Alternative Medicine

Blowing a raspberry

Imagine there is a door in front of you. There is a person standing next to the door:

"Hey there, pudgy, do you want to be thin and beautiful without having to do any exercise at all? All you have to do is hand me some cash and step through that door there."

This person goes on to explain that if you step through the magic door, you will step out of the other side with a perfect, slim figure. You won't need to change your diet or do any exercise. You just need to walk through the door. They show you some glossy before and after pictures. There are pictures of beautiful, smiling people holding out the waistbands of their old elasticated tracksuit bottoms, so you can see just how much more skinny they are now.

There is a slight rumble from behind the door. You ask what is behind it.

"Oh, we don't know. But honestly, it'll work." 
"But is it safe?" you ask. 

"Oh yes, its perfectly safe" is the reply. "All you need to do is go through that door, and you will definitely lose all of that stubborn weight and absolutely nothing bad will happen to you whatsoever. Now if you'll just hand me your money there, that'll be great."   

Sounds great, right? You excitedly take a step towards the door.

But before you step through the door, you take a moment to consider what might be behind it.  You don't know, and the person telling you to go through the door doesn't know what's in there either. No one has studied what's behind the door. There are no photos and  no videos of what's in there. All you have is this person's word that it is safe, and it will work. 

Broadly speaking, there are three possibilities of what's behind the door:

  1. Nothing. Its just a room. You go through the door, and nothing happens. You don't lose any weight, but you have lost your money. 
  2.  It works. You step through the door and emerge as a smiling, happy, beautiful, skinnier you. You quickly run home to find some horrible grey tracksuit so you can smugly show everyone how marvellous you are now you're skinny.
  3.  Something harmful is in there. Maybe there is a big pile of dog poo right behind the door, and you are destined to step in it, which will be mildly unpleasant for you. Or the door could be perched on top of a cliff, below which is a mesh of razor blades that will cut you into little pieces. Worse than that, perhaps Piers Morgan is through there.

Do you step through the door? 

Now, I really do want to lose weight. But I also don't like being deceived, and I really don't like being harmed. I also really don't like Piers Morgan. 

All of which brings me nicely on to this season's most fashionable weight- loss aid, Raspberry ketone. Its the chemical contained in raspberries that makes them smell nice. Its widely used as a flavouring and fragrance agent in foods, which begs the question: if its so effective, why don't we already lose weight when we eat food that it is in?

You've probably heard about it already. By which I mean that you've probably seen someone on Twitter tweeting about how they lost 3000 kg using raspberry ketone, along with a handy link to a website where you can buy it. You've also then probably seen the follow up tweets, that go something along the lines of "Urgh, my account has been hacked. I've changed my password now, sorry."

And there's the first warning sign. People who make real medicines which work don't tend to need to resort to hacking people's social media accounts in a desperate bid to get people to buy their wares. You don't see Pfizer or Glaxo, for all their faults, hacking into random peoples' accounts and mass tweeting "My cancer is in remission thanks to Drug X. Buy it here!!!!". Its not a particularly ethical way to sell healthcare products.

Putting all of that aside, is there any evidence that raspberry ketones work as a weight loss aid?

In short: no, except for 18 mice and a difference of about 5 grams at most. Which also means there is no evidence that it is safe. There are no human studies out there at all. All of this hype about it is based on the fact that its chemical structure looks a bit like two other chemicals (capsaicin and synephrine) which might have some effects on weight loss.

That's a bit of a stretch. Human bodies are complicated things, and we can't always predict how they will react to medicines. Even when we theoretically think that something might work for good, plausible reasons, there's no guarantee that it will (COX-2 inhibitors come to mind as an example). Marketing raspberry ketone as a foolproof weight loss aid just because it looks a bit like some other chemicals is like finding a random key on a street and expecting it to work without fail on your front door, just because it looks a bit similar to your front door key. 

If you were to decide to take raspberry ketone, you would essentially be walking through that door. You might lose a bit of weight, or you might not. You might be harmed, or you might not. There's just no way of knowing right now.

Hxxx


The Not-So-Wise Owls

You might have noticed that Holland and Barrett, the high street's most proliferative purveyor of pointless supplements, homeopathic, and herbal medicines are in the midst of a rather odd marketing campaign, called #AskOurOwls.

  *Gratuitous Fluffy Animal Pic* Meet Willow. Willow is a fully grown, 10 year old south African Owl who lives in Kielder Forest. Willow does not purport to be an expert in complementary and alternative medicines, but he does have very soft feathers. Willow would like to make it known that he does not condone the actions of Holland and Barrett owls

*Gratuitous Fluffy Animal Pic* Meet Willow. Willow is a fully grown, 10 year old south African Owl who lives in Kielder Forest. Willow does not purport to be an expert in complementary and alternative medicines, but he does have very soft feathers. Willow would like to make it known that he does not condone the actions of Holland and Barrett owls

#AskOurOwls means you can ask any question about a Holland and Barrett product, and if their staff can't answer your question, you get 20% off in store. This is accompanied by a kawaii cute animated advert featuring bunnies, hedgehog, and other adorable woodland creatures. Because natural remedies are always totally cute, safe and innocuous, right? And presumably because everyone who works there is in actual fact a shape-shifting owl cavorting as a human. Its like David Icke stuff, but with more feathers. 

In the words of the ad agency who designed it:

"The campaign aims to demonstrate Holland & Barrett’s USP of considerable staff expertise, endorsing the fact that every Holland & Barrett store within the UK has had an officially qualified associate to give advice on all own label supplements, vitamins, healthy foods and weight management products"

Now, I've lost count of the number of enquiries I've dealt with because of Holland and Barrett. These enquiries are usually along the lines of "My patient has bought <insert Holland and Barrett product> and wants to know if they're safe to use with their other medicines." In some of these cases, patients have presented with over £40 worth of herbal medicines etc, and have then been told that no, they can't take it, either because it will interact with their medicines, or because it isn't suitable to be taken by someone with their medical problems.

I have no idea what the Holland and Barrett in-house staff training consists of, but I'm not sure what part of it would allow someone to buy multiple, expensive remedies beforethey know if they are safe for them to use. Its not only a dangerous strategy, but its really very poor customer service, and doesn't do much to 'demonstrate considerable staff expertise'.

Anecdotally, I have heard that in some areas, Holland and Barrett employees have been known to send patients to a nearby pharmacy to ask if they are able to take a product. Whilst this at least demonstrates an awareness of their knowledge limitations, its also pretty inconvenient for the customer to have to traipse in and out of different shops, and i should imagine pretty irritating for the pharmacist, who is having to do H&B's work for them. And believe me, these sorts of enquiries aren't always easy to do, and can be very time consuming. 

So that's not all that encouraging for their #AskOurOwls scheme, is it? And it is a really quite bizarre strategy. If I ask a question about whether a product is safe for me to take, and they can't answer it, I can't really see how offering me a discount on something that I don't know is safe or not would help.

Of course the skeptical community understandably used this opportunity to Ask Some Owls some reasonable questions about where the evidence is for many of the products they sell, why they sell homeopathy when there is literally nothing in it, why they promote detox products when there is no scientific evidence for detox, why they sell high dose vitamins when there is some evidence that they may increase cancer risk etc. And no answers flowed in at all. I ask three questions, and got no response, then sent a Tweet about how I had gotten no response. This did attract a -very curt and actually pretty damn rude- reply from Holland and Barrett demanding to know if it was a question or not.

Funnily enough, after being bombarded with questions about their selling of quackery, the terms and conditions now read that the offer does not apply to questions asked via Facebook or Twitter. I have no idea at all whether these terms were the same at the start of the campaign (do let me know if you know), but it would seem very strange indeed if they have launched a campaign centred around a hashtag but which is not for use on social media. It would sort of suggest that they was actually being rather misleading, or just very careless in the original advertising campaign. Or, of course, that they hadn't quite thought through the consequences of encouraging people to ask questions about remedies that have no basis in science or evidence. Presumably they think that us mean skeptic-types will be so overwhelmed by their wondrous array of snake oil remedies that we will turn to mush and be unable to think of a question in store. 

Let's see what that ad agency says again, shall we?

"The brand strategy extends to social media, where customers can engage with Holland& Barrett staff via Twitter to answer relevant health questions. By using the hashtag, #askourowls, customers are directed back to the brand."

Suspicious, non? And lets just think about this strategy for a moment. They are encouraging people to ask them health questions in less than 140 characters. Given that people are complex, and may have multiple health issues and be on many different medicines, this seems a somewhat cavalier strategy.

Then again, Holland and Barrett are home to some other really quite bizarre offers as well. What on earth is going on with that buy one, get the other for 1p thing? Save everyone the bother of having to faff about with change and just do a plain old BOGOF, for goodness sake. Or, even better, how about not encouraging pointless polypharmacy with multi-buy offers in an area where they are clinically inappropriate and potentially even dangerous?  

So, next time you're passing a Holland and Barrett store, take a moment or two to drop in, and ask them for the evidence. If they can't provide you with any, then enjoy your 20% off- you should be able to find something to buy there- they do sell Bombay mix after all, which is approximately 50% more baked than their #AskOurOwls campaign ever was. Do let me know how you got on, if you do get a chance to ask a question.

You can read some more about how the #AskOurOwls campaign went wrong for H&B but right for skeptics here, and the sort of non-answer Slipp Digby got here.  

Hxxx

UPDATE: interestingly, a mere few hours after I published this post, I got an @reply from Holland and Barrett on Twitter, promising me that someone was looking into my enquiry about acai and i would hear from a nutritionist soon. At the same time, they were merrily sending out requests for follows so that they could DM answers to many other people who had asked similar questions. However, I've never heard anything since, or been asked to follow them to get a DM response-this is now 3 days after they told me someone would contact me.

Putting aside all the other problems with this campaign, this is just utterly terrible customer service. My job involves me dealing with often very complex enquiries, and it would maybe take me three days maximum to do a complex enquiry involving a full research strategy, medical literature searches, critical appraisal of multiple papers, and to compose an answer. I would, of course, acknowledge the enquiry immediately and let the enquirer know of any delays- its common courtesy.

I can't help but notice that on their Twitter feed they do appear to be answering other questions about their products using their Timeline. So why are they using DMs to answer any which question the efficacy of their products?  

I've decided to give them another chance, however, and have just asked them another, very specific question, which would take a pharmacist maybe 30mins-1 hour to answer fully:



We'll see how long that takes to get a response, shall we?

(Update: I never did hear back at all)

Wake up and smell the (green) coffee

The media is raving about it. Waif-like celebrities like Demi Moore are swallowing it like there's no tomorrow. Any internet search results in a tidal wave of websites and blogposts screaming that its the new "100% safe and natural!" weight-loss secret. In short, the world seems to be falling over itself to get its soon-to-be-no-longer-chubby hands on a green coffee extract supplement. We'll all be size zeros in a matter of days.

  Just one of the many hyperbolic stories appearing in the media.&nbsp;

Just one of the many hyperbolic stories appearing in the media. 

Green coffee beans are normal, every day coffee beans before they have been roasted. The roasting process decreases the amounts of chlorogenic acid contained in the products. Chlorogenic acid is thought to moderate effects of glucose metabolism and inhibit fat accumulation- sounds brilliant, right? Well, before I go off, burger in hand, to eat lots of cake safe in the knowledge that I'll be shopping in the size 8 section in no time thanks to green coffee, lets have a look at the evidence.

 Green coffee beans. Just like brown coffee beans, only, well... green.&nbsp;

Green coffee beans. Just like brown coffee beans, only, well... green. 

First things first: does it work?

The short answer is it might do, a little bit, but we don't really know yet. There are a couple of little trials here and there, but they're limited by their size and trial design, so the results could just be fluke. There's one systematic review, which found that overall the data from the better quality trials suggested that green coffee extract could lead to modest weight loss differences (about 2.47kg (95% CI -4.23 to -0.072kg) over about 12 weeks. That's hardly enough to transform my size 16 lumpen frame into a lithe size 8 overnight, or indeed over a year, despite what all the before and after pictures on the manufacturer's websites say.

And what of its safety?

Well, in short we have no idea. I've done loads of research into this and have been unable to find any good, reliable information on its safety. Green coffee contains a similar amount of caffeine as normal coffee beans, so we can assume that all of the nasty side effects from drinking too much coffee could also happen with a green coffee extract. Palpitations, anxiety, insomnia, diarrhoea, and heart problems may result, and even anaphylaxis in the worst cases. Some products claim to be decaffeinated, but as none of these products are regulated, there is no guarantee. 

There is nothing out there on the safety of chlorogenic acid. It seems to have been used in chinese medicine injections, and seemed to be thought to cause allergies. However it seems that there is some debate about this. One study in dogs seems to suggest that it could have an effect on the liver and kidneys, but whether it could damage human kidneys or livers is unknown.

So there we have it.

We basically know very little about green coffee extracts, despite what the websites that are selling it will tell you. It might work a bit, but its certainly not a miracle cure, and we don't really know whether or not its safe yet. It may well be safe, but we just can't say for certain yet. Instead of waiting until more evidence is known, however, it seems that manufacturers are gleefully happy to sell it far and wide.

What's particularly uncomfortable is that the sellers of green coffee extracts are taking the more and more common approach of marketing their products. Google "Green coffee extract safety" and instead of finding reliable sites or those actually looking at the safety of the product, the search is flooded with marketing sites masquerading as genuine safety sites. This sort of marketing feels really icky, and I don't like it at all.

Its yet another opportunity for unscrupulous people to make money from our insecurities. I'm overweight myself, and I know that I have to struggle against the urge to throw my skepticism to the wind and throw money at anything that claims it will help. The simple fact is that there wont be a miracle cure, and losing weight takes time, effort, patience and willpower, not to mention the fact that the desperation to be unhealthily skinny is dangerous in itself.

Hxxx

Some thoughts on quality and quantity

The sad news about Iain Banks has gotten me thinking today. 

I'll be honest here and say I've never read any of his books (so many books in the world, so little time!). I know nothing at all about him. Yet when I read his statement at work this afternoon, I had tears in my eyes. His words were so dignified, so stoical, and so noble that they really touched my heart. The ability to have humour at such a time is something I admire hugely.

I'm sure his words are the tip of the iceberg. I really can't even begin to understand what a lengthy, horrific process it must be to come to terms with such news. But what struck me most of all was his plans to spend his remaining time with his family, friends and loved ones. Isn't that, when it comes down to it, what we would all want? And yet it seems to me that cases such as his appear to be in the minority of those that are reported in the media. 

Many moons ago, at university, I went to a lecture by Sir Michael Rawlins. He discussed the thorny issue of how NICE assess drugs, and he touched upon quality of life measures. I remember being utterly shocked when he said that the majority of terminal patients choose longevity over quality of life. That's always stuck with me, as it seems so starkly counter-intuitive to me that I genuinely can't get my head around it. I also know that's very easy for me to say, and that I have absolutely no idea what it must be like to have to face such decisions. A few years ago I did my Diploma in Therapeutics, and we had to try out some of the quality of life rating scales that are used at NICE. Believe me, this really gets you thinking about how difficult these sorts of choices are. I also remember a really brilliant workshop with Claud Regnard, a palliative care consultant and author of some highly-esteemed books in the field. I remember being bowled over by how positive and creative such a potentially depressing subject could be.

We're a nation (and potentially a planet) that are very medicalised. We hunt for a cure for everything, and a miracle pill to make us cleverer, slimmer, healthier. When given the choice between taking a tablet and changing our lifestyles, I think it's safe to say that most of us would rather opt for the former. This is fuelled by any number of things, but I think the media has a lot to do with it: there's always a story about how some new drug is going to cure Alzheimer's, or obesity, or heart disease, and there's story after story of families desperately searching for a cure or treatment that can cure their love ones.

And here's what I've been thinking about: when all the options have been explored, and there is no cure, practitioners of conventional medicine (by which I mean medicine which is proven to work) will usually tell you so. 

At this point, the quest for something else, perfectly understandably, kicks in. Of course you would grasp at any straws, any vestige of hope. And so, right at the time where people should be spending their days doing what they love with the people they love, as Iain Banks is doing, some of them turn to alternatives. 

It could be weird diets, it could be homeopathy, it could be a certain well-known quack's clinic in Texas, it doesn't matter. What all of these things do is sell hope when all else has failed. They're a very seductive prospect, and it may well seem perfectly logical that you'd spend every penny in trying them, and you'd leave no stone unturned trying to find the perfect treatment for you, or your loved one. 

Just at the time when you should be kicking back and enjoying your time as much as you can, you end up on a plane across the world, which is stressful enough for anyone at the best of times. Or you might end up on a strict diet regime, having to deprive yourself of the foods you love just when you should be enjoying them more than ever. You might end up a slave to a complex regime of megadose vitamins, enemas, pills and injections when you should be being made as comfortable as possible with palliative care. 

These people who sell false hope rob patients not only of their money, but of their precious time as well. And that, in my opinion, is the most evil and unforgivable of sins. 

I hope that, eventually, we get to a place where a quality life and death become the most important thing to anyone with a terminal illness. 

This is yet another blogpost where I feel the need to write "hope this all makes sense" at the end. I probably should just plan posts better, but I've always found I'm usually better at just writing as I think at times. My humble apologies also for any typos... I'm absolutely rubbish at touch screen typing


Hxxx

The Burzynski Connection

There's an event coming up in Newcastle that I'm really looking forward to. There's a lot of excitement about Street Spice, a street food festival coming up at the end of February, dedicated to celebrating world spices and food. And, to make it even better, its being held to raise money for charity- Brain Tumour UK.

So how does this fantastic event cross over into the murky realms of Dr Burzynski's work? Many others have covered the Burzynski debacle much better than I would ever be able to do. If you do want to know more about it, I recommend starting at Josephine Jones' blog, as she has a pretty extensive list of her own blogposts, along with those written by many others in the skeptical community. 

The event is being held in memory of Kuly Ral, who died of a brain tumour. I know very, very little of this chap, except for the information given on the Street  Spice website:

"Kuly Ral made up one third of super Urban-Bhangra group RDB when his devoted family and Three Records label colleagues discovered that he had a terminal brain tumour. Although Kuly sought to get treatment in America for this, it was not to be:"

It's a very sad fact that my heart sinks every time I read or hear the words "treatment in America" for cancer. I can't help but dread that it means Burzynski's clinic, and with a bit of digging, it seems that in this case it was indeed Burzynski's clinic that Kuly was receiving treatment from when he died. I know nothing of the circumstances of his treatment, or how he died, but given that Burzynski supporters have been known to use the names of dead patients as testimonials for successful cancer treatment, showing no respect whatsoever to the deceased or their loved ones, I'm frankly amazed that Burzynski and his cronies aren't shouting from the rooftops about how they were treating such a high profile Bhangra personality. (In the past I have emailled the Burzynski Patients Group to ask if they were going to take down the name of a patient who had been dead for months. Unsurprisingly, I received no reply.)

I'm making no judgement here on anyone who would choose to go to Burzynski. I'm also still really happy to be going to any supporting the event, as it's raising money for Brain Tumour UK rather than for Burzynski himself. The person who I judge the most in this situation is Burzynski himself, who seems rather happy to be making his millions providing unproven treatments, deceiving patients, making shoddy movies, and claiming an FDA conspiracy, when he could quite easily silence his critics-and the FDA- by simply publishing the results of his "clinical trials". If he spent half the time he spends on shameless self-promotion by sitting at his desk and actually writing up some results, then at least he could back up all of his miraculous claims, and all of us who are critical of him would have to sit down, shut up, and happily accept that there is a cure for cancer on the market.  

So here is my own tiny little memorial to Kuly Ral. It takes the shape of a simple plea, and goes thus:
 

"Dear Dr Burzynski,
Please publish the results of your trials.
Its the least you could do"

Cherry picking the evidence

A good friend of mine is really into running, and has many half-marathons, kilomathons, and marathons under his belt (at least one of which was in a very hungover state). He is taking a sour cherry supplement, which has led to some heated debate about whether or not it works.

He eagerly googled, to bring up some small studies of the effects of sour cherry juice on pain after a marathon. More animated discussion took place. He seemed to think that the very existence of some studies meant that the stuff would definitely work:  So I thought this would be the perfect place to assess what evidence there is for sour cherry.

It would seem that there are several different types of cherry, sweet and sour. It is the sour, tart varieties which appear to be of interest in exercise products such as this. And these things are pretty expensive. 

My first point: the evidence appears to be looking at juice, not tablets. There is nothing to say that any benefits you might get from a juice will also be present in a tablet- think of garlic, for example, where allicin, the active ingredient, is mainly lost during the processing required to make a garlic supplement. 

My search strategy begins with my old friend Embase. eagerly, I find sour cherry in the database and search it, only to get 9 results. When I limit it to humans, I get 1 result, and that is assessing its effects on sleep quality, so is nothing to do with exercising.

And so, I move onto Medline, in which I find a grand total of 2 studies looking at the effects of sour cherry juice in recovery following exercise. 

The first study has 20 recreational marathon runners in it, so its tiny, and far too small to be able to draw any reliable conclusions from. Whilst it seems to show some positive results, with significant reductions in isometric stress, inflammation, and oxidative stress, there is no indication of how relevant this is clinically.1. Would I actually feel better after a marathon as a result of this? Is this increase in recovery of muscle function actually going to make a difference?

The second study has a grand total of 14 male students in it. It's randomised and placebo controlled, but again, to small to be of any interest. This study found that strength loss and pain were reduced in the cherry group, but relaxed elbow angle and muscle tenderness were no different. 2

There are a couple of other little trials dotted here and there are well. But they're all too small to suggest that there is any definite effect. Moreover, there is no information on the safety of such products. Any trials only apply to cherry juice, and can't as yet be extrapolated to cherry supplements such as tablets or capsules.

Whilst the preliminary evidence looks juicy, it's certainly not enticing enough to tempt me to pop my marathon cherry. 
 

I'll stick to my favourite types of cherries, if you don't mind, namely those that are steeped in sugar and  encased in pastry.

Search strategy: Embase:*sour cherry [Limit to: humans] Medline: (sour AND cherry).af OR (tart AND cherry).af [limit to: humans]

References: 1. Howatson G et al. Influence of tart cherry juice on indices of recovery following marathon running. Scandinavian Journal of Medicine & Science in Sports, 12 2010, vol./is. 20/6(843-52), 0905-7188;1600-0838 2. Connolly D et al. Efficacy of a tart cherry juice blend in preventing the symptoms of muscle damage. Br J Sports Med 2006; 40: 679-683

Malik's Mesothelioma Magic

I'm still pretty new to this skepticism thing, but I'm starting to become immune to the bog-standard nonsense claims that I see homeopaths constantly making. There are still the odd ones, however, that knock me for six and leave me feeling rather staggered at the sheer dangerous nature of the claims.

It'll come as no surprise to some of you that the culprit of the most recent of these claims is "Dr" Nancy Malik, who yesterday posted the following on twitter:

That's right, people, apparently mesothelioma is curable with "alternative and natural treatments". And so, with bated breath and already-slightly-higher blood pressure, I followed the link provided by I'm Not Really A Dr Malik. What I was faced with was, to say the least, rather misleading and made my blood boil. Take this paragraph for instance:

"If mesothelioma patients have the desire to maintain quality of life, often they will choose alternative and natural treatments for the disease. The survival rates for those having success with natural treatments greatly enhance quality of life during treatment due to the fact that they forego poisoning their systems using toxic chemicals that hamper the body's immune system."

In other words: if you choose conventional medicine, you're an idiot who is essentially killing themselves by choosing poison. So what would they recommend instead, this website which has no references at all to back up their claims, and who appear to be desperately trying to sell me various nonsense books? 

There is one thing I can say in defense of this website is at least it appears to be peddling herbal medicines rather than homeopathy. I wonder if "Dr" Malik has realised this, as she seems to have been furiously retweeting and promoting things from this website. 

They recommend Nigella sativa, celandine, mistletoe, and cat's claw. Oh really? let's check that, shall we, by having a lookie at the evidence for these products in mesothelioma, brb....
...
Nigella sativa: no evidence. 
...
Celandine: insufficient evidence to rate effectiveness for cancer. 
No evidence in mesothelioma

...
Mistletoe: insufficient evidence to rate effectiveness for cancer. No evidence in mesothelioma
...
Cat's claw: no evidence.

Well, that was quick then. For transparency, I checked the evidence using the Natural Medicines Comprehensive Database, a gold standard resource for information on herbal medicines. 

This website does of course close with the obligatory "It's all a big conspiracy and big pharma and the medical profession just want everyone to die horribly" statement, so any teensy tiny miniscule scrap of plausability has gone out the window even without the total lack of evidence to back up their claims.

Do these people really not realise the danger they put people in by encouraging them not to use conventional medicine (which we have evidence to say it works at least some of the time) and to use alternative medicines (which there is zero evidence to say if it works or not) So where is the conspiracy here, folks? Is it really from the people who know about physiology and pharmacology, and who are primarily motivated to help people? Or does it come from the "alternative" camp, who seem hell bent on selling various books and expensive remedies and are happily peddling misinformation like there is no tomorrow?

H xxx

Why St John's Wort scares me, even though it does probably work.

Hi all,

It's lovely for once to be able to write about something that works, instead of something which has little to no evidence of it working. However, I wanted to share with you some reasons why I would tend to steer people away from a "natural" remedy, despite the evidence being positive. Why St John's Wort today? Well, my RSS feed today popped up with:

31/12/2012
Daily Telegraph
By: Presswatch
GPs prefer herbal remedies to Prozac, says survey
A survey by Schwabe Pharma found that GPs are increasingly likely to prescribe herbal remedies such as St John's wort for depression rather than Prozac.(
(http://www.presswatch.com/health/index.php?d=2012-12-31#3)

I haven't been able to find the actual story, or the press release from Schwabe Pharma (who, incidentally, produce St John's Wort, so wouldn't be without bias), but it got me thinking anyway. 

Is it because of a big pharma conspiracy? Is it because I'm in cahoots with the evil drug companies and all I want is money? Is it because I'm just too close-minded to be able to accept anything other than conventional medicines? Is it because I love seeing patients suffer? Well, in short no.

I find herbal medicines really interesting. Unlike homeopathy, which has no theoretical possibility of working, herbal medicines contain plant material with high enough levels of chemical constituents to cause a pharmacological effect. There's something quite beautiful about the concept of using plants for medicinal purposes. The problem with them lies in the fact that there just aren't enough studies done for us to be able to say whether they work, or more importantly, whether they harm. Whilst herbal remedies have enough "medicine" in them to make them work, this also means they have enough in them to cause adverse reactions, to interact with other herbs, medication, illnesses and so on. Without Big Pharma funding, though, its not that likely that large, well designed trials will be undertaken on them, so using herbal medicines can be a bit like shooting in the dark. Even if we don't find any documented issues with a herb, this doesn't mean none exist, it may just mean that nobody has looked at (or published) any issues yet.

St John's Wort is different. There is now a pretty large body of evidence to suggest that it works, and that it works better than placebo and as well as conventional antidepressants like the SSRIs. We also know a fair bit about its interactions and its adverse drug reactions... So that's great then, yes? That means healthcare professionals should all consider it as a better choice than the conventional medicines, with all their nasty side effects etc, right? 

Well, in my opinion: not always. Whilst we know a fair amount about it, the problem here lies with production, and the inherent variability in herbal medicines. Because they're made from plant materials, there can be a huge amount of variability in what each tablet contains.. Even if you're using a product licensed under the Traditional Herbal Registration scheme, there can still be variability between each batch, depending on where the plant was grown, the time of year/ day it was harvested, and what it was treated after it was harvested. So, if you get stabilised on one batch of medicine, the next batch may contain differing amounts of active ingredients, which could mean a whole host of things might happen: it might work better, it might start interacting with your other meds, it might trigger a side effect etc. Then, just when you're getting used to that batch, the next one is different too, etc etc.

I've come across a few enquiries where a patient wants to use St John's Wort as add-on therapy along with their antidepressants. It maybe doesn't occur to the patient or their GP/pharmacist etc that it actually works in a very similar way to a conventional antidepressant. Combinations of antidepressants are usually only done under specialist care (with a few exceptions) because combining them increases the risk of some very severe side effects such as serotonin syndrome- the same applies to St John's Wort. The fact it's "natural" seems to blindside people into forgetting the usual principles of how medicines work. 

This is before we even get into the territory of risks associated with self-treatment of what can be a very, very serious disease. Would I exclude use of St John's Wort entirely, for everyone? No, because it does appear to work. But do I treat it with as much (if not more) caution than I would an SSRI? Yes, because there's still not that much information about its safety in the grand scheme of things. So this sort of negates the point of it, to be honest.

Hopefully that explains a bit about why I'm cautious about herbal medicines.

Have a lovely New Year's Eve folks, see you again in 2013.

Hxxx

Is Halotherapy (aka Salt Cave therapy) worth its salt?

Ages and ages and ages ago I wrote an initial blog post on halotherapy (salt cave therapy), and i promised you a follow up once I have looked at the available data for it.

In short, I always meant to get round to following it up, but kept forgetting or getting embroiled in something else instead. So here, dear friends, is the follow up post.

As you may recall, www.saltcave.co.uk were claiming their clinically tested, drug free treatment meant that many of their patients stopped taking their medications becuase they because symptom free. They claimed it would work for asthma, COPD, and sinusitis. So, I thought I'd test their claim for COPD, particularly since this illness can be particularly devastating and debilitating.

So here's what I did: had a look at their website, which attempts to helpfully provide a list of published studies. I the proceeded to ignore this entirely, and did my own search of Medline and Embase, the two leading medical literature databases in the world. If there was going to be any robust evidence, I would find it in those.

Now I'm interested in human clinical studies mainly as a starting point, because these are the ones that can actually tell us best whether or not something works. So I limited the searches to human trials: after all, The Salt Cave are claiming that it's a clinically tested therapy, right? I then combined the results for halotherapy, with results for chronic obstructive pulmonary disease, to see what would come up.

In Embase, I found one study. Unfortunately, it was in Russian, so I have to rely on the abstract. The study included 29 patients, and that's pretty much all that we know. The authors claim a significant positive effect, with no other information or data reported in the abstract. But frankly, a study with 29 patients in is neither here nor there- it's far too small to use to make any claims of benefit.It's worth noting, by the way, that these patients were in a "sanatorium" setting, which is likely to be a rather different setting to the middle-class-Ikea-£35 a go-UK based version that is being sold here. What other treatments would be given in a Russian sanatorium setting? How would any of this affect the patient's condition? How has this been controlled for in this study? Unfortunately, there's no way of knowing given how badly presented the abstract is.   

Okay, so what did I find in Medline? Well, in short, nothing. No results at all. 

So then I went back to the references provided by www.saltcave.co.uk and found very little to add. Another Russian-based sanatorium study, in abstract only, providing no data at al. Likewise, the study that they use on the "results" page of their website only include 26 patientswith COPD: again, too limited to draw any secure conclusions from. 

So my conclusion? The evidence for the use of salt cave therapy in COPD is far too limited to claim any benefit at this point in time. More research needs to be done in this area to be able to claim that it works. And this evidence base certainly doesn't justify £35 per hour. They can put as many testimonials as they like on their website but it still doesn't add up to good, robust clinical evidence. 

Hopefully this is a step to debunking some of the claims they are making on this website. Whilst there is a possibility that it might work, at the moment we just don't have enough information to justify the claims- and the cost. 

Further reading on halotherapy can be found at The 21st Floor and Sceptical Letter Writer

For transparency, here's my search terms: EMBASE: halotherapy.ti.ab AND Chronic obstructive ling disease/ MEDLINE: halotherapy.ti.ab AND Pulmonary disease, chronic obstructive

The Importance of Being Human

The more I talk to homeopaths and other alternative medicine practitioners, the more I realise that the distinction between in vitro and in vivo testing is unclear to many.

It may be due to ignorance, or it may be in a desperate bid to pad out the lack of real-life clinical evidence, or to stun us all into silence with impressive looking sciencey stuff, but it seems that alternative medicine supporters are desperate to throw in vitro studies my way as "evidence" that their treatments work. But here's the thing: it's not evdience that it works at all. In fact, for the purposes of informing treatment decisions, any in vitro data might as well be discarded before you even bother reading it. 

Why do i say this? Well, the easiest way to explain this is in picture form (drawings are courtesy of Haymond) :

 A petri dish filled with gel, with some cells in it (an in vitro experiment)

A petri dish filled with gel, with some cells in it (an in vitro experiment)

  A human being&nbsp; (well, okay, I know some people might think scientists aren't quite human beings but, y'know, we thought we'd still use one as an example). (in vivo)

A human being  (well, okay, I know some people might think scientists aren't quite human beings but, y'know, we thought we'd still use one as an example). (in vivo)


As you can see from these pictures, a few cells in a petri dish actually look (and act) rather differently to a functioning, whole human body. So positive (or negative) results in an in vitro study actually bear very little resemblance to real life clinical situations. What  in vitro testing is great for is as preliminary evidence- to make new discoveries and to guide further research, and to find out the all-important details of how something may work. But we can't use some cells in a petri dish to say "Yes, this will definitely work for this or that illness". The only sort of evidence that we can use to decide if a drug is effective in any particular illness is a robustly designed clinical trial, and even then we can't use that as a cast iron guarantee. 

I'm hoping that you will forgive me for this horrendous oversimplification, but it is hopefully a useful point to make. So, the next time you come across some in vitro studies being used as "evidence" that homeopathy works, you know that they're actually scraping the barrel, particularly gievn the fact that homeopathis is supposed to have been around for 2000 years. I'd expect after that amount of time that they'd have more than cell culture studies to their name. 

Hxxx

Alternative medicines and brain tumours- Some ramblings.

There's been a lot of press attention in recent days about the case of  Neon Roberts,whose mother had apparently ran away with him in order to avoid him being given post-surgery radiotherapy.

I will admit at this point that I haven't looked too closely into the case. I'm writing this on my lunch break so don't have time to go into all the details, but it appears that after being found, Neon has been taken into foster care and has been given the treatment he requires.

If the press reports are to be relied upon (and bear in mind my main source is the Daily Fail), this seems like a striking case of the sort of harm misinformation about alternative medicines can cause. Reportedly, the mother only wanted him to receive "natural remedies" as he recovers from his surgery. The implication is that natural remedies would be safer for the child, whereas conventional treatments like radiotherapy and chemotherapy are evil, toxic poisons.

And yet this distinction between "natural" and conventional medicines is highly blurred, particularly when it comes to chemotherapy. Some of our most powerful (and potentially toxic) chemotherapeutic agents are derived from plants- the taxols for example. Ultimately, the main difference between these agents and alternative medicines is that they have been tested and have been proven to work. If other natural, alternative medicines went through the same testing processes and also had positive results, they too would cease to be alternative and would become conventional medicines. Radiation, similarly, is an ultimately natural process. So how do the public at large decide what constitutes a "natural" remedy? We can see from this case the potential consequences of such misinformation.

Another thought that occurs to me is the distinction between complementary and alternative medicines. I think we can all agree that there is a potential benefit from somenatural remedies for some cancer-associated symptoms or problems. So as an example I have no problem with a patient who decides to try a herbal remedy to treat say anxietyalongside their conventional treatment, providing they are doing so with a knowledge of the pros and cons of the treatment, and with their healthcare provider's knowledge. Complementary therapy, in other words. What's infinitely more worrying is the concept of alternative therapy, e.g. where a patient makes a decision to not use conventional medicine but to use a herbal remedy(or homeopathy, or acupuncture etc) instead. The evidence base for alternative medicines is absolutely nowhere near the level required to justify a patient using them instead of conventional medicines for something as serious as cancer.

And this brings me on to homeopathy. Yes, homeopathy again. I'm not going to cover how homeopathy works, as its been done much better at this site:http://www.howdoeshomeopathywork.com/ . What is particularly worrying about this modality is the advice given that conventional medicines need to be avoided to allow the homeopathy to work. This is bandied about in an inocuous sort of a way by websites such as this. So, by recommending a homeopathic treatment for a serious condition, homeopaths are directly harming their patient by encouraging them to not take conventional medicines (which may have a chance of working at least) and to replace them with Magic Woo Memory Water Sugar Pills (which have zero chance of working). One of the most heart-breaking things i have ever read on the internet are the letters of Penelope Dingle to her homeopath, who treated her pancreatic cancer. If you haven't seen this already, I highly recommend that you have a look, but warn you that it is likely to induce tears, then rage. 

I've noticed that a few homeopaths on twitter have already picked up on the story of Neon Roberts, and are gleefully tweeting things like "UK Boy to Be Forced Into Chemotherapy" (forgetting the fact that it's actually radiotherapy that he will be receiving). Of course I'm Not Actually A Doctor Nancy Malik is involved. So I thought I'd have a look at what evidence there is that homeopathy can treat brain tumours, before they all start claiming that it can. So I've checked Medline and Embase, the leading medical literature databases in the world. My search stratedy was: Search for homeopathy. Search for brain tumours, and limit to therapy or treatment. Add the two together. See what comes out.  Makes sense, right? 

The answer, of course, is a big fat zero. 

I'm Not Really A Dr Nancy Malik, however, has other ideas, and has helpfully sent me links to 4 sources that she claims are evidence that homeopathy can work in brian cancer treatment. Three of which are studies looking at  tissue cell culture, and one of which is for treatment of side effects (ergo as complementary, rather than alternative therapy, and which bears no resemblance to whether or not it could actually treat a brain cancer). The in vitro studies are very interesting i'm sure, but to use them as evidence that homeopathy can treat brain cancers in humans is an enormous stretch. With something so serious, would you really be willing to base a treatment decision on what happens to a couple of cells in a lab? Or would you rather base it on what happens to thousands, if not millions of other people in real-life? I know which one I would go with.

One other footnote to this news story is one which I fear may have been forgotten about. Imagine being a child, who has just undergone surgery for a brain tumour. Imagine the fear this poor boy feels on a daily basis, not to mention how physically ill he may be. Now imagine being taken by your mother on a trip elsewhere, then being taken into foster care and having to be given radiotherapy, whilst a court case battles on around you. I can't even begin to imagine what this child is feeling. This time would have been bad enough for him as it was, without any of this being added onto his trauma. 

Hxxx

Quick Thought on Ancient Medicines

Hi folks,

I'm working on a little project about complementary and alternative medicines- a quick reference guide to the most common modalities, and how they differ in effectiveness, safety, theories etc. I've been using the Natural Medicines Comprehensive Database- a great (but unfortunately rather expensive) site for balanced, evidence-based information on alternative medicines- for information on different modalities, and I came across a statement that I hadn't considered so far, but one which I think may actually be quite persuasive to some when it comes to alternative medicine. It's quite simple, but the thought just simply hadn't occurred to me before. 

This is the fact that  a lot of modalities were developed prior to any sort of scientific knowledge about how the body works, or pharmacology. For example, homeopathy was developed at a time where it was thought "humours" were to blame for illness- a time where blood-letting was treatment of choice for much sickness. And as for Traditional Chinese Medicine (TCM), developed over 2000 years ago:

"At that time there was no scientific concept of disease or pharmacology in terms that can be related to our modern understanding of medicine. Therefore, the principles of TCM were formed based more on philosophy than on science"

The same goes for Ayurvedic medicine as well as anything that claims to be ancient. 

So, on this basis, why should we believe that any of these modalities are scientific, or likely to work? How can homeopaths, for example, claim that it is "science-based medicine" when it fact it predates the science of medicine? Why on earth do we think this is a good thing?

Why, in days where calculators are easily available, should we be expected to believe that using an abacus will be more effective and safer?

H xxx