I realize I’ve said it before, but I still can’t believe as many people read what I like to lay down on a daily basis right here on this blog. Believe me, it has nothing to do with an sort of false sense of modesty. After four years at this, I know I’m good at blogging. Real good. But good isn’t always enough to make much of a difference or even to garner an audience. Whether I’ve done the first, I don’t know. I like to think that I have. As for the second, I’ve done pretty well for myself. Indeed, after a year of stagnant traffic, January and February were the best months, traffic-wise, in the history of this blog. What that means, I guess, is that sometimes people whom I would never have expected to give a rodent’s posterior about what a nobody like me writes actually sometimes take note. Sometimes famous people, certainly far more famous and renowned than your humble pseudonymous blogger, are moved to leave a comment. Not surprisingly, these responses, on the fairly uncommon occasions when they appear, are usually provoked by something I’ve written that has–shall we say?–displeased the target of my insolence, be it of the respectful or not-so-respectful variety.
Such was the case late Tuesday night, when one of the Four Horsemen of the Woo-pocalypse himself, upon whom I had laid a bit of a smackdown in the course of lambasting Senator Tom Harkin (D-IA) for his plan to piggyback the legitimization of quackery onto any health care reform legislation that President Obama might try to get through the Congress. Because Harkin is a very senior and very powerful Senator, one who nearly single-handedly birthed the legislation that produced the Office of Alternative Medicine in the NIH, which later begot the monstrosity that has become the National Center for Complementary and Alternative Medicine (NCCAM), his intentions are very important, as he very well might succeed if President Obama is insufficiently serious about the promise he made in his Inaugural Address to restore science to “its rightful place.” A few of you know of whom I speak, as you took up the slack when I couldn’t respond right away due to yesterday being a travel day to the SSO Meeting in Phoenix. I’m referring, of course, to Dr. Dean Ornish, the Founder and President of the Preventative Medicine Research Institute, who left a comment that, because it got held up for moderation (I know not why), I did not see until very late. Suffice it to say, he is not particularly happy with me.
Although I can totally understand why Dr. Ornish might not appreciate my criticism, he should actually know that, of the Four Horsemen of the Woo-pocalypse, I consider him (probably) the least objectionable. Certainly he would not be Death (that would be Andrew Weil). Smart-ass that I am, maybe I’ll consider Dr. Ornish to be Famine, given that his claim to fame is the use of very low fat diets, along with major lifestyle alterations, to effect changes in health. The reason that I find Dr. Ornish perhaps the least objectionable is that at least he tries to do science. It’s preliminary science, and usually the controls aren’t the greatest, but it is for the most part science. My main beef with him is how he represents that science to the public. For his claims for dietary treatment of prostate cancer at least he tends to take preliminary studies of highly select patients and make way too much of them. Indeed, he often says one thing in his papers, where peer-reviewers force him to remain tentative and keep him from going too far off into the deep end with his claims, but quite another thing to virtually everyone else, including the aforementioned Senator Harkin and, even worse, to the recent Institute of Medicine/Bravewell Collaborative conference on alternative–excuse me “integrative” medicine–from which he hopped over to the Senate to do a two-fer of woo promotion in our nation’s capital.
My post about him and his fellow horsemen led him to respond in the comment section thusly (comment reproduced in its entirety), after which I will provide my response:
For someone who prides himself on attention to detail, it’s surprising that you haven’t done your homework. My testimony that comprehensive lifestyle changes may affect the progression of early-stage prostate cancer was not based solely on the paper that my colleagues and I published in the Proceedings of the National Academy of Sciences last year (Proc Nat Acad Sci USA 2008; 105: 8369-8374. Ornish D, Magbanua MJM, Weidner G, et al. Changes in prostate gene expression in men undergoing an intensive nutrition and lifestyle intervention. Proc Nat Acad Sci USA 2008; 105: 8369-8374).
It was based on a randomized controlled trial that I directed in collaboration with Peter Carroll, M.D. (Professor & Chair of Urology, School of Medicine, University of California, San Francisco) and the late William Fair, M.D. (Chief, Urologic Surgery and Chair, Urologic Oncology, Memorial Sloan-Kettering Cancer Center) which was published in one of the leading peer-reviewed urology journals (Ornish DM, Weidner G, Fair WR, et al. Intensive lifestyle changes may affect the progression of prostate cancer. Journal of Urology. 2005;174:1065-1070). Other subsequent studies have shown similar findings.
In September, we published a pilot study in The Lancet Oncology in collaboration with Dr. Elizabeth Blackburn, who was awarded a Lasker prize for discovering telomerase, showing that these comprehensive lifestyle changes increased telomerase by almost 30%. This is the first study showing that any intervention may increase telomerase.
Our earlier studies showing that comprehensive lifestyle changes may stop or reverse the progression of coronary heart disease were published in several peer-reviewed journals, including:
• Ornish D, Scherwitz L, Doody R, et al. Effects of stress management training and dietary changes in treating ischemic heart disease. JAMA. 1983;249:54-59
• Ornish D, Brown SE, Scherwitz L, et al. Can lifestyle changes reverse coronary atherosclerosis? The Lifestyle Heart Trial. The Lancet. 1990; 336:129-133.
• Gould KL, Ornish D, Scherwitz L, et al. Changes in myocardial perfusion abnormalities by positron emission tomography after long-term, intense risk factor modification. JAMA. 1995;274:894-901.
• Ornish D, Scherwitz L, Billings J, et al. Intensive lifestyle changes for reversal of coronary heart disease Five-year follow-up of the Lifestyle Heart Trial. JAMA. 1998;280:2001-2007.
You can do a medline for more references.
Although you dismiss this statement as “nonsense,” we are, in fact, more than just genes and germs, microbes and molecules. You might begin by reading some of Leroy Hood’s work (no slouch as a scientist) who described systems biology and the concept of synergy. I cited his work in my keynote talk at the recent Institute of Medicine’s “Summit on Integrative Medicine” at the National Academy of Sciences that will be posted later this week (http://www.iom.edu/integrativemedicinere) in which I describe the studies of those such as Sheldon Cohen in JAMA showing that not everyone who is infected with rhinovirus develops the signs and symptoms of a cold, and found a direct relationship between the degree of social support and immune function.
The best scientists are open to new ideas, not glibly dismissing them just because they don’t agree with their preconceptions.
Dean Ornish, M.D.
Founder and President, Preventive Medicine Research Institute
Clinical Professor of Medicine, University of California, San Francisco
Ow. That’s gonna leave a mark.
Well, not really. In fact, I’m rather disappointed that Dr. Ornish played the “close-minded” gambit so vociferously. Whether consciously or not, Dr. Ornish appears to have missed the broader point I was making about how pseudoscience had coopted what should be the very science-based interventions of diet and exercise as a “wedge strategy” designed to open the way for the entry of all manner of quackery in order to focus like a laser on the much narrower point of my criticism of his work. When I first saw Dr. Ornish’s response, I was half-tempted to ignore his complaints about my criticism of him, because even if each and every point he makes about his diet and lifestyle interventions were 100% perfect science with overwhelming support and I really were a close-minded, lousy scientist, it wouldn’t change one whit my annoyance with him for allying himself with supporters of pseudoscience to support Senator Harkin (the broader point of my broadside against Weil, Hyman, Oz, and him), as I’ll explain a little later. However, when someone throws down the gauntlet like Dr Ornish, I have a tendency to pick it up and slap him across the face with it, accepting the challenge. Even if I end up losing badly, better to go down honorably than to slink away. So let me deal with a handful of the specifics of Dr. Ornish’s complaints before I move on to finish this post addressing the broader point of why Dr. Ornish drives me crazy.
First off, Dr. Ornish is mistaken to assume that I have not read or was not aware of his other papers testing his diet against prostate cancer. I’ve read them all, although I’ve done a detailed deconstruction of only the microarray paper that I mentioned. I’ve even obliqulely alluded to his telomerase paper before, and I’ve read several of his others. Consequently, it’s probably my fault that he got the impression that the microarray paper was the sole basis of my criticism. However, my post was long and a detailed discussion of all of Dr. Ornish’s work in prostate cancer was beyond the scope of the post; so I picked one example that I had already discussed, which you can read again right here if you so desire. In the meantime, let’s look at a couple of the other papers Dr. Ornish cites as evidence that I am a close-minded, careless dolt, as well as a brief look at the microarray paper again.
The telomerase study, which did indeed appear in The Lancet Oncology in September, was entitled Increased telomerase activity and comprehensive lifestyle changes: a pilot study, is very interesting in that Dr. Ornish reported telomerase activity results on the same patients upon whom he did his microarray experiments. This is what Dr. Ornish said about this problem in the discussion section of the PNAS microarray paper:
…our analysis was limited to normal prostate tissue because tumor tissue was present on the biopsy specimens of only a minority of patients. Thus, the implications of this study are not limited to men with prostate cancer. Because of the microfocal nature of low-risk prostate tumors and the limitations of ultrasound biopsy guidance, we were unable to precisely match pre- and postintervention tumor samples for individuals in our cohort…Because only one-third of patient biopsies in our study included tumor tissue, we were limited to examining the response of the normal prostate tissue (stroma and epithelium) to the intervention. It will be very important for future work to examine tissue molecular responses to determine whether the normal stroma, tumor stroma, normal epithelium, tumor epithelium, or a combination of these tissues respond to diet and lifestyle changes.
I will admit that it is fair enough to point out that, if the results are validated, that the changes in gene expression occurred in normal prostate cells does imply that his diet might be useful for prevention. However, given that he missed cancer epithelium 2/3 of the time, it’s really difficult for him to conclude anything whatsoever about his microarray experiment. In fact, what I’d be interested in is a comparison of the array results of tissue samples with no tumor tissue versus those with tumor tissue. All it would take is a couple of patients whose pre-diet biopsy had tumor tissue but whose post-diet biopsy did not to significantly affect the results. That was the main basis of my skepticism over whether the PNAS paper meant much of anything.
Moving on, I have to admit that the telomerase paper led me to scratch my head. In cancer, telomerase is generally a bad thing. To put it simply, telomeres are repetitive DNA sequences at the end of chromosomes. They serve to keep chromosomes from degradation. The reason chromosomes degrade during replication is that the enzymes that replicate the chromosome cannot replicate the DNA all the way to the end of the strand. Consequently, during each round of cell division and chromosome replication, some DNA sequence is lost. With telomeres at the end, what is lost is noncoding repetitive DNA, and no important DNA sequences that code genes or regulatory regions are lost. In most eukaryotic organisms, an enzyme known as telomerase adds these DNA sequences to the end of the chromosomes. However, in the adult telomerase is generally active only in cells that need to divide a lot, such as stem cells and immune cells but only expressed little, if at all, in most normal cells. In immune cells, which is where Dr. Ornish looked, decreased telomerase activity has been associated with an increased risk of atheroclerosis, although, as he himself points out in the paper, telomerase length is not.
In any case, I went back and looked at the telomerase paper again. To boil it down, what Dr. Ornish found was that his diet is associated with an increase of about 25% in telomerase activity in peripheral blood monocytes (PBMC). The standard deviations are quite large and overlapping, and the statistical significance is there, but not impressive. I looked at the table that showed all the telomerase activity values “before and after” (statistical significance tested, appropriately, with Student’s paired t-test) and saw huge variability, with telomerase activities actually decreasing slightly in some patients. This leads me to concede that there is probably a difference in telomerase activity, but to wonder whether the difference is clinically relevant. Moreover, that increased telomerase activity appears to be associated with Dr. Ornish’s diet in PBMCs makes me wonder something. If his diet does definitely increase telomerase activity in PBMCs (something that remains to be demonstrated), then could it be possible that it does the same thing in cancer cells? Remember, many cancers have high telomerase activity, and telomerase inhibitors are being developed for various cancers. Just a random thought. I went back to look at the microarray paper to see if telomerase gene expression levels increased or decreased in prostate tissue as a result of the Ornish diet, but couldn’t find anything.
Finally, there are the two papers, one in Urology and one in the Journal of Urology, reporting that the Ornish diet is associated with slower progression of early stage prostate cancer in men who choose watchful waiting for their tumors, and a longer time to progression, all of which is very interesting, although pretty preliminary given the few numbers of men. In addition, I won’t go into the cardiovascular papers (much), because (1) I’m a cancer surgeon and (2) no one is arguing, least of all me, that diet and exercise don’t play a very important role in contributing to (and potentially preventing) cardiovascular disease. I’m not even that skeptical that diet and exercise might be preventative for prostate cancer and other cancers–or even mildly therapeutic. It’s a straw man to say otherwise. My sole purpose in mentioning some of the papers that Dr. Ornish cited is to emphasize that they are all pilot studies and that their results are tentative at best. Moreover, what I have been arguing is that Dr. Ornish has willingly and enthusiastically allied himself with the “alternative” medicine movement, many of whose leaders are boosters of pseudoscience, when the use of diet and exercise, the very health interventions he champions, are not and should not be in any way considered “alternative.” Worse, Dr. Ornish is overselling his results to Congress, the medical profession, and the public in order to champion them as “alternative.”
Which brings me back to my main complaint about him, the complaint that he completely ignored, which is why I’m going to e-mail him and make sure he sees this response, given that he was kind enough to comment.
As an example, let’s go back to his article in the Washington Post in January, in which in addition to Dr. Weil, Dr. Ornish teamed up with, of all people, Deepak Chopra and Rustum Roy. Let’s get one thing straight. Deepak Chopra is a booster of pseudoscience. There’s no other scientifically accurate way to describe him. Indeed, he is so full of pseudoscience that I can take credit for coining a term that has spread through the blogosphere for the nonsense that he regularly that he regularly lays down: Choprawoo. I and others have deconstructed the nonsense about medicine, evolution, and other “quantum” nonsense. His contortions of science are legion (and legendary). The same is true of Rustum Roy, who has become known above all else for his support for the quackery that is homeopathy.
This leads me to ask: Does Dr. Ornish think there is anything at all to homeopathy or the “memory” attributed to water by homeopaths? If so, he has left the path of science, as homeopathy is quackery. Period. If not, then why on earth did he associate himself so publically with a booster of such quackery? Rustum Roy is one of the most famous current supporters of homeopathy. Talk about shooting oneself in the foot, scientifically speaking! Let’s put it this way: Palling around with Deepak Chopra and Rustum Roy–and even going so far as to write an article on alternative medicine with them to be published in the Washington Post–do not exactly constitute a sound strategy to enhance one’s scientific credibility, if you know what I mean. An analogy would be hanging out with Bernie Madoff as a strategy to enhance one’s cred as an honest investment guru.
Given Dr. Ornish’s obvious distress at my criticism, though, I had considered apologizing for having gone a bit far and getting a bit too testy (although I take back absolutely nothing that I said about Senator Harkin and the rest). Truly, sometimes I do get a bit carried away when I’m on a roll, particularly after coming up with a pithy phrase like “the Four Horsemen of the Woo-pocalypse,” which, if I do say so myself, is one of my better ones. Then I saw Dr. Ornish’s slide set from his presentation to the Institute of Medicine/Bravewell Collaborative woo-fest last week, which, not-so-coincidentally, overlapped Senator Harkin’s woo-fest.
Now I’m half-tempted to conclude that I may not have been hard enough on him.
The first thing that bugs me is that Dr. Ornish invoked Leroy Hood. Since he told me in his comment, in essence, to “go read some Leroy Hood,” I can’t resist pointing out that I have, in fact, “read some Leroy Hood” and that I have, in fact, attended talks by Leroy Hood. It can even be said that I rather admire Leroy Hood. In fact, I have even blogged about Leroy Hood and exactly why I like his systems biology approach. I am even currently striking up a collaboration with a systems biologist at my own institution who’s very big on network analysis. Nonetheless, I still have a great many reservations about whether the hype over systems biology as epitomized by Leroy Hood is an accurate reflection of its ability to deliver truly “personalized medicine” (very much like the dubious “individualization” of medicine claimed by CAM advocates, which is, in most cases, a synonym for “making it up as I go along). I won’t rehash my comments here, but rather refer readers to my post on the issue. I will, however, reply to Dr. Ornish by saying, “You, sir, are no Leroy Hood.” Nor is Dr. Hyman, Dr. Oz, Dr. Chopra, Dr. Roy, or Dr. Weil, for that matter. The reason is that Leroy Hood, for whatever faults he may have in perhaps overselling his work a bit, does not represent his approach as “alternative,” nor does his approach embrace pseudoscience along with his science, as apologists for “alternative” and “integrative” medicine all too frequently do. Invoking Leroy Hood as a supporter of the kind of arguments that Dr. Ornish made at the IOM is akin to Deepak Chopra’s invoking Einstein, the only exception is that it is not clear that Hood will have anywhere near the effect on medicine that Einstein had on physics.
Next, Dr. Ornish invokes Dr. Hyman’s functional medicine, which is, in fact, nothing more than a mish-mash of a lot of old woo about “balance” (just leaving out the yin/yang or qi) given a fresh “science-y” gloss, as longtime skeptic Wally Sampson has described. Dr. Ornish also cites approvingly a paper that claims that “mindfulness meditation” improves the antibody titer response to the influenza vaccine. I went and looked up that paper to read while I was on the plane to Phoenix. I have to say, I was underwhelmed; indeed, it reminded me of a similar study of Tai Chi that I blogged about in that there was no attempt at blinding, but, even worse, the measures used to control for confounding factors were truly inadequate.
But Dr. Ornish hit the jackpot in provoking my annoyance when cited an acupuncture study thusly:
In patients with low back pain, response rate was 47.6% in the acupuncture group, 44.2% in the sham acupuncture group, and 27.4% in the conventional therapy group.
The medical blogosphere extensively covered this study, as did I. Suffice it to say, the study fell far short of how it was represented. Morever, the most obvious conclusions about acupuncture from the study are that: (1) it’s a placebo effect and (2) acupuncture meridians are bunk, given that there was no difference between the sham acupuncture and “real” acupuncture group. In all fairness, I don’t know what Dr. Ornish said about the slide, because the video of the conference hasn’t been posted yet, but his slide sure does lead me to suspect that, when it comes to science-based medicine, he just doesn’t get it, as does his comment to me remonstrating with me for taking him to task for saying that we are “more than just genes and germs, microbes and molecules.” Indeed, if he thinks that Leroy Hood’s work indicates that to be true, he is more misguided than I thought. Nothing in Leroy Hood’s work indicates that we are “more” than these things, only that how these things work in human physiology and disease is likely to be far more complicated than we had previously thought. It does not imply any sort of dualism, which is what Dr. Ornish seems to think that it does. He can correct me if I’m wrong.
Finally, Dr. Ornish truly buried himself when he finished up with a series of slides that concluded:
With all due respect, I ask: Transformation into what? One does not have to embrace pseudoscience to “transform” healthcare. Indeed, the best transformation of health care would be to make it more science-based. If science shows that lifestyle alterations are the best treatment for some conditions, bring it on! I’ll be all for ’em, as they say. If science bears out Dr. Ornish’s results, I would happily recommend his diet to men with early stage prostate cancer. To me, there is no such thing as “alternative” or “integrative” medicine. There is medicine that has been validated by science as effective and safe, and there is medicine that has not. In fact, I would happily recommend even something that I now think as ridiculous as homeopathy if science could show that (1) it works significantly better than a placebo and (2) provide an reasonable scientific mechanism by which it could work. Indeed, I’d even scratch #2 if someone could show me that homeopathy could cure an incurable disease like pancreatic cancer.
In the end, the problem is that Dr. Ornish has yoked his science to advocates of pseudoscience, such as Deepak Chopra and Rustum Roy. Why he’s done this, I don’t know. The reason could be common philosophy. It could be expedience. It could be any number of things. By doing so, however, Dr. Ornish has made a Faustian deal with the devil that may give him short-term notoriety now but virtually guarantees serious problems with his ultimately being taken seriously scientifically, as he is tainted by this association. Let me yet again reemphasize that this relabeling of diet, exercise, and lifestyle as somehow being “alternative” is nothing more than a Trojan Horse. Inside the horse is a whole lot of woo, pseudoscience and quackery such as homepathy, reiki, Hoxsey therapy, acid-base pseudoscience, Hulda Clark’s “zapper,” and many others, all contradictory, virtually all pseudoscientific, but all intentionally hidden within the Trojan horse of diet and exercise. Once the horse is within the fortress of scientific medicine, the quackery will leap out and take over. Thus, as far as I’m concerned, the answer is not to blindly accept diet and exercise as “alternative,” but rather to smoke out the quackery from within the Trojan horse constructed by CAM advocates and then return diet, exercise, and lifestyle interventions to where they were before they became “alternative” and to where they should be: In the realm of scientific medicine. Dr. Ornish could be a huge help in accomplishing this. Indeed, one of my commenters put it very well:
You’re doing science-based preventive medicine. Prevention and health care maintenance have always been core concerns of medical science. Nothing “alternative” about it.
So what do you need CAM for?
Why sit with that army of anti-science quacks on their side of the table when you could be over here with us? (Srsly. Take a look at Weil. Dude knows his way ’round a bong and a sandwich LOL.)
We try not to lie to the people, even though it might be fun. We don’t like to over-state our data, unless we’re really drunk. We don’t like getting called on our bullshit, but we accept that this might sometimes be necessary for the greater good.
We are tough. We are rockin’. Chicks dig us!
So get yer ass over here!
I echo the sentiment, and say to Dr. Ornish: “Get your ass over here, back on the side of science- and evidence-based medicine.” Or, channeling Luke Skywalker trying to persuade Darth Vader, “I know you can still turn away from the Dark Side.”
What do you need “alternative” medicine for, Dr. Ornish? Really? Think about it. What has it done for you other than lump you together with the crystal gazers, shamanic chanters, and purveyors of quackery? I do not say “unfairly lump you,” because you yourself chose this association, and you yourself can choose to end it.
You have the potential to be a pioneer in showing scientifically just what dietary and lifestyle interventions can really do, but instead, you’re letting a bunch of opportunistic apologists for quackery coopt you and your work for their own purposes. They’re using you, and your diet is nothing more than a convenient tool, a “foot in the door,” if you will, behind which quackery will follow.
Stop it. Please.