, pointing out that the risk for her was in excess of 80% given family history and evidence of specific expressed genetic mutations.

Lumpectomy is the standard of care for small, well-defined tumours; radical mastectomy is not recommended lightly.

The moral of this story is, listen to oncologists, not cranks who hate the entire world of medicine on reflex.

87 Let’s fix your inguinal hernia

The wise doctor will delay surgery until the patient is in pain or discomfort—partly because he knows that surgical repair carries a long-term risk of recurrence and can itself cause more groin pain than the hernia, as it does in a quarter of patients.55 When more than 700 men with hernias underwent watchful waiting instead, the vast majority carried on with their everyday lives without a moment of pain and without the need for surgery.56

Reference 55: Ann Surg, 2001; 233: 8 Groin Pain After Hernia Repair, Robert E. Condon.

Reference 56: JAMA, 2006; 295: 285–92 Watchful waiting vs repair of inguinal hernia in minimally symptomatic men: a randomized clinical trial. Fitzgibbons RJ Jr, et. al. 

Once again, WDDTY recommends the standard of care. Well done for telling your readers what doctors already do tell them.

The only problem with WDDTY’s commentary is that it seems designed to deter anyone from undergoing repair, based on a speculative finding from 2001 (“Could it be that the major change in the technique of hernia repair that has evolved over the most recent two decades—the widespread use of implanted prosthetic mesh, whether needed or not—is a cause?”) and a report based on minimally symptomatic patients.

The 2001 paper refers to what is now termed post herniorraphy pain syndromeW, a recognised complication that leads to – guess what? – the standard of care being “watchful waiting” for minimally symptomatic patients. The problem does not seem to be caused by mesh itself, but by damage to the nerves, which may be consequent from the original injury

So as usual it’s safe to follow WDDTY’s advice as long as you’re not actually ill…

88 Let’s cut out your gall bladder

This procedure (cholecystectomy) may increase the risk of colon cancer, according to a review of 33 studies.57 Surgery can often make matters worse by injuring the bile duct, releasing gallstones and causing more digestive issues. Stones can usually be sorted out by avoiding processed food and sugar, eating less red meat and eschewing HRT, which doubles the risk.

Reference 57: Gastroenterology, 1993; 105: 130–41 A meta-analysis of cholecystectomy and risk of colorectal cancer. Giovannucci E, Colditz GA, Stampfer MJ.

CONCLUSIONS: Because the risks varied substantially by study design and because time since cholecystectomy or potentially confounding factors were often not considered, we could not firmly quantitate this risk. However, the findings are consistent with other evidence that suggests some characteristic of bile acid metabolism increases the risk of cancer of the proximal colon.

CholecystectomyW became much more common in the 1990s after laparoscopic techniques were devised which made the surgery effectively a day-case. Yes, like any surgical procedure, it has potential complications, and those should be (and are) taken into account when considering surgery.

The accuracy of WDDTY’s commentary can be demonstrated pretty simply:

WDDTY: Surgery can often make matters worse by injuring the bile duct, releasing gallstones and causing more digestive issues

Goldman’s Cecil Medicine (24th ed.): The most serious complication of cholecystectomy is damage to the common bile duct. This occurs in about 0.25% of cases.

Often… 0.25%. I think this might be a problem of perspective.

WDDTY: “Stones can usually be sorted out by avoiding processed food and sugar, eating less red meat and eschewing HRT, which doubles the risk”

NHS: “There are several non-surgical ways to break down gallstones, but they are only effective in around less than 1 in 10 cases and are rarely a viable option.”

Perhaps WDDTY has been mistaking the claims of its advertisers for fact.

89 Sort your overactive thyroid with surgery

Nearly a third of all cases will resolve on their own. Even when just part of the thyroid is removed, only 30 per cent will have normal thyroid levels after eight years, a whopping 41 per cent will have a permanently underactive thyroid and 12 per cent will still be hyperthyroid.58

Reference 58:  J Endocrinol Invest, 1993; 16: 195–9 Follow-up evaluation of patients with Graves’ disease treated by subtotal thyroidectomy and risk factor analysis for post-operative thyroid dysfunction. Sugino K, Mimura T, Toshima K, Iwabuchi H, Kitamura Y, Kawano M, Ozaki O, Ito K.

Grave’s diseaseW is the commonest but not the sole cause of hyperthyroidismW, and it’s not the sole indication for thyroidectomy. In fact, it’s been considered debatable for some time:

Operation is indicated mainly when the disease is severe with a larger goitre or in younger age groups (below 40 years) where radioiodine may not be advisable. For preoperative treatment the use of antithyroid drugs in preferred, although iodine perhaps in combination with beta blockers may be used safely as well at least for moderate cases. In the presence of alternative means of treatment surgery should not exceed an operative risk of 0.5-1.5% with virtually no mortality

It’s unlikely that any patient will be offered surgery for management of hyperthyroidism without first excluding non-surgical approaches. WDDTY seems to think partial thyroidectomy is common, in the UK at least this is not the case. As the NHS says:

Surgery to remove all or part of the thyroid gland is known as a total or partial thyroidectomy. It is a permanent cure for recurrent overactive thyroid.

Your specialist may recommend surgery if your thyroid gland is severely swollen (a large goitre) and is causing problems in your neck.

Other reasons for surgery include:

  • a person is unable to be treated with radioiodine treatment as they are pregnant and they are unable or unwilling to take thionamides
  • a person has a severe form of Graves’ ophthalmopathy
  • the symptoms return (relapse) after a previous successful course of treatment with thionamides

It is normally recommended that the entire thyroid gland is removed as this means there will be no chance of a relapse.

See that word “specialist”? In the UK you will not get anywhere near thyroidectomy for Grave’s disease without seeing a specialist endocrinologist and exhausting the alternatives.

It’s almost as if doctors know what they are talking about and WDDTY don’t.

90 You need a blood transfusion

This routine medical practice suppresses the immune system, increasing the chances of infection, pneumonia—and cancer. Patients who received a transfusion during cancer surgery are 42 per cent more likely to develop cancer again, say Johns Hopkins University researchers.Transfusions should be reserved for emergencies like trauma or haemorrhage, when they can be a lifesaver.59

Reference 59: Anesthesiology, 2012; 117: 99–106 Variability in blood and blood component utilization as assessed by an anesthesia information management system. Frank SM, Savage WJ, Rothschild JA, Rivers RJ, Ness PM, Paul SL, Ulatowski JA.

CONCLUSIONS: The use of data acquired from an anesthesia information management system allowed a detailed analysis of blood component utilization, which revealed significant variation among surgical services and surgical procedures, and among individual anesthesiologists and surgeons compared with their peers. Incorporating these methods of data acquisition and analysis into a blood management program could reduce unnecessary transfusions, an outcome that may increase patient safety and reduce costs.

Needless to say, this does not support WDDTY’s statement. The article proposes spreading of best practice in the context of the US health system (where interventions may risk being profit-driven).

Yes, transfusions might indeed have negative effects, especially in the US where payment for blood donors has led in the past to contaminated supplies. However, cancer surgery tends to be at the upper end of things that are not considered “emergencies” even by WDDTY’s rather arbitrary standards, and some people might consider that the chances of being offered a transfusion just on the off chance when you’re not in mortal danger is probably pretty low. Especially in the NHS.

100 ways to live to 100: 10 drugs to avoid whenever possible

Part of a series on WDDTY’s “free” advertorial report “100 ways to live to 100

10 drugs to avoid whenever possible

WDDTY frame this with a truly staggering statement of faith:

After 24 years of publishing WDDTY, we’re still searching for one single drug out there besides antibiotics that actually cures something. We still haven’t found one. Virtually all drugs are for maintenance—that is, they manage, ease or suppress symptoms, but they do not cure. In spite of assurances from the pharmaceutical industry that drugs can target certain receptors in the body with laser-like accuracy, the fact is that many unrelated systems in the body have identical receptors—which is why drugs invariably affect other parts of the body indiscriminately and cause side-effects.

There is a better, alternative solution to virtually every chronic health problem except emergency medicine, which is where orthodox medicine comes into its own. If you’ve been shot, stabbed or run over, or suffer a heart attack or stroke, then modern Western medicine is without parallel for fixing you. In those cases, get to a hospital without fail. Otherwise, here are the10 drugs you might be better off avoiding. In no particular order:

We’re pleased to be able to help WDDTY out here. Again, since this is not the first time WDDTY have made this claim.

  • Tetanus antitoxin cures tetanus.
  • Antimalarials cure malaria.
  • Chemotherapy cures liquid tumours especially in children.
  • Antivenins cure venomous bites.

But why exclude antibiotics? Not only are they the best known and least ambiguous example of drugs that cure, but WDDTY also disputes their utility. The exclusion of this class of drugs seems to be capricious and specifically designed to assert that, excluding the vast number of illnesses they can cure, doctors can’t cure anything. Of course, unlike quacks, doctors don’t claim to cure disease unless they actually can, but n the end this reminds us of something:

But ultimately this is a categorical fallacy. Think for a moment: what is the definition of a chronic disease? It’s one that cannot presently be cured. A hundred years ago, syphilis was a chronic disease. Now it’s not. So WDDTY are taking a class of diseases defined by the fact that medicine cannot currently cure them, and asserting that, shockingly, medicine cannot cure them.

Is maintenance and management of symptoms necessarily a bad thing? Ask a type I diabetic or an asthmatic. 

Are there better alternative solutions to “virtually every chronic health problem”? No. Minchin’s Law applies: these things are alternative because they have not been demonstrated to be better. In most cases they haven’t been demonstrated to be as good. Many of them don’t work at all, and several are actively harmful.

71 Statins

These can cause cancer and definitely cause muscle weakness.

So they might, but the benefit outweighs the risks according to large studies.

A meta analysis of randomised controlled trials found:

Conclusion In patients without established cardiovascular disease but with cardiovascular risk factors, statin use was associated with significantly improved survival and large reductions in the risk of major cardiovascular events.

WDDTY has a long-standing agenda against statins, leading to its promotion of the idea that cholesterol is OK as long as it’s the “good” kind, but this is mainly arguing backwards from ideological opposition to statins. As always, the NHS has more nuanced and more accurate information.

72 Prozac and other antidepressants

These can cause rebound anxiety, suicide and addiction, and have been sold to us on a faulty premise—there is no brain chemical imbalance to fix.

This is pure propaganda. Antidepressants and antipsychotics have a role in the management of acute disease, and trying to tough it out without them can and does lead to suicide.

Epidemiological analysis shows that SSRIs reduce suicide rates. There is a specific problem with use in children, but it’s uncertain whether this balances out or not – however, this does not undermine the conclusion that:

[T]he strongly positive results of the TADS study indicate that medication treatment is vital for effective treatment of adolescent depression. With the confusing results of studies to date, fluoxetine is a good first choice for antidepressant treatment of adolescents. However, there may be reasons that clinicians choose to start other antidepressants instead. For instance, adolescents with a good prior response to another antidepressant, who are currently on another antidepressant with good response, or who have a history of poor response to fluoxetine, would probably be started or stay on another antidepressant.

In other words, follow the data not the dogma.

73 Tumour necrosis factor (TNF)-blocking drugs

Meant to replace painkilling COX-2 inhibitor drugs, they’ve been linked to tuberculosis and cancer.

Having “been linked to cancer” is a standard WDDTY weasel phrase. Yes, there is a plausible link between TNF inhibitor|TNF inhibitorsW and cancer. This applies to both synthetic drugs and natural TNF inhibitors such as curcuminW, catechins and canabinoids.

As with any effective treatment, it’s a question of risks versus benefits.

74 Atypical antipsychotics

These next-generation drugs, classed as the ‘new’ antipsychotics, include olanzapine (Zyprexa), quetiapine (Seroquel) and risperidone (Risperdal). Studies show they’re no better than the older variety, and may cause Alzheimer’s disease and hasten mental decline in the elderly. They also cause sexual dysfunction and depression, and so make any psychiatric condition worse.44

Reference 44: Clin Neuropharmacol. 2005 May-Jun;28(3):111-4. Use of ziprasidone in parkinsonian patients with psychosis. Gómez-Esteban JC, Zarranz JJ, Velasco F, Lezcano E, Lachen MC, Rouco I, Barcena J, Boyero S, Ciordia R, Allue I.

A source at last! So what does it say?

Twelve patients with Parkinson disease and psychosis were included in an open-label 12-week trial of ziprasidone. Two patients withdrew from the treatment because of adverse effects. The remaining 10 patients reported a significant improvement in psychiatric symptoms. Altogether, there was no deterioration of motor symptoms (UPDRS III score: basal 40.4 +/- 11.1, first month 41.1 +/- 10.8; final visit, 37.7 +/- 13.3). Two patients (20%) suffered a slight deterioration in motor symptoms and another patient suffered deterioration of gait. No analytic alterations or serious adverse effects that could limit the use of ziprasidone were observed. Although controlled trials are needed, the findings suggest that ziprasidone may be effective in parkinsonian patients with psychosis.

Is it just me, or does that say pretty much the opposite of what WDDTY claim? Be in no doubt: ziprasidoneW is an atypical antidepressant, the fifth such to be licensed by the FDA.

This is unusually dishonest even by WDDTY’s standards: the paper supports the use of the drug in Parkinson’s sufferers, but this is spun as a recommendation against it.

75 Anticholinergic drugs

These have a long list of side effects, including dementia.

This is not specific to anticholinergicW drugs, but to anticholinergics generally, including plants of the solanacae family, henbane and mandrake.

They also have a long list of beneficial effects. They suppress muscle spasms, for example, so are often used in gastritis and ulcerative colitis. But the major source of adverse reactions appears to be in recreational drug users, not least because medical use tends not to be long-term. One of the better known anticholinergics is butylscopolamineW, marketed under trade names such as Buscopan, which is used to control stomach cramps. It tends to be used episodically and not chronically.

76 Bisphosphonates

These osteoporosis drugs can halt bone loss, but they’ve also been linked to high rates of atrial fibrillation, a heart-rhythm disorder that can lead to stroke.45

Reference 45: N Engl J Med, 2007; 356: 1809–22: Once-Yearly Zoledronic Acid for Treatment of Postmenopausal Osteoporosis, Black et. al.

RESULTS: Treatment with zoledronic acid reduced the risk of morphometric vertebral fracture by 70% during a 3-year period, as compared with placebo (3.3% in the zoledronic-acid group vs. 10.9% in the placebo group; relative risk, 0.30; 95% confidence interval [CI], 0.24 to 0.38) and reduced the risk of hip fracture by 41% (1.4% in the zoledronic-acid group vs. 2.5% in the placebo group; hazard ratio, 0.59; 95% CI, 0.42 to 0.83). Nonvertebral fractures, clinical fractures, and clinical vertebral fractures were reduced by 25%, 33%, and 77%, respectively (P<0.001 for all comparisons). Zoledronic acid was also associated with a significant improvement in bone mineral density and bone metabolism markers. Adverse events, including change in renal function, were similar in the two study groups. However, serious atrial fibrillation occurred more frequently in the zoledronic acid group (in 50 vs. 20 patients, P<0.001).

The question then would be: are you better off suffering a hip fracture due to untreated osteoporosis, or atrial fibrillation, which may or may not result in a stroke?

WDDTY claims to be all about informed choice, but by giving only a tiny subset of the information, they actively impede a properly informed choice. It’s about as much use as advising everybody never to leave the house in case they get knocked over crossing the road.

77Aspirin

It’s the ultimate just-in-case lifestyle drug, taken to ward off heart disease and stroke, but it actually increases the risk of stroke sevenfold.46 It can also cause serious gastrointestinal bleeding. Other NSAIDs now carry warnings regarding their cardiovascular and gastrointestinal risks—and guess what? They haven’t been proven to reduce inflammation.

Reference 46: Lancet Neurol, 2007; 6: 487–93 Change in incidence and aetiology of intracerebral haemorrhage in Oxfordshire, UK, between 1981 and 2006: a population-based study. Lovelock CE, Molyneux AJ, Rothwell PM; Oxford Vascular Study.

This is a long-term study of stroke risk which finds that in the over-75s long term use of antithrombotics (aspirin) is associated with an increase in stroke incidence. This is most likely to be based on a population with higher dosages, as the prophylactic dose recommendation has reduced over time.

Reliable sources support low dose aspirin as a prophylactic against heart disease and stroke, unreliable sources promote more aspirin (mainly out of date) or none (WDDTY and other natural-woo promoters).

The Mayo Clinic has a useful reference. One interesting point that WDDTY didn’t make is that if you’re already taking aspirin daily, stopping can cause a rebound effect and actually trigger a stroke. Let’s hope nobody suffers a stroke after following WDDTY’s advice and sues them.

The important thing to remember is that a paediatric dose confers most of the benefit, but most of the risk studies refer to an adult dose, two to four times as great. As always discuss it with your doctor, not some anti-medicine crank.

78 HRT and the Pill

Their cancer connections are finally indisputable, even though drug companies keep fighting the evidence.

We already covered HRT. The pill? WDDTY really are becoming more reactionary over time.

Here’s what Cancer Research UK say about the Pill:

  • There’s a small increase in risk of breast cancer, which reduces when you stop taking the pill and returns to normal by 10 years after you stop taking it.
  • There’s an association with cervical cancer, likely to be down to the fact that cervical cancer is rarely seen in women whoa re not sexually active.
  • There’s a reduction in the risk of ovarian cancer, and the longer you take the pill the lower the risk gets.
  • There’s a reduction in cancer of the uterus which lasts for around 15 years after you stop taking the pill.
  • There may also be a reduction in bowel cancer.

Oh, and you tend not to get pregnant.

Your doctor knows all this, it’s safe to take your doctor’s advice rather than the ideological nonsense form WDDTY.

79 Antiepileptic drugs

These can lead to suicide and also cause potentially fatal liver failure. Many of the newer ones like Keppra (levetiracetam), Topamax (topiramate) and Sabril (vigabatrin) increase the risk of depression and suicide or self-harm threefold.47

Reference 47: Neurology. 2010 Jul 27;75(4):335-40. Use of antiepileptic drugs in epilepsy and the risk of self-harm or suicidal behavior. Andersohn F, Schade R, Willich SN, Garbe E.

Once again, WDDTY misrepresents the source. Here’s what it actually says:

Newer AEDs with a rather high frequency of depressive symptoms in clinical trials may also increase the risk of self-harm or suicidal behavior in clinical practice. For the most commonly used other groups of AEDs, no increase in risk was observed.

So: older AEDs do not increase the risk of suicide. Newer ones might, so doctors should be on the lookout for symptoms of depression. Which may well be partly due to the well documented tendency of practitioners to be more conservative and report more adverse reactions in new drugs than for well understood ones, where they know that symptoms are unlikely to be directly related.  Nothing to see here, move along please…

It’s hard to express how inappropriate it is to issue a blanket warning against antiepileptic drugs based on a misrepresentation of early studies on an entirely new class of drug that’s only recently entered clinical practice.

80 Zetia and other second-generation cholesterol-lowering drugs

Not only do these drugs not work, but they’re also hard on the liver.

We totally understand: cholesterol is natural so trying to control it is evil. Heart attacks are natural too, as is dying by the age of 40.

NICE don’t endorse ezetimibeW other than in cases where statins are not well tolerated, or as an adjunct to statins where cholesterol remains stubbornly high. It’s a relatively new class of drug and the evidence base is changing fairly quickly. Your doctor should be reading up on this, so it’s worth discussing the findings of ENHANCE and, when published, IMPROVE-IT with your doctor. As always, the advice form your doctor is likely to be evidence-based not ideology-based like WDDTY.

Cholesterol levels are a proxy marker and the jury is still out on whether reducing cholesterol levels is a valid end in itself; however, the outcome of statin trials does indicate a significant reduction in cardiac events so it does seem likely.


Errata and corrections:

  • Thanks to Andrew Crysell for spotting a schoolboy howler in the first section, fixed on 27/12/2013

100 ways to live to 100: Think twice about these tests

Part of a series on WDDTY’s “free” advertorial report “100 ways to live to 100

Think twice about these tests

This is an area where WDDTY is more likely to be right, simply because there is a reasonable consensus that screening leads to overdiagnosis and false positives. However, WDDTY’s advice is based on prejudice and dogma. It is less complete and less well argued than the numerous evidence-based discussions of the pros and cons of various tests.

Our advice on avoiding unnecessary tests is this: read Dr. Margaret McCartney’s The Patient Paradox. This will help you to understand false positives and false negatives, and to ask intelligent and informed questions that will lead you to make a pragmatic choice over a particular test, rather than hysterical anti-medicine rejection of all tests however appropriate.

51 The PSA (prostatespecific antigen) blood test for prostate cancer

It produces false negatives a third of the time and has overdiagnosed more than one million men since its introduction in 1987.29 Unless you have an aggressive cancer, consider watchful waiting. Ditch statin drugs, which increase your risk of this cancer by one-and-a-half times, and reduce carbs, avoid red meat and eat a Mediterranean diet.

Reference 29: J Natl Cancer Inst, 2009; 101: 1325–9 Prostate cancer diagnosis and treatment after the introduction of prostate-specific antigen screening: 1986-2005. Welch HG, Albertsen PC.

PSA is a marker, it is useful in monitoring progression as part of “watchful waiting” (the standard of care for indolent prostate cancers) but its use as a screening test is controversial, not least because the “normal” level of PSA varies widely. From the Wall Street Journal:

Richard Ablin, a professor of pathology at University of Arizona College of Medicine, discovered the prostate-specific antigen in 1970, and for nearly as long, he has argued that it should not be used for routine screening.

So the fact that PSA screening is problematic is not only not something “doctors don’t tell you”, it’s something that the inventor of the test itself has been saying for decades, and which medical journals are confirming.

PSA screening has been discouraged in the UK since the 1990s.

WDDTY can never resist a dig at statins (we’ll review that later), or an opportunity to plug the mediterranean diet (presumably in a modified version that does not include pasta, breads or tomatoes, since these are all fingered as causing problems within this article as well as elsewhere).

52 Routine mammograms (unless cancer is suspected)

This blunderbuss approach, which uses X-rays to detect breast cancer, doesn’t see cancer at its earliest stages and fails to pick up aggressive tumours. For every woman whose cancer is correctly detected, 10 healthy women will go through unnecessary worry, further testing and even treatment before doctors realize they’ve been misled by a false-positive. Consider thermography instead.

So close! This was almost a correct piece of advice, and then they went and ruined it by promoting a quack diagnostic technique instead.

Breast thermography is, to put it bluntly, useless as a diagnostic tool. It’s dissected here by David Gorski, a surgical oncologist specialising in breast cancer. To quote the American Cancer Society:

Thermography has been around for many years, but studies have shown that it’s not an effective screening tool for finding breast cancer early. Although it has been promoted as helping detect breast cancer early, a 2012 research review found that thermography detected only a quarter of the breast cancers found by mammography. Thermography should not be used as a substitute for mammograms.

Oh, and mammograms do detect cancer, just not perfectly. As with any area of medicine, breast cancer staging and screening is a work in progress. There is a debate about what to do with DCIS, for example. There is certainly a debate about routine mammography and the ages at which it should be considered. Above all, our understanding of the nature of indolent disease is developing rapidly. It seems likely that as the population ages many more people are likely to die with cancer than die of cancer.

53 Blood pressure readings

Many factors can distort a BP reading by as much as 5 mmHg: acute exposure to cold, recent alcohol intake, incorrect arm position, an incorrect cuff size—and even the presence of the doctor, now so common that it’s called ‘white-coat’ hypertension. Blood pressure falls at night, and night-time blood pressure is considered the most accurate predictor of heart attack.30 Consider 24-hour blood-pressure monitoring, not the old-fashioned cuff.

Reference 30: Lancet. 2007 Oct 6;370(9594):1219-29. Prognostic accuracy of day versus night ambulatory blood pressure: a cohort study. Boggia J et. al.

Why don’t doctors tell you this? Oh, they do. A single high reading in the doctor’s surgery is never the trigger for intervention unless it’s very high. Normal range is 120/80 to 140/90, so the uncertainty of 5 mmHg is clinically insignificant – if your pressure is 200/100 this is not going to be down to the white coat effect.

Compare and contrast WDDTY’s advice with that from the National Institutes for Health.

54 Routine smear tests

Many doctors still offer women an annual smear test for cervical cancer—even though they’ve been told the test can do more harm than good. The test throws up many false positives—incorrectly ‘seeing’ abnormal tissue that triggers a series of further and more invasive tests, plus needless worry. Even the advises a smear test once every three for those aged over and once every five years for those between 30 and 65.31

Reference 31: Am J Prev Med, 2013; 45: 248–9 The times they (may) be a-changin’: too much screening is a health problem. Harris R, Sheridan S.

Routine smear tests are a curate’s egg. In women at high risk, they are likely to be warranted. In women at low risk, not so much. If your GP is not up on the current state of knowledge (and they should be), ask for a referral to a specialist gynaecological clinic.

The take-home message that must be reinforced here is not that screening is evil, but that a borderline positive smear is not a cause for worry, it is a prompt for further investigation only.

55 Routine dental X-rays

Your dentist keeps telling you it’s safer than an airplane flight, but dental X-rays could triple the risk of meningioma, a kind of brain tumour. Children who have a Panorex or full-mouth X-ray before the age of 10 run the greatest risk, and even bitewing X-rays increase risk. Regular exposure may also cause heart disease. Annual checkups should be urgently reconsidered, say Yale University researchers.32

Reference 32: Cancer, 2012; 118: 4530–7 Dental x-rays and risk of meningioma. Claus EB, Calvocoressi L, Bondy ML, Schildkraut JM, Wiemels JL, Wrensch M.

Actually we agree that you should avoid unnecessary X-rays, because unlike WDDTY we understand the difference between ionising and non-ionising radiation. X-rays are ionising radiation. 

But good dentists don’t do routine X-rays. They use them to diagnose and guide treatment. If your dentist recommends routine X-rays then consider changing your dentist.

If you want an example of gratuitous exposure to unnecessary X-rays, look to your local chiropractor.

56 CT (computed tomography) scans

This whole-body, three dimensional imaging system is one of the most sensitive early-warning detectors of cancer, internal bleeding, heart problems, stroke and neurological disorders, but the standard course of two or three CT scans is equivalent to the radiation levels of Hiroshima or Nagasaki atomic bombs;33 just one scan is equivalent to around 500 standard chest X-rays, reckons the Royal College of Physicians of Edinburgh. Children who are scanned run a far higher risk of developing cancer.34 Ask for any other kind of imaging exam first.

Reference 33: N Engl J Med, 2007; 357: 2277–84 Computed Tomography — An Increasing  Source of Radiation Exposure David J. Brenner, Ph.D., D.Sc., and Eric J. Hall, D.Phil., D.Sc

Reference 34: Radiat Res, 2010; 174: 753–62 Thyroid cancer risk 40+ years after irradiation for an enlarged thymus: an update of the Hempelmann cohort. Adams MJ, et. al.

This is a rehash of a story in the December 2013 issue, “CT scans increase children’s cancer risk“. The second reference is puzzling as it refers to patients who had radiotherapy, not CT scans. The evidence for increased risk of cancers in children following CT scans is epidemiologically sound and does not rely on making inferences from unrelated research.

CT scans are used to rule out potentially life-threatening conditions, especially in children. Brain haemorrhage, for example. The sources are unanimous in supporting their diagnostic use and the fact that the benefits outweigh the risks, but equally unanimous in urging caution and ruling out other diagnostic tests first.

It should be pointed out that radiation increases risk, but does not inevitably produce cancer. Tsutomu YamaguchiW was exposed to radiation equivalent to the Hiroshima and Nagasaki bombs, having been caught in not one but both blasts. He died in 2010 aged 93. The Wikipedia article on hibakushaW (survivors of the atomic bombs) is interesting; the fact that the memorials are still being updated annually does indicate that being exposed to radiation is not a death sentence, however undesirable it might be.

The take-away message here is that it’s fine to challenge the diagnostic necessity of any test, but don’t rule out scans that reveal potentially fatal conditions just because of fear of some uncertain future consequence.

57 Routine prenatal ultrasound

The prenatal ‘miracle’, which uses high-frequency pulsed sound waves to image the fetus in the womb, gets it wrong so often that up to one in 23 women told by doctors they’ve miscarried may end up terminating a pregnancy. Scans see’ a miscarriage the pregnancy is viable, say researchers London and Belgium.35 Reserve this when something really wrong, and consider waiting before ‘completing’ termination if the test concludes you’ve miscarried.

Reference 35: Ultrasound Obstet Gynecol, 2011; 38: 503–9 Gestational sac and embryonic growth are not useful as criteria to define miscarriage: a multicenter observational study. Abdallah Y, et. al.

A second bite at the cherry for ultrasound (should we dock one from the tally of 100 things and make it 99 things?). Does the source support WDDTY’s conclusion? Only partly:

There is an overlap in MSD growth rates between viable and non-viable IPUV. No cut-off exists for MSD growth below which a viable pregnancy could be safely excluded. A cut-off value for CRL growth of 0.2 mm/day was always associated with miscarriage. These data suggest that criteria to diagnose miscarriage based on growth in MSD and CRL are potentially unsafe. However, finding an empty gestational sac on two scans more than 7 days apart is highly likely to indicate miscarriage, irrespective of growth.

In other words, there is a level at which ultrasound can detect a definitely non-viable pregnancy, but the margins are more blurred than was thought. This is in first trimester pregnancies, where only a few generations ago many women would not even know they were pregnant. Spontaneous abortionW is common in the early stages, often before the woman is even aware that she’s pregnant.

The source absolutely does not support a blanket rejection of obstetric ultrasonographyW, or even of early ultrasound where bleeding is present. However, the mandatory use of ultrasound introduced by anti-abortionists in some US states is unquestionably abusive and morally repugnant.

58 Peripheral bone densitometry

It’s the most commonly diagnostic tool for osteoporosis, and it measures usually the hip and spine, but bone mineral density (BMD) is not uniform throughout the skeleton. Although the WHO criteria for a healthy BMD apply only to the hip and spine, a wide range of ‘normal’ BMDs elsewhere in the body may be misdiagnosed as abnormal by these criteria. Diagnosing osteoporosis is still not an exact science, say researchers; you have a strong chance of being misclassified, especially when the test is done in those under 65.36

Reference 36: BMJ, 2000; 321: 396–8 The increasing use of peripheral bone densitometry (Editorial)

Differential diagnosis of osteoporosisW versus osteopeniaW is indeed a grey area, but it’s a distinction without a difference as both indicate a loss of bone density. DEXA scans can be perofrmed on central or peripheral bones, peripheral scans are easier and the machinery is smaller (and often portable).

Needless to say the BMJ article does not undermine the use of bone densitometry, but does question the use of a pragmatic epidemiological definition of osteoporosis, as the threshold for intervention. In other words, it may be valid to treat low-end osteoporosis as osteopenia – essentially using calcium and vitamin D as a first line of treatment before launching right in with bisphosphonatesW. This is what any good doctor would do anyway. But how will the doctor make the diagnostic call without a DEXA scan? Would you prefer a core DEXA, involving a trip to the radiology department of your nearest big hospital and a longer procedure with greater X-ray exposure, or a possibly clinic-based scan that will give a less accurate but probably still clinically useful answer?

As usual, WDDTY takes an absolutist stance that doesn’t help.

59 Biopsy

In a biopsy, a small bit of tissue is removed under local anaesthetic to diagnose a serious illness like cancer. Besides infection, puncturing nearby organs, and causing tears and bleeding, the greatest danger is that biopsies can inadvertently ‘seed’ or spread cancer. With breast biopsies, the risk of recurrent cancer from a ‘needle metastasis’ is about one in 15.37 Request PET (positron emission tomography) or MRI (magnetic resonance imaging) instead.

Reference 37: Acta Radiol Suppl. 2001 Dec;42(424):1-22. Aspects in mammographic screening. Detection, prediction, recurrence and prognosis. Thurfjell MG.

The relevant section of the abstract is:

Local recurrences in 303 nonpalpable breast cancers with preoperative localizations and breast conservation therapy were evaluated for needle-caused implant metastasis. A total of 214 percutaneous biopsies were performed. There were 33 local recurrences. Needle-caused seeding or implantation as based on the location of the recurrence in comparison to the needle path in the mammograms was suspected in 3/44 (7%) invasive cancers without radiotherapy.

This absolutely does not support the idea of rejecting biopsy. These instances of needle-caused seeding are primarily in women who had breast-conserving surgery (“lumpectomy”) for active cancers, and note that it’s more likely to happen when women opt not to have radiotherapy. In the absence of cancer, there are no seed cells.

The overall thrust of the article is actually a vindication of diagnostic mammography:

Screening mammograms comprising of 32 first round, 10 interval and 32 second round detected cancers and 46 normal were examined by an expert screener, a screening radiologist, a clinical radiologist and a computer-assisted diagnosis (CAD) system. The expert screener, screening radiologist, clinical radiologist and the CAD detected 44, 41, 34 and 37 cancers, respectively, while their respective specificities were 80%, 83%, 100% and 22%. Later, with CAD prompting, the screening and the clinical radiologist detected 1 and 3 additional cancers each with unchanged specificities. Screening mammograms comprising 35 first round, 12 interval and 14 second round detected cancers and 89 normal findings were examined without and with previous mammograms by experienced screeners. Without previous mammograms, the screeners detected 40.3 cancers with a specificity of 87%. With previous mammograms, 37.7 cancers were detected with a 96% specificity.

Neither PET nor MRI can accurately diagnose whether a tumour is malignant or not. If your doctors recommend a biopsy, it’s because they think you are likely to have cancer. The utility of baseline mammograms is demonstrated, as is the importance of having a properly trained clinical radiologist review the films.

As to the issue of seeding, Prof. Bill Heald CBE, pioneer of the total mesorectal excisionW procedure for colorectal cancer, is a firm advocate of lavage to minimise seeding – he routinely flushed the abdominal cavity and port sites with copious amounts of dilute antiseptic.

Discouraging people from having a truly accurate differential diagnostic pathological test to differentiate the presence, type and possibly aggression of a cancer? I’d question the medical credentials of anyone giving such advice. If indeed they had any.

60 Computed tomography (CT) angiography

The use of intravenous dye and CT technology to provide an ‘inside view’ of the coronary arteries is fast replacing the exercise stress test done in doctors’ surgeries. It’s also doubling the rate of invasive cardiac procedures, including surgery, say Stanford University School of Medicine researchers.38 Ask to have the standard gym bike or treadmill stress test instead.

Reference 38: JAMA. 2011 Nov 16;306(19):2128-36. Association of coronary CT angiography or stress testing with subsequent utilization and spending among Medicare beneficiaries. Shreibati JB, Baker LC, Hlatky MA.

WDDTY advocate an older test because it finds fewer cases. Remind me again why that would be a valid criticism? Computed tomography angiographyW is a relatively new technique. As with any CT scan, there is exposure to ionising radiation. As with any CT scan, it will only be appropriate when the risks are outweighed by benefits. Rejecting a test on ideological grounds, as WDDTY do, is foolish.

 

100 ways to live to 100: Your healthy diet

Part of a series on WDDTY’s “free” advertorial report “100 ways to live to 100

Your healthy diet

1 Customize your diet to match your biochemistry

William Wolcott, the world’s leading authority on metabolic typing and author of The Metabolic Typing Diet (New York, NY: Doubleday, 2000), followed in the footsteps of his mentor, cancer pioneer Dr William Kelley, by exploring how the sympathetic and parasympathetic branches of the nervous system each regulate a different set of metabolic activities and so different organs and glands.

Most of us are influenced more strongly by one or the other neurological system, according to Kelley’s theory, depending on whether we are ‘sympathetic-dominant’ or ‘parasympathetic-dominant’—so one man’s meat may literally be another man’s poison. A high-protein diet has one effect on a ‘protein’ type, but a totally different effect on a ‘carb’ type. Wolcott discovered that by customizing a person’s diet according to metabolic type, many people with serious illnesses—including cancer—regained their health.

For a detailed test to determine your metabolic type, go to www.healthexcel.com.

William Wolcott is claimed to be the world authority on Metabolic Type® and The Metabolic Typing® Diet. Genuine physiological concepts do not have registered trademarks. Nobody is the world authority on Digestion®.

One of the more baffling things about WDDTY is its failure to appreciate that the same issues of commercial conflicts apply to the world of SCAM, as apply to “big pharma”. Merely liking the sound of what someone says does not change whether they have a vested financial interest in it.

The Kelley cranks are a weird lot. Bill Wolcott is an acolyte of Kelley, a former real estate salesman who married Kelley’s ex-wife Suzi and took up Kelley’s mantle; Kelley himself was an orthodontist who developed a version of cancer quackery that forms the basis of the Metabolic Type®  nonsense. He also used prayer and osteopathic manipulation.

Kelley’s most famous patient was Steve McQueenW. As usual in the world of quackery, McQueen’s rapid decline and death was no barrier to continued commercial success. Kelley became paranoid and depressive as a result of his failure to convince the medical community, was divorced by Suzi, lost his dental license, and his health deteriorated. He finally died of a heart attack in 2005.

Nicholas GonzalezW developed his quack cancer diet from Kelley’s. MSKCC describes both as lacking any credible evidence of efficacy: a clinical trial in 2009 found that patients on the regime died faster and experienced worse quality of life. Like McQueen’s death, this has done nothing to lessen the commercial success of the regime.

It is theoretically possible to accumulate more red flags for quackery, but it is quite challenging.

And this is no. 1, so presumably top of the list in terms of purported value.

2 Check your acid/alkaline balance—but in relation to your metabolic type

A food’s effect on the body depends upon the body’s many homeostatic controls, including the autonomic nervous system, the master controller of metabolism. According to Wolcott, vegetables alkalinize an autonomic-dominant person, but acidify an oxidative dominant type, those whose oxidative or aerobic system (responsible for the ‘long slow burn’ that keeps running in the background) is the controlling force. To maintain a slightly alkaline status, determine and eat for your metabolic type.

The human body has intricate homeostatic mechanisms that maintain bodily pH in the range 7.35-7.45. A blood pH below 7.35 is called acidosisW, and a blood pH over 7.45 is called alkalosisW.

Virtually everything said by nutritionists about pH is nonsense. This is no exception.

As noted above, Wolcott has absolutely no medical qualifications whatsoever. If you fancy trusting your health to a former estate agent who ran off with the wife of the many who taught him the quackery from which he now makes an evidence-free living, you are probably beyond help.

3 Eat organic whole foods and opt for locally grown, seasonal organic produce

Pesticides have been implicated in many illnesses, including infertility, cancer, birth defects, skin irritations and impotence. Organically reared stock fed on grass (what they’re meant to eat), not grains, and organic produce not only contains substantially more of the basic nutrients than intensively farmed varieties, but also up to 10,000 secondary nutrients essential for human health. As organic bacon and sausages may still include nitrates (carcinogens), purchase them from sources that guarantee nitrate-free products.

Over 50 years of nutritional assays have failed to establish that organic produce is nutritionally superior to non-organic. The evidence of pesticide effects is based on much higher exposures than the safe levels in produce, and as a recent WDDTY piece pointed out, these pesticides are much more serious in unregulated sources such as Chinese herbs.

Is whole food better for you? Maybe not.Whole grain products may be short of fibre.

If you are environmentally conscious it may make sense to buy from a local farmer’s market, but even that is open to question.

4 Cook from scratch

Avoid anything processed, canned, fried, preserved or laden with chemicals, processed, refined or in any way interfered with. Vary your diet as much as possible; most allergy specialists claim that allergies are more likely from tins and plastic bottles, which can leach bisphenol A, and avoid water in plastic bottles, which may contain oestrogen mimicking phthalates.

Terms like “laden with chemicals” are emotive but lack any substance. Everything is made of chemicalsW. That is rather the definition of chemicals. Canned and preserved food can be an important source of vitamins during the off-season (which is why canning was invented in the first place). Processed food is a pejorative without a formal definition. It covers everything from KFC to craft-produced ragout in jars at Waitrose.

The correct mix of foods and how they are prepared is strongly dependent on your household budget, not that WDDTY seem to understand or care about anything outside its core demographic of ABC1 women.

5 Eat a ‘power breakfast’

Those who consume a large proportion of their total calorie intake in the morning eat significantly less over the course of the day, which helps to treat or prevent obesity.2 Plus skipping breakfast increases your chances of a heart attack, high blood pressure and diabetes.

Reference 2: J Nutr. 2004 Jan;134(1):104-11. The time of day of food intake influences overall intake in humans. de Castro JM.

The results suggest that low energy density intake during any portion of the day can reduce overall intake, that intake in the morning is particularly satiating and can reduce the total amount ingested for the day, and that intake in the late night lacks satiating value and can result in greater overall daily intake.

Or to put it another way, people who snack in front of the TV at night, eat more.

This one study definitely does not prove a causal link, it is associative only – and as we know, most observational studies are wrong, though there is evidence that skipping meals causes people to overeat at the next meal. Skipping breakfast is probably a bad idea, but stuffing yourself full of carbs at breakfast time may well not make any difference over and above a normal healthy breakfast.

6 Don’t limit saturated fats and don’t ever opt for ‘low-fat’ or hydrogenated foods

The supposedly ‘good fats’—polyunsaturated fats from vegetable oils (corn, soy, safflower and the like)—appear to predispose people to cancer, whereas animal fats may be protective, preventing heart disease, osteoporosis and even cancer. Two large studies show that regularly consuming more saturated fats leads to less disease progression than following a diet higher in polyunsaturated fats and carbs.3

But avoid trans fats—produced by hydrogenation, when hydrogen added to liquid vegetable oil to make it solid at room temperature—as they’re linked to greater risks of heart disease and stroke.4

Reference 3a: Am J Clin Nutr. 2004 Nov;80(5):1175-84. Dietary fats, carbohydrate, and progression of coronary atherosclerosis in postmenopausal women. Mozaffarian D, Rimm EB, Herrington DM.

Reference 3b: J Intern Med. 2005 Aug;258(2):153-65. Dietary fat intake and early mortality patterns–data from The Malmö Diet and Cancer Study. Leosdottir M, Nilsson PM, Nilsson JA, Månsson H, Berglund G.

Reference 4: J Am Coll Nutr. 1996 Aug;15(4):325-39. Dietary trans-monounsaturated fatty acids negatively impact plasma lipids in humans: critical review of the evidence. Khosla P, Hayes KC.

A rather more sensible approach is to eat less fat. The three studies’ findings:

  1. In postmenopausal women with relatively low total fat intake, a greater saturated fat intake is associated with less progression of coronary atherosclerosis, whereas carbohydrate intake is associated with a greater progression.

  2. With the exception of cancer mortality for women, individuals receiving more than 30% of their total daily energy from fat and more than 10% from saturated fat, did not have increased mortality.

  3. Preliminary evidence suggests that at least part of [trans fats’] impact on lipoproteins reflects increased serum cholesteryl ester transfer protein activity, i.e., increased transfer of cholesteryl esters from HDL to LDL. Since the adverse effects of t-FA on human plasma lipids may be confined to specific isomers, future studies delineating their effects are warranted.

So a source which applies only to post-menopausal women is asserted to be general, a source that finds no increase in cancer except for women is portrayed as saying that saturated fats prevent cancer (pretty much the opposite of the actual finding, which finds an increase in women but not much of one), and a technical preliminary finding that is spun because WDDTY love the idea of the “good cholesterol vs. bad cholesterol” debate that they use as a stick with which to beat statins.

In other words, this is agenda-driven and often counterfactual spin. You should not eat unlimited saturated fat as they claim.

7 Don’t count calories

Keep your weight steady with index diet (or When compared diets, the GI diet was the best of all for losing weight.5 The diet ranks carbs according to their effect on blood glucose levels. Carbs with a low GI score produce only small fluctuations in blood sugar and insulin levels, whereas high-GI foods cause a sudden sugar rush. Avoid processed foods and ‘white stuff’—white bread, white sugar and white rice—as well as fried foods and potatoes in favour of low-GI meats, fish, pulses (beans) and most vegetables.

Reference 5: Cochrane Database Syst Rev. 2007 Jul 18;(3):CD005105. Low glycaemic index or low glycaemic load diets for overweight and obesity. Thomas DE, Elliott EJ, Baur L.

This study does not claim that GI is the best diet, only that it was more effective than the other diets tested. It refers primarily to obese people undergoing treatment for obesity. It acknowledges that further work is required to establish whether there is a long term benefit.

However, the low-GI diet is rational and not in the least bit alternative. It was first proposed over 30 years ago in the American Journal of Clinical Nutrition, and is a mainstay of the advice offered by dieticians. There is no doubt that nutritionists like those who write and advertise in WDDTY follow a range of fad diets of variable implausibility so if this represents the first steps in a move away from advertising fad diets and towards evidence-based advice, it’s good. Admittedly the blanket prohibition on “white stuff” is not a good start; dieticians tend to look at the overall diet not just howl “teh processed!” at things they find ideologically unacceptable.

8 Don’t drink the water

Our entire water supply contains some 350 toxic chemicals plus industrial waste, disease-carrying microorganisms, chlorine and fluoride, some 100 pharmaceutical Pregnant women usual heavily chlorinated water double their risk of giving birth to a child with serious defects.6 Consider installing a reverse osmosis water filter with an added carbon filter, which will remove everything. But as this includes minerals too, be sure to supplement.

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There is no credible evidence of a general requirement to filter domestic mains water in this way, and WDDTY’s advice to use bottled water is diametrically opposite to their advice re buying local produce – transporting bottled water is an incredibly wasteful business because whatever WDDTY claim, the water delivered to your tap by your water company is clean, safe and environmentally sustainable. It almost certainly contains no significant levels of the “toxic chemicals” WDDTY assert, though this is hard to verify because as always the appeal to “toxins” lacks any actual definition of what toxins and at what level.

Water itself is toxic, in excess. It’s also a chemical. So arguably, yes, your tap water contains dangerous levels of deadly dihydrogen monoxide.

9 Get your omega-3 to omega-6 ratio right

Avoid an imbalance between the ratio of omega-3 to omega-6 essential fatty acids (EFAs), as these fats regulate the major bodily functions, and deficiencies are behind many degenerative diseases. The optimal ratio is 1 to 1,7 but the modern Western diet’s usual ratio is around 1 to 20 in favour of omega-6 EFAs from vegetable oils (like safflower, sunflower and corn oils). As a general rule, increase your intake of omega-3s (like eicosapentaenoic acid, or EPA) and reduce your omega-6s (like gamma-linolenic acid). Opt for fish oils and foodgrade flaxseed (or linseed) oil, which is 60 per cent omega-3.

This claim was covered in our discussion of the December 2013 issue’s nonsensical article on arthritis. It’s not well supported.

10 Eat fish with caution

Most are now tainted by industrial waste and high levels of mercury, including ‘farmed’ fish, which have been fed inappropriately with grains. Avoid swordfish, tuna and other deep-water fish, as these are likely to have more mercury than smaller varieties of fish from shallower waters. Rotating your protein sources will help to minimize your exposure to specific chemicals.

WDDTY is turning into an Eddie Izzard skit on the Daily Mail. Fish is good, but it gives you cancer. The reference to “specific chemicals” is amusingly ironic, since it’s unspecific and everything we eat is made of chemicals by definition.

How about: eat a balanced diet? Would that cover it? I’m sure doctors don’t tell you that, at least not unless you actually ask them.