Respectful Insolence

One of these days I’m going to end up getting myself in trouble.

The reason, as I’ve only half-joked before, is that, even though I’m not even 50 yet, I’m already feeling like a dinosaur when it comes to “complementary and alternative medicine” (CAM) or, as it’s called more frequently now, “integrative medicine” (IM). These days, we now have the National Center for Complementary and Alternative Medicine (NCCAM), the Bravewell Collaborative, and a number of other forces are conspiring to “integrate” quackery with real medicine. As part of that task, it’s been necessary to rebrand quackery, a process that’s been going on for at least 20 years now. I described this evolution of quackery in what was a bit of a facetious post that strikes me in retrospect as being a bit pretentious when I reread it. Not that I’m incapable of pretentiousness; it’s in my blood, and at times it has to come out.

In any case, near the end of that post, I pointed out that CAM was rebranded because the very name contained the words “complementary” and “alternative,” both of which imply (correctly, as it turns out) that the quackery falling under the CAM rubric is inferior to science-based medicine, mere icing on the cake. Where real medicine does the real work of curing the patient, CAM is merely “complementary”; i.e., unnecessary but helpful. Of course, CAM is not only unnecessary but most of it is not particularly helpful (some of it can even be harmful). Calling it “integrative medicine” is a subtle change, but, I think, intentional. If you “integrate” something, it implies more equality. Indeed, practitioners of IM even come out and say that they’re “integrating” the “best of both worlds.” In reality, as I like to emphasize agains and again as something that can’t be repeated too often, IM is “integrating” quackery with medicine. I’ll also repeat what I said a couple of weeks ago after reading the words of a CAMster: CAM is indeed dead, but it is the CAMsters themselves who killed it. The killing of CAM was deliberate and calculated, with CAM replaced by IM. I speculated that it wouldn’t be long before even the term “integrative medicine” wouldn’t be enough.

I was more right than I realized.

So sayeth Barrie Cassileth, PhD, Chief of the Integrative Medicine Service at–depressingly–one of our greatest cancer centers, Memorial Sloan-Kettering:

During the 1960s and 1970s, the concept of a holistic approach to treating disease that took into account the body, mind, and spirit grew in patient popularity and morphed into two basic categories: alternative and complementary, which later became known by its acronym CAM (complementary and alternative medicine). However, because alternative therapy refers to unproven or disproven treatments that have no place in legitimate cancer care, integrative medicine experts, including Barrie R. Cassileth, PhD, Chief, Integrative Medicine Service at Memorial Sloan-Kettering Cancer Center in New York, say the terminology is misleading and confusing and needs to be abandoned. Even the term “integrative medicine” can be misleading, said Dr. Cassileth, who instead uses a more accurate term to describe the practice of integrative oncology: evidence-based complementary medicine.

One wonders, one does, why Dr. Cassileth doesn’t eliminate the name “integrative medicine” from her own service at MSKCC, given that she’s the chief of the service, if she really thinks that the term is now outmoded. Of course, “Evidence-Based Complementary Medicine” Service would be kind of a clunky name, but I suppose it could be shortened to EBCM, which reminds me of ICBM, which reminds me of nuclear explosions. Sorry, I just can’t help it. I was, after all, raised during the Cold War and still remember the fallout shelter and air raid drills we had in grade school. Younger farts than this old fart probably won’t make such associations.

It is, of course, also interesting that Dr. Cassileth doesn’t choose to use the term “science-based complementary medicine.” I’ve discussed the difference between science-based medicine and evidence-based medicine before, and Dr. Cassileth seems to be perpetuating the difference. Remember, evidence-based medicine downplays prior plausibility based on basic science, relegating basic science considerations to the lowest rung on the evidence hierarchy, whereas science-based medicine does consider prior plausibility. I know I use the example of homeopathy often in trying to illustrate this, but it’s just so perfect an example. Homeopathy, as you recall, posits that (1) like cures like (i.e., you use a substance that causes a symptom in order to eliminate that symptoms) and (2) diluting such a remedy to the point of nonexistence (as in many orders of magnitude more than Avagadro’s number) makes it stronger. It’s pure magical thinking, invoking the ancient principles of sympathetic magic. Even so, because of the limitations in randomized clinical trials and the fact that, by design, at the very minimum 5% of such trials will be false positives because of where scientists choose by convention to set their measure of statistical significance, there are a number of false positive trials of homeopathy. Also, as John Ioannidis has shown us, in actuality it’s more than 5% of clinical trials that produce false positive results. Because evidence-based medicine fetishizes randomized clinical trials above all else, it just won’t allow scientists to reject homeopathy, because there are always equivocal trials to which woo-meisters can point as “evidence” that there might just be something to homeopathy. Contrast this to science-based medicine, where, because the principles of homeopathy violate well-established laws of physics, homeopathy can be relegated to being impossible; that is, until homeopaths produce evidence for it at least as compelling as all the evidence from physics, chemistry, and biochemistry that say homeopathy can’t work.

Here’s a hint: Equivocally “positive” clinical trials are not enough.

I realize that I just digressed into fairly well-trodden territory, but I felt I had to do it, because Dr. Cassileth said something in this interview that actually partially made sense:

By making the term evidence-based complementary medicine more commonplace, Dr. Cassileth is hoping to educate both medical professionals and patients about the helpful, appropriate complementary therapies that are available, and distinguish them from the all-too-available questionable approaches.

“If promoted techniques are found to be worthless or if they are patently absurd, such as homeopathy, they should be avoided. The medical world is in turmoil around these issues, and the public typically cannot tell the difference between viable interventions and quackery. I spend half my time studying whether complementary approaches relieve patients’ specific physical and emotional symptoms and the other half trying to get rid of quackery. It’s not an easy task,” said Dr. Cassileth.

Did Dr. Cassileth just characterize homeopathy as “patently absurd” and “useless”? Shockingly, she did! It’s rare indeed for an advocate of CAM/IM to characterize any alternative medical system as absurd. True, it’s completely appropriate to characterize homeopathy as absurd. It’s even refreshing to hear. There’s just one problem. As you might recall, Dr. Cassileth herself supports alternative medicine modalities every bit as ridiculous as homeopathy, having done a number of studies of acupuncture, including for hot flashes. When the study was negative, she tried to spin it as being due to acupuncture that was “not optimal.” She’s also proud of a study she’s doing on acupuncture right now:

We are also enthusiastic about our acupuncture research program, and we’re about to complete a study of acupuncture treatment for lymphedema. We first conducted a small pilot to make sure that acupuncture was safe. It was. The study had a stopping rule: achieving at least a 30% reduction in lymphedema in a minimum of 40% of patients. The study stopped very quickly. Now we are embarked on a larger pilot with a mechanism component.1 The regimen is two acupuncture treatments a week for 4 weeks and then monthly follow-up phone calls to make sure that no adverse late events occur. These are important areas of research for us.

I would argue that Dr. Cassileth is rather selective in what she considers to be “patently absurd” and that the principles of acupuncture are pretty darned absurd, arguably as absurd as those of homeopathy. Think about it. What’s the idea behind acupuncture? Basically, it’s vitalism, in which it is believed that sticking needles into certain parts of the body somehow “unblocks qi,” which is basically “life energy” or “vital force.” This qi flows through pathways known as meridians, which (of course) do not correspond to any known anatomic structures, no matter how much acupuncturists try to convince us that they do. What is less “patently absurd” about acupuncture than homeopathy? I’m having a hard time thinking of anything, other than the fact that acupuncture involves the insertion of actual needles into the skin and can therefore cause actual complications.

In any case, I went and looked up Dr. Cassileth’s study, A safety and efficacy pilot study of acupuncture for the treatment of chronic lymphoedema. First off, it didn’t help that the study was published in Acupuncture in Medicine. CAM journals tend to be–shall we say?–not particularly rigorous. Dr. Cassileth’s paper fits right in. Basically, it’s an uncontrolled study of acupuncture in women with lymphedema due to breast cancer surgery. Practitioners of traditional Chinese medicine on staff at MSKCC treated nine women with lymphedema, and these were the results:

Study goals were met after nine subjects were treated: four women showed at least a 30% reduction in the extent of lymphoedema at 4 weeks when compared with their respective baseline values. No serious adverse events occurred during or after 73 treatment sessions.

Now hold on there, pardner.

I realize that this study was designed only to assess safety, but without a control group the 40% of women showing at least 30% decrease in lymphedema is a meaningless number. For one thing, four weeks is far too short a time period. Lymphedema can wax and wane over time; that several women at four weeks doesn’t mean much at all; doing nothing could well have yielded a similar result. There’s no way to know. Similarly, because lymphedema can wax and wane, single measurements are not particularly informative. Repeated measurements over time are needed. Finally, the most accurate way to measure lymphedema is not arm circumference, but rather water displacement. (The patient sticks her arm in a long bucket of water, and the amount of water displaced is measured.)

More importantly, when I looked at Table 2, which showed the characteristics of the women who had a “response” to acupuncture, I noticed something right away. The baseline difference in centimeters between the unaffected arm and the lymphedematous arm was much smaller in the responders (2.2 cm) than in the non-responders (6.4 cm). In other words, the women who “responded” to acupuncture had mild lymphedema, which is the sort of lymphedema that’s more likely to wax and wane. Basically, as far as telling us anything other than that they didn’t have any complications in nine patients; the study tells us little or nothing about acupuncture for lymphedema. Based on physiology and science alone, however, it’s incredibly implausible that acupuncture would do anything for lymphedema anyway.

Basically, Dr. Cassileth is trying to have it both ways. First, she’s trying to paint herself as a proponent of science, an enemy of quackery, even, describing a recent IM conference:

At the other end of the spectrum, in Europe and in other parts of the world, purveyors of bogus “treatments” have taken over the term “integrative medicine.” In Europe especially, integrative medicine and integrative oncology have become synonymous with quackery.

An important issue that emerged at this conference was the extent to which quackery is a huge problem throughout Europe and in other parts of the world. In the United States, where quackery has been prominent for many decades, it is a $40 billion-a-year business.

All of which makes me wonder how Dr. Cassileth defines “quackery,” when she believes that acupuncture works. She does realize, however, the power of language, as she laments the association of “integrative medicine” with quackery:

It also makes it very difficult for health-care professionals because they’re not always sure what the terms integrative medicine and integrative oncology imply. Words have meaning, and they can have a detrimental as well as clarifying impact. We fought very hard to get away from the term “alternative therapy” because there are no viable alternatives to mainstream cancer care. We have to clarify the terminology, and I am now referring to complementary therapies as “evidence-based complementary medicine.”

Dr. Cassileth’s right. Words have meaning, and language has power. That’s the very reason that “quackery” morphed into “alternative medicine,” “alternative medicine” morphed into “complementary and alternative medicine,” and “complementary and alternative medicine” morphed into “integrative medicine.” It’s the same reason that “integrative medicine” is now morphing into the clunkier, less sexy, “evidence-based complementary medicine.” The problem is that evidence is as evidence does, and the evidence being used to support quackery like acupuncture is no better than the evidence homeopaths use to try to support their woo. I’m glad to hear that Dr. Cassileth is worried about quackery; I’m not so glad to see that the main reason she’s worried about it is because she wants to protect the quackery she believes in from being tainted with all the other quackery. I would suggest that Dr. Cassileth needs to reassess exactly what it is that she means by “evidence-based complementary medicine” and consider adding some actual basic science considerations to the mix. I realize that she’s trying to be one of the good guys, but she’s become part of the problem.

Comments

  1. #1 Melisssssssssa
    August 16, 2011

    I… just… hate it when women fall for these post-hoc-ergo-propter-hoc “actupuncture made my lymphedema all better!” CAM treatment fallacies. It plays into all the stereotypes about women not being logical thinkers and more likely to buy into CAM modalities. GRR! And Dr. Cassileth’s tiny little study here is (unintentionally, I hope) only serving to fuel this stereotype!!!

    Did I mention, GRR!?

  2. #2 daijiyobu
    August 16, 2011

    “We are no longer the Knights Who Say Ni. We are now the Knights Who Say…”

    And they want another shrubbery.

    And the rebranding is endless.

    -r.c.

  3. #3 Dianne
    August 16, 2011

    I suppose it could be shortened to EBCM, which reminds me of ICBM,

    The abbreviation also reminds me of the MMPI, meaning that an EBCM would be an extroverted ICBM which I suppose would be an ICBM that really liked what it did…never mind, this train of thought isn’t going anywhere good.

  4. #4 Denice Walter
    August 16, 2011

    This so-called “study” is like those often foisted upon the public by woo-meisters ( see NaturalNews; Gary Null.com; Mercola.com; AoA) who label it “science” and themselves “scientists”( more creative wordplay) while presenting it as “evidence” for whatever woo *du jour* they happen to be hard-selling on that particular day. Usually the audience is unable to differentiate why this stuff is so bad, thus small sample size, lack of controls, self-reports, weird measures, unrelatedness to other research, and highly imaginative use of statistical analyses don’t cause the least hesitation in their acceptance of drivel. Alt med is based in PR not R&D.

    I think that it’s important for us to remember that the general public is not very well-versed in this area: it is another reason why charlatans are able to inveigle consumers into purchasing products, treatments, and ideas that are based on whimsy rather than on serious research. They present themselves as “truth tellers”, “investigative reporters”, and “whistle blowers” who have the public interest at heart. (How very “Through the Looking Glass” or “1984″ of them.!)

    Portraying alt med ( or whatever they’re shilling it as *this* week) as the “wave of the future” is also wishful thinking as well as creative writing on their part: nothing they talk about is new- Hahneman, TCM, herbalism, “chi”, toxin-phobia, and energy medicine have all been around the block a few times. Selling techniques ( and language) are what’s constantly re-booted.

    SBM is intrinsically based on the integration of new information derived from ever-improving research methods, up-dated continuously at a furious pace- it’s hard to keep up with your own area, let alone the whole expanse. This is also difficult to communicate to the un-informed through sound-bite sized exclamations.

    This specific backward glance ( alt med) is like so many others that have haunted our vision since the enlightenment- there is resistance to the *new* and so-called “materialism” by those who espouse traditionism and spiritualism even when they call it something else.

  5. #5 Mu
    August 16, 2011

    While the qi part of acupuncture is nonsense, I give Cassileth half credit for his attempt to separate “violating the laws of known physics” and “maybe effective by an unknown mechanism”. After all, even medieval barbers knew that you cut off a leg when it turned black, even when the discovery of Clostridium perfringens was still half a century off.
    Maybe that’s why sham acupuncture with toothpicks works just as well as “real” pricking of the skin, it’s not the penetration that makes the difference but the skin stimulation in the right spot. Not bloody likely, but not a priori out of the question.

  6. #6 Dianne
    August 16, 2011

    I give Cassileth half credit for his…

    Her.

  7. #7 Todd W.
    August 16, 2011

    Here’s a tip for Dr. Cassileth, if there is some modality that actually works and has good evidence (and science) to support it, just call it “medicine.”

  8. #8 Jojo
    August 16, 2011

    For someone who criticizes ducks so much you would think Dr. Cassileth would notice all of the “quacks” coming out of her mouth.

  9. #9 Scott Cunningham
    August 16, 2011

    I would argue that Dr. Cassileth is rather selective in what she considers to be “patently absurd” and that the principles of acupuncture are pretty darned absurd, arguably as absurd as those of homeopathy. Think about it. What’s the idea behind acupuncture?

    They’re totally different. Acupuncture is based on appeal to the exotic, argument from antiquity, and ad populum. Homeopathy is based on ad populum and argument from authority. And the authority is a dead German guy, too. Boring. There’s plenty of people who like the exotic and ancient sort of logical fallacies who’d balk at obeying the authority of a German “doctor.”

    Not that this is, you know, sensible, but some people have personal preferences in logical fallacies.

  10. #10 Edith Prickly
    August 16, 2011

    SBM is intrinsically based on the integration of new information derived from ever-improving research methods, up-dated continuously at a furious pace- it’s hard to keep up with your own area, let alone the whole expanse. This is also difficult to communicate to the un-informed through sound-bite sized exclamations.

    Very true, and unfortunately the alties have become very skilled at making this work in their favour. “See! science can’t make up its mind about what works, they’re always changing! that means they don’t know what they’re doing and using you as their guinea pigs! Our methods are ancient and timeless and we put YOU at the centre of treatment…blah di blah di blah, buy my supplements and detox powder.” And I’m not blaming average people for getting taken in by this gambit – I went through a woo-zy period in my twenties like a lot of people (it happened to coincide with the Great Woo-ification of the 1990s) then lost interest in spending money on supplements that didn’t seem to do much.

    It is a challenge to keep up with SBM even if you’re an interested layperson. I read RI and other medical blogs to keep myself informed and learn how to evaluate questionable claims by alties, but not everyone has the time or ability to do that and even I have to skim some of the more detailed discussions that take place here. But I learn a lot, even from the trolls (no names mentioned!) and I hope I can do my part to stop the spread of woo, even as a non-scientist with no Big Pharma payoffs to lose (I kid, I kid!)

  11. #11 Bryan Elliott
    August 16, 2011

    My suspicion is that Dr. Cassileth is carefully moving her field away from anything-goes-wooism concerning cancer and into the realm of “These are the demonstrably effective steps we take to mitigate the hell of cancer therapy”.

    The return to complimentary; the addition of a basis. Sure it’s not science based, but it’s closer to reality than anecdote-based, which appears to be the default for alt med.

    She’s trying to move forward. Keep the criticism on, but praise what she’s doing right.

  12. #12 JustaTech
    August 16, 2011

    In college we had a saying “LGNs (low grade notices) aren’t the end of the world, ICBMs are the end of the world”. I thought it was very funny, but by the time I told that joke to my freshmen (~2005) at least a third of them had no idea what I was talking about.

  13. #13 Calli Arcale
    August 16, 2011

    JustaTech — what’s perhaps scarier about your anecdote is that ICBMs remain on ready alert in both the US and Russia, and small nations are getting close to developing their own (instead of just the IRBMs they currently have). There’s no good reason for college freshmen today to not know what an ICBM is. High school history classes must still be stopping around WWII.

  14. #14 Roadstergal
    August 16, 2011

    Doesn’t anyone watch The Atomic Cafe anymore? Duck… and cover…

  15. #15 Rogo5
    August 16, 2011

    Maybe if the Quackery Leaders like Dr. Mercola start speaking about Evidence-Based Complementary Medicine instead of Integrative Medicine it’ll hopefully turn off his readers. I mean, what average consumer wants to really think about the boring, technical details of “evidence”? EBCM sounds so dull and dry. However, since Mercola and others have such a huge, loyal following, it’s hard to tell if EBCM might have a negative effect if he starts using it.

  16. #16 larry
    August 16, 2011

    I don’t know if this is considered woo by anyone but it worked. Sciatica for months
    improved by PT- recurred again- went to one of the best spine drs. in nyc- he found
    3 herniated discs on MRI. He didn’t know why PT worked but referred me to it again- said no need for surgery.
    Physical Therapist had hunch-asked me where I keep my wallet- left pocket same side as sciatica- found sitting on wallet is cause-
    myofascial trigger point activation- message and not siiting on wallet cured it. Pain
    free for a year-(but I do watch my back now)

  17. #17 Vicki
    August 16, 2011

    I can’t speak for everyone, but I wouldn’t call that woo: the physical therapist found a physical cause, you stopped doing that thing, and the problem was cured. There is a straightforward connection between cause and effect there: a lump under one buttock is going to affect how you sit. I spent significant time working with someone to adjust my posture and stride so my knees wouldn’t hurt; I did most of the work, of course, but she showed me what to do and ways to get there: for example, focus on the position of the feet, which I can just look down to check, rather than look for subtleties in the knee. (It hasn’t been 100% effective, but they’re a lot better than when we started.)

  18. #18 TBruce
    August 16, 2011

    larry:

    Not woo at all – Google “wallet sciatica”.

  19. #19 Krebiozen
    August 16, 2011

    Larry,
    Sometimes a problem can be ridiculously simple to solve. In my 20s, some years ago, I started suffering from a racing heart and palpitations, which was unpleasant and frightening. My GP suggested I was suffering from anxiety (news to me), sent me to a counselor, ordered an ECG and prescribed beta blockers. Then a friend pointed out to me how much coffee I was drinking (rather a lot really). It had never occurred to me that I might be suffering from caffeine poisoning. I switched to tea and the problem went away for good. Had some excellent chats with the counselor though, mostly about literature as I recall…

  20. #20 Jonathan
    August 16, 2011

    Acupuncture deserves to be researched by US academicians. There is enough preliminary evidence that warrant ongoing study. Up until recently, I was assisting in a clinical trial at the Hospital of the University of Pennsylvania Perelman Cancer Center in which acupuncture was being used to impact hot flashes for women on aromatase inhibitors. The physicians at the Perelman Cancer Center (rigorous academic scientists in their own right) have seen enough anecdotal cases of hot flash success that they have opened an acupuncture center within the Cancer Center and are commiting time to the clinical trial (being performed by a prolific researcher).

    It should be noted, that acupuncture science is in its very early stages. Currently, they are performing efficacy trials for a wide variety of symptoms. If there is some level of efficacy established, then acupuncture trials will focus more deeply on mechanism studies.

    This order (efficacy then mechanism) may be foreign for some segments of the physician-scientist population, perhaps because they are used to studies using the opposite order. First, a mechanism is established. Next, drugs are tested on people. (Then later, more mechanisms may be investigated).

    However, for many reasons, traditional medicinal systems are studied in the opposite order. That’s just the way the NIH is rolling right now with their funding of CAM treatments.

    That said, although the “vitalistic” aspect of acupuncture treatments may not survive rigorous testing, if there is proven efficacy, then there must be a mechanism. “Vitalistic” descriptions may not add validity to some segments of physician-scientists, but to other segments use them as a launching point into researching efficacy and later mechanism.

    Although I will not comment on Dr. Cassileth’s study, if there are scientists that are willing to investigate traditional medicinal systems, they should go for it. Science allows for many false starts, and with something as ubiquitously used as acupuncture, it deserves proper consideration.

    If I were to offer any speculation into the mechanism of acupuncture, I would suggest to scientists that they stop focusing on “meridians” and start focusing on whether specific acupuncture points will consistently cause specific networks of genetic expression in target tissues. It will be an extensive laborious process taking many scientists working for generations if they will ever create an acu-genetic map. But nonetheless, if acupuncture works, an acu-genetic map will bring acupuncture from its vitalistic roots into the forefront of human science.

    The genetic map is one of many relay stations that must be discovered for acupuncture mechanism (another is how the signal gets to the target tissue). But as complex as genetic expression can be to research, it does offer a potential mechanism that can be investigated once efficacy for certain symptom management is established.

  21. #21 Michael
    August 16, 2011

    @10- the idea that science is always changing is a very old criticism of science and not limited to the alties. Certain rabbis, for example, express skepticism of scientists because their theories “change every morning and night”.

  22. #22 Interrobang
    August 16, 2011

    The ever-changing terminology reminds me a lot of how “creationism” evolved into “creation science” evolved into “cdesign proponentsism” evolved into “intelligent design.” Same bullshit anti-rational thinking, different euphemisms.

  23. #23 sbear
    August 17, 2011

    It does annoy me when ‘integrative’ and ‘holistic’ are waved about. Good doctors do actually treat whole patients, not just symptoms!

  24. #24 Lycanthrope
    August 17, 2011

    Primary lymphedema patient here. Something else to consider: OF COURSE poking lots of little holes in the first few layers of skin is going to help lymphedema in the short term, because you’re bound to leak a bit of lymph fluid! The problem is determining whether there is any consistent long-term improvement, which as Orac points out is devilishly difficult.

    Furthermore, taking care of the skin over the affected area is critically important, because it’s very prone to tissue infections like cellulitis from even the tiniest points of entry. Perhaps it’s not the best idea to introduce a bunch of potential entry points for infection on a regular basis? It may be a small risk, but when extreme caution is the name of the game, Dr. Cassileth needs to weigh it against any benefit she may see, especially when that “benefit” is so questionable on so many levels.

  25. #25 Orac
    August 17, 2011

    If I were to offer any speculation into the mechanism of acupuncture, I would suggest to scientists that they stop focusing on “meridians” and start focusing on whether specific acupuncture points will consistently cause specific networks of genetic expression in target tissues.

    And why would we bother with that, when we already know from numerous that (1) it doesn’t matter where you stick the needles (i.e., the concept of “meridians” or even specific acupuncture points is nonsense) and (2) it doesn’t even matter if you stick the needles in (there’s a study where investigators used toothpicks as a control; there was no different between “toothpick acupuncture” and “real acupuncture”). Given that, it’s a complete waste o time and resources to try to create an “acu-genetic map.”

  26. #26 mikmik
    August 17, 2011

    Jonathan = “and start focusing on whether specific acupuncture points will consistently cause specific networks of genetic expression in target tissues”

    Yet another example of BS couched in scientifically sounding nonsense.

    It will be an extensive laborious process taking many scientists working for generations if they will ever create an acu-genetic map

    How the f*%# would you know this? First you say there is no understandable mechanism of any sort, then you are postulating on decades of intensive research on a specific mechanism (that doesn’t even have a real meaning in the first palce)? WTF?
    Oh, science hasn’t proven it yet. But they will, you see, after many generations, so what you’re really saying is equivalent to ‘never.’
    Here’s my learned prognostication: After many generations of failure to show any correlation, let alone causation, of acupuncture to health benefits, acu-weasels will still come up with mind numbingly insipid acu-terminology to explain why acu-puncture hasn’t quite been demonstrated yet, even though it will be in a few generations(after we are all dead and can’t verify or falsify these claims).
    Acu-genetic networks, LMFAO! You forgot to mention that these are ‘quantum acu-genetic networks.’ WTF is a genetic network, anyways”?

    Up until recently, I was assisting in a clinical trial
    What were you, a candy striper?

  27. #27 BadDragon
    August 17, 2011

    @mikmik You are wrong, my friend, terribly wrong. I said it before and I will say it again and again until you will understand, I will hit you with the Light of Knowledge until you will finally jump on a higher level of Existence and Understanding: it is Qwooantum acu-genetic networks, Qwooantum Mechanics, Qwooantum Psychology.

    Please stop insisting in applying your pitiful, limited theories to the infinity of the Universe and open your Eye to the true, holistic and never-wrong-unless-you-apply-it-wrongly fountain of knowledge.

  28. #28 puppygod
    August 17, 2011

    If I were to offer any speculation into the mechanism of acupuncture, I would suggest to scientists that they stop focusing on “meridians” and start focusing on whether specific acupuncture points will consistently cause specific networks of genetic expression in target tissues.

    If I were to offer any speculation into the mechanism of superluminal travel, I would suggest to scientist that they stop focusing on “wormholes” and start focusing on whether specific dilithium crystal aplication will consistently moderate matter – antimatter annihilation.

    Well, technobabble is technobabble. Yours is medicine related, mine physics related, but it’s the same thing – that is, nothing related to actual, physical world.

  29. #29 Jonathan
    August 18, 2011

    I disagree with your premise, Orac, that further research is a waste of time.

    The degree to which ‘random’ needling can affect clinical outcomes has not been established. That is, whether or not specific “points” exist vs general areas that when needled produce productive outcomes. The concept of “sham” acupuncture has not been defined (different researchers use different standards for this word), and therefore the effects of “sham” acupuncture cannot be generalizable, yet. The studies that I assisted with at UPenn’s cancer center addresses this question in a novel way. It will be interesting to see their results in a few years (the study will take at least three years to complete).

    If it turns out that complete random needling (a treatment calls for needles in the toes, but needles are placed in the cheek), then that finding would be significant. However, even if random needling were demonstrated as equally effective as “informed” needling, the results would demonstrated that an acupuncture system would be proven false, but the act of needling itself (without being tied to a formal system) would be interesting to investigate… if it produced improved patient outcomes (such as decreasing hot flashes in patients who are taking aromatase inhibitors, or increasing fertility outcomes in women attempting IVF treatments) That said, this paragraph is pure conjecture as per statements emphasized in paragraph one.

    For the sake of completeness to your thoughtful response, whether wooden needles vs metal needles are used… so what? New information that leads to new unanswered questions refine the parameters of the search, not throw the idea of searching out the window.

    At the end of the day, if a treatment produces patient outcomes, mechanism exists. If mechanism exists, they should be allowed to be investigated, if a researcher is interested in discovering that knowledge.

    As for mikmik, I am not sure what attacking “research assistants” does for your cause, but it does show that you have had a temporary lapse (or perhaps exist in a permanent state) of chauvinism.

  30. #30 Beamup
    August 18, 2011

    Without any sort of indication of any benefit whatsoever, OR any vaguely credible argument for such benefit would be expected, needling is indeed a waste of time.

    Resources for research are very limited. Research projects with real potential are not. Completely random research projects with nothing to support them (like in this case) are infinite.

    Research into acupuncture can only take place at the expense of research which actually has some grounding in reality.

  31. #31 Vicki
    August 18, 2011

    Jonathan–

    You’re missing the point on the toothpicks. It’s not a question of what the needles are made of: when toothpicks are used for sham acupuncture, they don’t break the skin.

    To put it simply: inserting a needle in an “appropriate” place, inserting a needle in a random place, and touching the skin but not breaking it all have the same effect. And that effect is minimal.

    If a treatment consistently produces patient outcomes, mechanism exists. If a treatment does not product patient outcomes, it’s worthless. Either there is no mechanism, or the mechanism is not medically useful. (You could claim that dyeing hair blue was a treatment for cancer. There is an obvious mechanism: the hair dye. That doesn’t mean the “treatment” works, so there’s no point in asking how the chemicals in the dye affect cancer.)

    A lot of doctors looked at acupuncture seriously, because there were claimed effects, and there was a mechanism: the insertion of needles into the skin. Trial after trial, and it became clearer and clearer that inserting needles doesn’t help.

    How many studies that showed no effect would it take for you to admit that acupuncture was not in fact a useful “treatment”?

  32. #32 Jonathan
    August 18, 2011

    Beam Up,

    I agree with your premise that research projects with real potential should be given precedence.

    Acupuncture and systemized standardized herbal combinations fit that bill according to many researchers. As in Fertil Steril. 2006 May;85(5):1341-6 which showed significant increase in successful IVF when combined with acupuncture day of the IVF day of the IVF as opposed to acupuncture given two days after IVF and no acupuncture control group.

    There seems to be a double standard found in this blog. For example, should pharmaceutical companies continue to research drugs to treat obesity? Even big pharma is admitting that after a generation of 10s, if not 100s, of billions of dollars of public and private research money, they have come up dry, and the obesity epidemic has sky-rocketed.

    It has been said before on this blog that big pharma ‘does a lot of our [academic] research for us.’ The same can be true of some alternative treatments. For example, there have been numerous anecdotal cases of reversing type 2 diabetes within 30 days using raw vegan foods. This was originally thought to be fringe, anecdotal, and a bunch of BS… Until it was proven in a real clinical trial (mechanism included

    Kim EL “Reversal of type 2 diabetes: normalisation of beta cell function in association with decreased pancreas and liver triacylglycerol” Diabetologia 2011.

    It is striking that the Kim 2011 clinical trial was performed with similar parameters as those previously established by a “fringe” food guru whose approach recently made press with a live-footage documentary on his successful treatment of type 2 diabetes. This diet is so far removed from the USDA diet, that it can only currently be called an “alternative” medicine, until more trials are conducted.

    Well, let’s see if money pours in to examine this prospect further (which has significant indication of broader implications and is firmly grounded in reality) or whether money continues to pour into pharma research that by and large has come up dry for actually reversing diabetes.

    I suspect, that money will continue to pour into the pharma treatments rather than extensive lifestyle interventions. I further posit that research into pharma treatments for obesity (rather than research into alternative diets) will continue to be embraced by contributers to this blog.

    There is a double standard due to a culture that is entrenched in and trained to investigate pharmacological agents and surgeries. Although I embrace scientific rigor, I reject the knee-jerk reaction that seems to occur whenever something new (meaning non-pharma, non-surgery, non USDA) shows promise.

  33. #33 Beamup
    August 18, 2011

    Acupuncture and systemized standardized herbal combinations fit that bill according to many researchers.

    Acupuncture only fits that bill according to researchers who don’t have a clue what the evidence actually shows. And finding pharmacalogically useful components in plants is the long-established scientific field of pharmacognosy, having nothing to do with CAM. Unless one tries to claim that some variable-concentration impure dose of a plant is superior to
    an purified form of known concentration, in which case one is simply wrong.

    As in Fertil Steril. 2006 May;85(5):1341-6 which showed significant increase in successful IVF when combined with acupuncture day of the IVF day of the IVF as opposed to acupuncture given two days after IVF and no acupuncture control group.

    Unblinded and no sham control, so it can be charitably described as unconvincing. “Meaningless ****” would be more precise. And more recent larger studies show that sham acupuncture has the same effect, i.e. the acupuncture did nothing. Discussed here at length; enter “acupuncture IVF” in the search box.

    For example, should pharmaceutical companies continue to research drugs to treat obesity? Even big pharma is admitting that after a generation of 10s, if not 100s, of billions of dollars of public and private research money, they have come up dry, and the obesity epidemic has sky-rocketed.

    IMO only with their own money.

    Kim EL “Reversal of type 2 diabetes: normalisation of beta cell function in association with decreased pancreas and liver triacylglycerol” Diabetologia 2011.

    No control group and small size makes this highly dubious. In particular there isn’t the faintest shred of a hint that any particular diet had anything at all to do with it, as opposed to simply ANY well-controlled diet. It’s very well-established and universally accepted that diet and exercise can do a great deal to control type 2 diabetes.

  34. #34 Jonathan
    August 18, 2011

    Vicki,

    I could be convinced that acupuncture did not warrant future research. I will be interested to see if the UPenn cancer center’s trial comes up dry (simply because I was involved in the trial and they have convinced me that the current control groups are sufficient).

    I could also be swayed if major medical journals in China demonstrated no efficacy.

    In terms of the US public, there is a systemic confounding factor with regard to making use of traditional treaments. That is the US diet is wrought will chemicals, processed foods, extensive use of industrialized animal foods (that contain exhorbitant amounts of omega 6 leading to chronic inflammation). Between the obesity and the constant state of inflammation in the US public, these could be considered significant confounding factors in compounds or treatments that may be less effective in causing a specific outcome (note: “less effective” here means less effective given the stated confounding factors in affecting a specific biomarker).

    What would convince me? Personally, I would need to see rigorous clinical trials performed on people who have previously established and maintained a minimally processed, freshly prepared, predominantly plant-based diet, supplemented as needed with grass-fed animal foods. That is my baseline standard for investigating herbal medicines and acupuncture.

    I am not saying that this needs to be everyone’s standard, I am just answering your question.

  35. #35 TBruce
    August 18, 2011

    For example, there have been numerous anecdotal cases of reversing type 2 diabetes within 30 days using raw vegan foods.

    Diabetes mellitus used to be treated by starvation diets before insulin was available. Type II diabetes frequently can be reversed by diet, weight loss and exercise. A balanced conventional diabetic diet works fine. There’s nothing special about a raw vegan diet in this situation.

  36. #36 Jonathan
    August 18, 2011

    Beam Up: “It’s very well-established and universally accepted that diet and exercise can do a great deal to control type 2 diabetes.”

    If that is the case, why is there a “glaring deficiency” in research into lifestyle interventions for the treatment of diabetes? (Lancet 2010, Type 2 Diabetes- Time to change our approach)?

    Why? Because there is a near complete entrenchment by physicians and researchers into the pharmacological model of treatment and research. Most physicians and researchers are swimming in their trillion dollar ocean and have no concept of fresh water.

  37. #37 Vicki
    August 18, 2011

    Jonathan,

    That sounds as though the claim that you think is worth teesting is “acupuncture combined with a specific largely vegetarian diet, and meat only from grass-fed animals, can be medically helpful.” Do you have any particular basis for the idea that the acupuncture is relevant here?

    This has little to do with acupuncture as it is generally marketed and practiced in North America. I have friends who have tried acupuncture, and none of them was told that they should adopt the diet you describe for some length of time and then come back for their first acupuncture session. The intervention that is actually being promoted, and that people want to keep testing, is “sticking needles in specific bits of the skin,” not “change the patient’s diet for a significant length of time, and then stick needles in the skin, while keeping the patient on the new diet.”

    With regard to diabetes, I think the essential problem is that getting people to make long-term changes in their habits is difficult: it’s relatively easy to get someone to eat differently for a month, or to floss for a week after each visit to the dentist, or to go to the gym once. Fewer people are still exercising at the end of that one-year membership the gym manager convinced them to sign, or flossing every night of the year. I’m mentioning flossing because relatively inexpensive, doesn’t take a lot of time, and can help save your life, and most people still don’t do it. To do research on ways of changing people’s habits, you need hypotheses to try: “we want people to exercise more” is not a hypothesis.

  38. #38 Beamup
    August 18, 2011

    You’re using an EDITORIAL to make your case? Amusing. Especially when it doesn’t support it at all. Seriously – did you actually read it? He’s not saying that we need some new magic diet. He’s saying that the things we already know work need to be put into more effective practice.

    Yes, there is research needed, but it’s not research trying to find some magic diet. It’s finding ways to help people stick to the lifestyle modifications that are universally known to be effective. Seriously, EVERYBODY knows that we should eat more fruits and vegetables, less fat and sugar, and get more exercise. But we don’t, for the most part, actually do it.

    What would convince me? Personally, I would need to see rigorous clinical trials performed on people who have previously established and maintained a minimally processed, freshly prepared, predominantly plant-based diet, supplemented as needed with grass-fed animal foods. That is my baseline standard for investigating herbal medicines and acupuncture.

    Ludicrous. Unless you have some actual evidence that such is relevant, then you’re just making up reasons to ignore inconvenient facts. Let’s also, for the sake of argument, suppose you were correct and such would be necessary for acupuncture to be effective – this would then make it completely useless since it wouldn’t actually apply to the general public!

  39. #39 Jonathan
    August 18, 2011

    Vicki, I agree. The essential question for diet and lifestyle interventions (currently) is how to affect behavior change. This is a topic that I am a dedicated to investigating (with the help of my mentor). What types of interventions (educational, interactive, social support, etc… including many subcategories with each). There is a dearth of research into this subject, comparatively speaking to the mountains of research spent on pharmaceutical agents. One factor that seems to becoming relevant due to research done by Erica Frank is how to make physician’s themselves to become healthier. There is even a greater dearth of research on this subject compared to the billion dollar industry of grossly ineffective CME programs (Cochrane Reports, and Davis in JAMA)

    So where is all this complaining by people on this blog coming from that insinuates that CAM researchers are nothing but a misguided wayward bunch who are wasting valuable research dollars? From my perspective, there is a lot of waste going into conservative medical efforts as it stands. CAM research money is a drop in that bucket of misguided policies, even if its research were to come up completely dry. Sounds like some people here are yelling for the sake of yelling, and holding on dearly to their own political agenda.

    Personally, as a tax payer and a student, I support further research into acupuncture and synergistic herbal remedies. I also believe that those modalities may show better efficacy if used on individuals who maintain a natural foods diet (defined here as minimally processed, freshly prepared plant foods combined with grass fed animal foods as necessary). I am not moving the goal post here. That is what I think. And I look forward towards working to have a nation that is healthy enough to test that hypothesis.

    In contrast, some people on this blog seem to put forth the idea that because some of the acupuncture and herbal research performed in cohorts of modern-worst-diet-ever people have demonstrated lack of efficacy, then all future research into these areas should be stamped out and, hopefully, the medicinal traditions that they evolved from should be buried as a load of crap. I disagree with that stance. I think that traditions deserve more openness, and, in the very least, not to be stamped out and potentially lost.

  40. #40 Vicki
    August 18, 2011

    Jonathan:

    How do you feel about traditional European medicine? Would you like your herbalist to select a treatment based on the doctrine of signatures? How do you feel about being bled? Would you go to a doctor who used mercury to treat syphilis?

    That something is traditional does not mean it’s a good idea. Also, not everything that someone claims is “traditional” is really old.

  41. #41 herr doktor bimler
    August 18, 2011

    those modalities may show better efficacy if used on individuals who maintain a natural foods diet

    So you are recommending the use of tax money to investigate magical-thinking treatments that you have already stipulated will not work on the vast majority of the population. Really?

  42. #42 Jonathan
    August 18, 2011

    Vicki, I agree. Accuracy of language is difficult when dealing with such broad issues. I stick with diet, herbs, and acupuncture as what I personally deem as needing further research, coupled as always with minfulness and exercise systems.

    Each researcher (and the public who support them) must delve into areas that they deem justified. From my understanding (both personal experience and guidance from my mentors), I suspect that their have been some methodological flaws in some of the US research into acupuncture and herbal medicines, and I will continue to support efforts into better research into these areas.

    That said, I will personally be dedicated towards studies into diet and lifestyle interventions. To me, diet is one of the most pending issues of our time, and frames the entire issue of what any medicinal system looks like, including our current one.

    Many of our modern drugs are inneffective compared to the onslaught of the US industrialized diet. It is only rational, that herbs (exogenous) and acupuncture (working through endogenous elements), which probably have less affinity (by compound or by quantity found in the treatment), would also demonstrate less efficacy than they would in people with a significantly better diet; even according to an adage in the ayurvedic system, “If diet is incorrect, medicine is of no use.”

  43. #43 Jonathan
    August 18, 2011

    Herr Doctor Bimler,

    I don’t own a magic wand. Personally, I would spend the lion’s share of research dollars into diet and lifestyle interventions, until that area of health has reached sufficient resolve.

    Beyond that, I would spend some tax money in herbal research and possibly acupuncture research in “otherwise healthy individuals” until we could establish mechanism (do hormone levels change? do bio markers change?). If mechanisms were established, then I hope we could research how to apply these findings to people with real illnesses.

    That said, I have no magic wand, so the most that I hope for during the current political-economic state of medicine is openness and a dedication towards patient empowerment to take better care of their health.

  44. #44 lilady
    August 18, 2011

    @ Jonathan: Well that tax money for additional research into CAM will have to come from somewhere.

    Now, it’s not as if we have budget surpluses, so in order to fund yet another study into CAM modalities, why don’t we stop government backed student loans, throw the elderly off social security and medicare and boot the indigent and disabled off SSI and Medicaid? We could also return to the compulsory draft with no student deferments permitted, which would dramatically decrease the military budget. So what do think of these proposals Jonathan?

    I too am a taxpayer who is retired from a career in public health…I know what the science of medicine and dietetics is and I know how proper research is done. I think your ideas are utter nonsense because you are merely dabbling, certainly not “majoring” in the sciences and are unable to differentiate between science and pseudo-science.

  45. #45 Krebiozen
    August 18, 2011

    Since acupuncture in its modern form was essentially adapted from medieval-style bloodletting in the 1930s, and so many trials show such little promise, I think further research is a waste of time.

    From Ben Kavoussi’s Science Based Medicine article linked to above:

    If the current map of acupuncture points and meridians is distinct from the vasculature, it is because in the early 1930s the pediatrician Cheng Dan’an (承淡安, 1899-1957) resurrected and rehabilitated the vanishing street trade of therapeutic piercing by moving the treatment loci away from the blood vessels. He illustrated his revisions by painting the new pathways onto the skin of individuals and then photographing them. He also replaced the coarse medieval tools with the fine needles we associate with acupuncture today. It is the reproduction of these new pathways in modern acupuncture textbooks, and the new use of fine needles that Langevin and Yandow have unknowingly taken for historical facts.

  46. #46 Jonathan
    August 18, 2011

    Krebiozen, Why don’t you send your article to the scholars at Shanghai University and see what they say about it? Get back to me on that. I will be interested in what they have to say.

    Lilady, Diet and lifestyle modification would indeed save an enormous amount of US medical expenses. According to a recent White House report, if we could reduce obesity to the levels that our nation maintained in 1980, we would have a surplus of money allocated to health care well beyond the additional spending of the new trillion dollar healthcare plan.

    But then again, scientists can believe in their voodoo medicine that obesity related illnesses will be reversed by pharmacological interventions.

    It is total BS and a total waste of GDP.

  47. #47 lilady
    August 18, 2011

    Now just how did Jonathon switch from CAM research to changing obesity rates? When called out about his uninformed knowledge of science-based medicine and his devotion to yet additional go nowhere research into CAM, he switches to the epidemic of childhood obesity leading into adult obesity and the medical problems associated with obesity.

    I think Jonathon has finally figured out there is no Santa Claus, no Easter Bunny and the money under his pillow for his baby tooth got there through his parents’ sleight of hand…yet he still falls for the sleight of hand arguments of CAM practitioners and has unsuccessfully tried that trick here.

    Herbs and acupuncture for treating real non-obesity related diseases have been studied and re-studied and they are ineffective.

    Seems to me Jonathon that is “into” patient empowerment and into a libertarian mindset about Big Government and Big Pharma…it’s his developmental stage (callow youth) and there may be hope for him yet, once he gets into the real world and has a basic understanding of how he is being manipulated into his belief of pseudo-science. He might even take some academic courses in anatomy and physiology to see how needling meridiens to relieve or cure disease is totally bogus.

  48. #48 Krebiozen
    August 18, 2011

    Jonathan,

    Why don’t you send your article to the scholars at Shanghai University and see what they say about it? Get back to me on that. I will be interested in what they have to say.

    It’s not my article, it’s Ben Kavoussi’s as I clearly stated. Kavoussi has thoroughly researched the subject and I find his arguments compelling and his conclusions inescapable. If you have information that refutes his findings, please share it. I’m sure the scholars at Shanghai University would disagree. What would that prove?

    Personally I think that recent Chinese interest in traditional medical practices has more to do with cultural pride than actual efficacy. Life expectancy in ancient China was less than 40 years, and did not increase substantially until modern scientific medicine was introduced, which does not suggest TCM was or is very effective.

    I’m sure you are aware that alleged anesthesia using acupuncture was found to have been faked, and of the history of TCM in relation to Mao’s Cultural Revolution. Western interest in TCM is, again in my opinion, rooted in romantic notions of the inscrutable and mystical orient.

    It is total BS and a total waste of GDP.

    If you wrote that about acupuncture I would agree with you. What is so unlikely about finding a safe, effective pharmaceutical way of preventing or treating obesity-related illnesses? It seems much more likely than finding that sticking needles in people does anything particularly useful.

  49. #49 herr doktor bimler
    August 18, 2011

    a natural foods diet (defined here as minimally processed, freshly prepared plant foods combined with grass fed animal foods as necessary).

    I’m not sure if this can be imposed on the majority of people without depopulating the cities and dispersing populations across the country, which did not work so well when implemented by Pol Pot.

  50. #50 herr doktor bimler
    August 18, 2011

    voodoo medicine
    Why use ‘voodoo’ in this pejorative way? It has more empirical support and a longer history of traditional practice than modern acupuncture…

  51. #51 lilady
    August 19, 2011

    “From my understanding (both personal experience and guidance from my mentors), I suspect that their have been some methodological flaws in some of the US research into acupuncture and herbal medicines, and I will continue to support efforts into better research into these areas.”

    Just two questions Jonathan:

    Who are your mentors?

    What research into acupuncture and herbal medicines do you suspect had methodological flaws. How about providing citations for these flawed studies and your analysis of the methodological flaws?

  52. #52 Jonathan
    August 19, 2011

    Lilady,

    My mentors are currently from Harvard Medical School and UPenn School of Medicine.

    I came on this site for two reasons.

    1) I enjoy discussing topics with a pack of wolves.
    2) The blog advertises itself as a blog that is interested in science.

    To answer your earlier question, I brought up obesity-related illness specifically because this blog and its members seem to be aggressive about money wasted in “useless research.” There is a gross irony here. The money that researches CAM is a drop in the bucket compared to the money that is outright wasted in treating obesity-related illnesses with pharmaceutical and surgical interventions. However, those are the same types of interventions that this blog and its members would approve of.

    Those inteventions cost hundreds of billion dollars per year every year in research and treatment, yet are utter failures when it comes to reversing the trend of obesity-related illnesses.

    I was merely pointing out that both the writer of this blog and this blog’s followers are complaining about a toothpick worth of ‘wasted’ money when they are leaning on a tree trunk worth of wasted money.

    That strikes me as having a sided agenda.

    I came here to have a conversation about science. It has become apparent that the writer of this blog and its followers are about as even handed as Rush Limbaugh and his devotees.

    Thanks, but no thanks. I think I will stick with my current mentors. I think they have a fine handle on the situation.

    And yes, I agree with you Lilady. I will turn out just fine.

  53. #53 plutosdad
    August 19, 2011

    Another study that tries to say diet and exercise is CAM:

    http://medicalxpress.com/news/2011-08-doctors-nurses-holistic-medicine.html

    “Doctors, nurses often use holistic medicine for themselves”

    Again in the study they say that massage and chiropractic medicine are alternative. A lot of chiropractic is of course, but some chiropractors also have physical therapy licenses and are really physical therapists, I’m not sure how CAM that truly is but I bet the study didn’t really differentiate.

    They also include diet as CAM.

    sigh

  54. #54 Vicki
    August 19, 2011

    Jonathan:

    I repeat my questions, and add one:

    How do you feel about traditional European medicine? Would you like your herbalist to select a treatment based on the doctrine of signatures? How do you feel about being bled? Would you go to a doctor who used mercury to treat syphilis?

    And if you don’t accept these things just because they are traditional, why should we accept other treatments because they are claimed to be traditional?

  55. #55 lilady
    August 19, 2011

    @ Jonathan: You have raised some serious questions about research into acupuncture, herbal medications, dietary changes and leveled charges against the science community and Big Pharma, yet have failed to provide one citation where research into acupuncture and other CAM modalities was flawed and your personal analysis of how the study is flawed.

    In science we don’t “believe”, “sense” or “suggest” that a study is flawed. If you really have even one instance of a flawed study and if you know what the gold standard for study design, execution and analysis of the result, it should be quite easy to provide a citation with your expert analysis.

    The NCCAM has spent over $ 1 Billion to study CAM…its budget for this coming FY is way beyond $ 100 Million. Why not look at some of their studies, for your citation and analysis of flaws?

    Don’t come back and criticize us for not using the basics of good health such as balanced diet, exercise and weight control for maintenance of body stasis…it is the basis of our clinical practice.

  56. #56 augustine
    August 19, 2011

    The NCCAM has spent over $ 1 Billion to study CAM…its budget for this coming FY is way beyond $ 100 Million

    Lilady, you are doing EXACTLY what Jonathon said you were doing. Complaining about a toothpick while leaning on a tree trunk of wasted money.

    http://healthcare-economist.com/2008/11/07/us-spends-700-billion-on-unnecessary-medical-tests/

    “Peter Orszag, director of the Congressional Budget Office, estimates that 5 percent of the nation’s gross domestic product-—$700 billion per year –goes to tests and procedures that do not actually improve health outcomes…The unreasonably high cost of health care in the United States is a deeply entrenched problem that must be attacked at its root.”

  57. #57 augustine
    August 19, 2011

    http://www.overdosedamerica.com/2008/06/dose-of-bias-is-unhealthy.html

    It’s not just the commercially biased “educational moments” that are the quid pro quo that come with the gifts to doctors. No, the problem starts with the “scientific evidence” that we doctors read in our most respected journals.

    More than two-thirds of the clinical trials that are published in our most trusted medical journals are commercially sponsored. And the odds are five times greater that the commercially sponsored studies will conclude that the sponsor’s drug is the treatment of choice compared to non-commercially funded studies of exactly the same drug. (Wouldn’t it be nice to take those odds to the casino?)

    In other words, what we naively think of as objective science is more often than not an extension of marketing – an infomercial.

    This is an enormous problem and goes a long way toward explaining why Americans pay twice as much for health care as the citizens of the next 21 wealthiest countries, but actually live two and a half fewer years in good health than the citizens of those countries.

    Liladay

    Don’t come back and criticize us for not using the basics of good health such as balanced diet, exercise and weight control for maintenance of body stasis…it is the basis of our clinical practice.

    So what percentage of your patients visits ended up with you giving an exercise routine and shopping plans to? How many left your county health department with a pharmaceutical product?

  58. #58 herr doktor bimler
    August 19, 2011

    However, those are the same types of interventions that this blog and its members would approve of.

    Add mind-reading to Jonathon’s other talents.

    I came here to have a conversation about science.
    Perhaps it would have helped if you had mentioned some science. Instead you threw around some frshly made-up bullshit about “an acu-genetic map”, before arguing for the proposition that scarce public research funds should be spent on a diet / acupuncture combination that at best would only benefit the minority of people who can afford elite unprocessed foods. Naturally you received mockery.

  59. #59 lilady
    August 19, 2011

    Please ignore ignorant, uneducated on-the-dole troll with his “mommy fixation”. Too bad Orac didn’t keep the troll in moderation purdah.

  60. #60 Jonathan
    August 20, 2011

    Lilady spouts some BS: “Don’t come back and criticize us for not using the basics of good health such as balanced diet, exercise and weight control for maintenance of body stasis…it is the basis of our clinical practice.”

    In reality, doctors are niether sufficently trained, nor encouraged to counsel about diet and lifestyle (Citation: Adams 2010. Nutrition Education in US Medical Schools. Academic Medicine) Only 25% of US medical schools have a required nutrition course. Of those medical schools that teach nutrition, students receive an average only 19.6 hours of coursework in total. Approximately 75% or more of incoming freshman medical student believe nutrtition is important for health. Less than 40% of outgoing senior medical students believe that nutrition is important. (Citation Erica Frank’s publication on the Women’s Physicians Health Study in collaboration with Harvard School of Public Health). Less than 50% of primary care physicians counsel their patients on diet and lifestyle. (Citation: look it up yourself. It is not hard to find. Perhaps start with some Erika Frank publications)

    So, no. Physicians do not adequately use diet and lifestyle as the “basis” of their clinical practice. Extensive research into interactive educational interventions designed to improve this area of healthcare are both warranted and necessary; especially in light of the current obesity epidemic.

    To answer your questions earlier Vicki, no I would not recommend studying treatments that are known to cause harm. To use this posturing demonstrates that you have little to no understanding of CAM research. The rigorous trials conducted by contributors to the Bravewell Collaboration have nothing to do with your ridiculous suggestion. No I am not missing the point of your suggestion. The fact is, both the writer of this blog and most of its contributors use posturing such as “Do you agree with mercury poisoning as a medical treatment” is clear political posturing that has nothing to do with with rigorous CAM research that occurs today with our modern scientific diagnostic techniques.

    Furthermore, I have been attacked a great deal on this blog for offering a “speculation” into identifiable ways to potentially research acupuncture. Last I checked, scientists and students of medicine were allowed to speculate, so long as they clearly state that the idea is a “speculation” rather than fact. If acupuncture does demonstrate efficacy in future trials (Look for UPenn’s Hot Flash and aromatase inhibitor phase II trial that will be published soon enough), then genetic expression must occur somewhere in that equation. So it is a reasonable “speculation” that there could be predictive correlation between needling certain areas and causing certain patient outcomes. That said, it is a “speculation” and nothing more. No citation necessary.

    So, I repeat my question to you. Why do you commend (tacitly or vocally) the utter 100s of billions of dollars per year of research and treatment money that goes to pharmacological and surgical remedy to obesity-related illnesses? This is a complete waste of scientists’ intelligence, research money, public funds, and patient lives all in service to a blind and entrenched way of operating a failing direction of medicine that has existed for the past 30 years. Why do you waste your time worrying about a grain of sand (CAM research) when you are standing on a beach (costs of false start, unsuccessful, still wrong headed obesity related illness research and treatment)?

    Go ahead, show me that diet and lifestyle are the foundation of medical treatment and are actively used by the majority of medical practices (please provide citations). Show me that the obesity trend has been reversed by all the 100s of billions of dollars that have gone into pharma treatment of obesity (please provide citations). Show me that CAM research costs as many lives every year as the false-direction of research into obesity related illnesses (please provide citations). And if you can’t, take your bullshit potential of a researcher and start working on the real problem.

  61. #61 Roadstergal
    August 20, 2011

    “Acu-genetic map.” Good christ.

    From the above post: “Citation: look it up yourself. It is not hard to find.” Followed by: 3x “please provide citations.” Translation – I’m lazy, you do all the work.

    I did look at the citations in the first paragraph. Your statement “only 25% of US medical schools have a required nutrition course” is misleading. From the paper: “Of these 109 schools, 103 (94%) reported that nutrition instruction was required.” Some have it in a dedicated nutrition course, some have that education as part of other courses. The survey did indicate that med students and instructors alike feel nutrition education is important and deserves a more solid academic foundation, which I definitely agree with, and absoutely highlights the need to not bog down the curriculum with crap on CAM.

    I also looked up Frank et al, the results from the Women Physicians’ Health Study, Arch Intern Med v. 159 no. 13. It was a survey of women physicians and job satisfaction metrics. It said nothing about whether they thought nutrition was important; the word ‘nutrition’ did not even appear in the article. I’ll have to chalk this one up to Making Stuff Up. So as for the third, no, I won’t look it up.

    “To answer your questions earlier Vicki, no I would not recommend studying treatments that are known to cause harm.”

    Like acupuncture, which runs the risk of infection? Acupuncture was a risk factor for HCV infection in cohorts examined in China (PMID 21328375), Australia (PMID 19811480), and Brazil (PMID 19684968). And that was from just a quick look at PubMed. Not to mention the risk of having your wallet emptied for a placebo instead of doing something to actually help whatever condition you have.

    My old PI went to UPenn, getting her VMD and PhD there, and I did some research there as well. It makes me sad to think they’re giving time and space to bullshit.

  62. #62 herr doktor bimler
    August 20, 2011

    Why do you commend (tacitly or vocally) the utter 100s of billions of dollars per year of research and treatment money that goes to pharmacological and surgical remedy to obesity-related illnesses?

    Attributing “support for X” to your opponents in an argument where no-one has said “I support X” does not bode well for honesty or good faith. “Tacitly commending” seems to translate as “no-one has criticised obesity research in a thread devoted to quite different topics”.

    Try tying the strawmen to the top of the goal-posts; they might enjoy the ride.

  63. #63 General Tanz
    August 20, 2011

    Why do you waste your time worrying about a grain of sand (CAM research) when you are standing on a beach?

    Why so much fuss about one murdered prostitute when there’s a war going on?

  64. #64 Jonathan
    August 20, 2011

    Adams. 2010 in Academic Medicine:

    “Of the 105 schools answering questions about courses and contact hours, only 26 (25%) required a dedicated nutrition course… Only 28 (27%) of the 105 schools met the minimum 25 required hours set by the National Academy of Sciences; in 2004, 40 (38%) of 104 schools did so.”

    Frank E, et al Predictors of nutrition counseling behaviors and attitudes in US medical students. Am J Clin Nutr. 2006;84:655-62:

    “Freshmen students were more likely (72%) to find nutrition counseling highly relevant than were students at the time of ward orientation (61%) or during their senior year (46%; P for trend 􏰅 0.0003). Those intending to subspecialize had lower and declining perceptions of counseling relevance… The perceived relevance of nutrition counseling by US medical students declined throughout medical school, and stu- dents infrequently counseled their patients about nutrition. Interventions may be warranted to improve the professional nutritional practices of medical students.”

  65. #65 Jonathan
    August 20, 2011

    Frank E 2002 Personal and professional nutrition-related practices of US female physicians

    Forty-three percent of physicians performed nutrition counseling, and 50% performed weight counseling with patients at least yearly. Forty-six percent thought that discussing nutrition was highly relevant to their practices, 47% thought the same about discussing weight, and 21% stated that they had received extensive related training.

  66. #66 Jonathan
    August 20, 2011

    These postings seem to randomly be accepted or for require approval.

    In one posting, and in order:

    Adams 2010. Nutrition Education in U.S. Medical Schools: Latest Update of a National Survey. Academic Medicine: “Only 28 (27%) of the 105 schools met the minimum 25 required hours set by the National Academy of Sciences; in 2004, 40 (38%) of 104 schools did so.”

    Frank E et al 2006 Predictors of nutrition counseling behaviors and attitudes in US medical students “Freshmen students were more likely (72%) to find nutrition counseling highly relevant than were students at the time of ward orientation (61%) or during their senior year (46%; P for trend 􏰅 0.0003). Those intending to subspecialize had lower and declining perceptions of counseling relevance ”

    Frank E 2002 “Personal and professional nutrition-related practices of US female physicians”: “Forty-three percent of physicians performed nutrition counseling, and 50% performed weight counseling with patients at least yearly. Forty-six percent thought that discussing nutrition was highly relevant to their practices, 47% thought the same about discussing weight, and 21% stated that they had received extensive related training. “

  67. #67 Militant Agnostic
    August 20, 2011

    @herr Doktor bimmler

    Try tying the strawmen to the top of the goal-posts; they might enjoy the ride.

    I am stealing that

    would only benefit the minority of people who can afford elite unprocessed foods. Naturally you received mockery.

    Someone proposed turning a good chunk of the American Midwest into a Buffalo Commons in response to Global Warming and water shortages. This would ensure a supply of delicious (as long as you don’t cook it too long) meat with the appropriate omega 3 / omega 6 ratio. Requiring the traditional first nation practice of hunting them on foot with stone age weapons would go a long way to reducing the incidence of heart disease and cancer. Perhaps Jonathon would like to try doing acupuncture on a Bison.

  68. #68 lilady
    August 21, 2011

    With a rather slick segue Jonathan switches from his opinions about the efficacy of acupuncture to nutrition…while being totally unable to describe how doctors, nurses and registered dieticians (not self-styled nutritionists), can motivate a patient toward good dietary control to avoid the onset of metabolic syndrome.

    How would Jonathan design a program to educate adults in the proper diets for growing children and for their own health?

    More importantly how would Jonathan inspire patient compliance of strict adherence to a lifestyle of balanced diets and exercise?

    Furthermore, what should a doctor do when he sees a patient in his office with low stroke volume and there is evidence of congestive heart failure. I suspect Jonathan would lecture the patient about his poor diet and lack of exercise and not prescribe medication…or perhaps send him to an acupuncturist…there must be a dietary and exercise motivation median.

    Jonathan only claims to be interested in science-based medicine and only thinks he is an expert on diet. Jonathan needs more intensive courses in human anatomy and physiology, chemistry and disease processes.

  69. #69 Chemmomo
    August 21, 2011

    In case Jonathan doesn’t pick this point out from Lilady’s post:

    How would Jonathan design a program to educate adults in the proper diets for growing children and for their own health?

    If you have any constructive ideas about this, please share .

    I don’t know that throwing research dollars at the problem will provide answers that will help the general public. Human nature is what it is. I know (please excuse the anecdotal illustration) both Type II diabetic adults who have benefited from being counseled on lifestyle changes, and those who continue to ignore them in spite of declining health. And I also know those who didn’t listen to the counseling, but whose health improved once their diets were controlled by someone else (and in case anyone cares, those diets weren’t vegan).

    All the research in the world is not going to get people to change what they want to eat.

    That said, I’ve got one more question for Jonathan: why are you criticizing pharmaceutical companies for spending their own research dollars on pharmaceuticals to treat obesity? They’re pharmaceutical companies – it’s what they do! They make pharmaceuticals! On their own dime. Suppose the pharmaceutical companies were not researching pharmaceutical options to treat obseity – would you be asking them why not?

  70. #70 BadDragon
    August 21, 2011

    Sorry to digress, but you brought obesity into discussion. Here are my two cents on the American obesity problem:

    There is a myth circulating in my country about the Americans being fat because they eat only junk food. I can see Americans themselves are inclined to think of the same. Some blame processed food, the additives, industrialized animal foods, chemicals for the obesity.

    Well… I’ve been twice in USA and I was shocked. Not by the poor quality of the food but by the quantity. This is not a science-based empirical truth, this is just a personal opinion based solely on my experience and my careful observation. So, in my opinion, the main cause for obesity there is the huge amount of food consumed by the average person. While I was there I was incapable to eat even a half of a portion (actually once I ate 3 times from a portion of pasta with chicken and the rest I had to throw away because it was becoming boring). It was a loss of money and food.

    Maybe we do not like the “ancient far-eastern alternative treatments” but we might pay attention to some of the ancient far-eastern wise words. Like “never leave the table with a full stomach”

  71. #71 herr doktor bimler
    August 21, 2011

    This would ensure a supply of delicious (as long as you don’t cook it too long) meat with the appropriate omega 3 / omega 6 ratio. Requiring the traditional first nation practice of hunting them on foot with stone age weapons would go a long way to reducing the incidence of heart disease and cancer.

    Of course it would be nice if the entire population of the US were locavore hipsters, living only on sustainable fresh produce bought from the nearest Farmers’ Market (having been carted there in recycled Trade-Aid coffee sacks on the backs of humanely-treated donkeys). Then Jonathon’s fantasy therapy would work on them. However, it’s hard to see how to get there from the current socioeconomic condition, without a Pol Pot-style Year Zero.

    Sadly, the current situation restricts the fantasy (“speculative”) acupuncture / life-style therapy to a narrow social stratum… one whose needs are already the subject of the lion’s share of pharmaceutical-company research. Do yuppies really need a special slice of public research funding as well?

  72. #72 Matt G
    August 21, 2011

    Creationism becomes Creation Science becomes Intelligent Design. A pile of dung by any other name….

  73. #73 lilady
    August 21, 2011

    @ Bad Dragon: Yes, you brought up an excellent point about the sheer size of portions…they are huge in moderately priced restaurants…more normal sized in the more expensive restaurants.

    But, again how do we motivate (force) people to cook for themselves, with a variety of nutritious foods…I know Jonathan has some ideas…why doesn’t he share them?

    I don’t think Jonathan is aware of the “natural” deterioration of the aging body that occurs in people who have always made good choices or that some people have genetic hyperlipidemia. I suspect due to his callow youth and his good health at his age, he has a very narrowed perspective of people who require medical and (shudder) modern pharmacological interventions. All the additional acupuncture studies, using up limited research dollars will not help the patient who needs immediate attention for cancer treatment, hypertension and cardiac problems…to name just a few of the diseases and disorders that are treatable.

    BTW, I read the study that Jonathan assisted in at U Penn; the lead investigator was Dr. Mao who has an MD and who is also a world authority on acupuncture. That same doctor is now also studying “electroacupuncture” treatments for the arthralgias associated with aromatase inhibitors for cancer treatment. Here is what Orac has to say about “electroacupuncture”:

    Electroacupuncture: The bait and switch of alternative medicine-June 24, 2009

    “What acupuncturists call “electroacupuncture,” we in the medicine biz call transcutaneous electrical nerve stimulation (abbreviated TENS). What acupuncturists don’t tell you is that electroacupuncture is, in essence, TENS without science or any scientific rationale for the placement of the electrodes (which is, after all what the needles become when hooked up to an electrical source). In effect, electroacupuncture replaces science-based positioning of the electrodes with woo-based positioning. Despite that, though, it actually sometimes works, because, as TENS shows, using a weak electrical current to stimulate certain nerves can indeed relieve pain in some cases, and that’s all so-called “electroacupuncture” does. Mainly this occurs by utter coincidence, when acupuncture meridian points happen to overlie actual nerves. Indeed, I strongly suspect that the reason many of these acupuncture points are selected for various studies isn’t based on traditional Chinese medicine precepts, but because it was realized that they were close to real nerves that might do real things in the body when stimulated.

    Here’s the problem. Acupuncturists take a science-based modality (TENS) and “rebrand” it as some sort of “alternative” therapy like electroacupuncture. After all, why use boring old TENS to try to relieve chronic pain when you could instead be using–ta da!–electroacupuncture. So much cooler So much more…alternative! It’s a classic bait and switch, in which woo-meisters take a modality like acupuncture, add something to it that science tells us will have a physiological effect (like electricity), find a result, and then use that to imply that the whole “alternative” medicine modality really does work after all.

    That’s exactly what advocates of electroacupuncture do.”

  74. #74 Denice Walter
    August 21, 2011

    @ Chemomo
    @ BadDragon
    @ herr doktor bimler

    Woo-meisters often scream about how doctors don’t focus on diet while it is more likely that doctors’ patients don’t *follow through* or *continue*.( The American Diabetes Association assists patients by presenting plans as well).

    The diets promulgated by the idiots I survey involve spectacularly manicured regimes of raw foods, veganism, blenderised vegetable concoctions, and handfuls of supplements usually consumed ritually on schedule several times a day. Most people can’t do this or keep it up. There’s a point to all of this: if you can’t perfectly emulate the guru, it illustrates your weakness ( For shame!) but also makes you a likely candidate for purchasing supplements to make up the difference.

    The ability for self-control is a complex psychological issue the usually develops in adolescence, making childhood obesity a family issue. People with problems in this area might be those most in search of plans for weight control: and the charlatans see them coming. Peruse any woo-drenched web site and you’ll find a section about weight control secrets or suchlike. They have all the answers. ” Never eat anything substantial, especially if you’re hungry.” Great students of human nature aren’t they?

    BadDragon: about portion size in the US- while the concept of “plenty” has been historically significant, in recent years it has quite literally gone mad – with a few exceptions: more expensive sophisticated dining ( including “locavore hipsters”), cuisine from Asia, and vegetarian “health food”. These alternatives are especially noticable on the coasts. I eat lots more Thai, Indian, etc. than I do Italian, French, etc.

  75. #75 Jonathan
    August 21, 2011

    Reversing the obesity trend will require much effort, but to brush it off as unlikely and to continue to poor research into pharmaceuticals will not help.

    In my opinion, reversing the obesity epidemic will require interventions to physicians and interventions to patients.

    Physicians must be trained in the importance of diet and in how to effectively cause change in patient behavior. Physicians must also be taught how to eat better themselves. Frank E 2004 Physician Health and Patient Care JAMA explains that the number one predictor across specialities for physicians to counsel patients on preventive measures is whether or not a physician practices the behavior themselves. Remarkably, when physicians practice the behavior themselves, they not only counsel more on the behavior, but are more BELIEVAVBLE by the patients.

    In order to educate physicians, we must first research how to create effective CME programs. The multi-billion dollar a year industry of CME as currently run through didactic formats is completely ineffective Davis 1999 Impact of formal CME JAMA. It is noteworthy, since this blog often cites wasted money, that the yearly expenditures on CME are 20 to 30 fold more than the yearly expenditure into CAM research, yet CME as currently run are completely ineffective in changing physician behavior and patient outcomes. Discovering CME formats that work (interactive, multidisciplinary, or others to be discovered) are imperative to combating obesity.

    Then we must research interventions that work for changing patient behavior (possibly interactive plus adequate support systems, and others to be discovered). There is a dearth of research in this department, and research is the only way that we can improve patient buy in.

    If you have other ideas on how to actually improve research in these departments, I am all ears.

    If you want to throw up your hands and say it can’t be done, I have better things to do.

    It has been swell. I have enjoyed the more productive aspects of this conversation. I am off to go camping now.

    Have a lovely summer, and good luck with your current and future endeavors of how to improve people’s health. In the end, I think that is what we all want.

  76. #76 lilady
    August 21, 2011

    Too bad I have a long comment stuck in moderation about Jonathan’s mentor at U Penn, Dr. Mao,s who in his latest study is combining acupuncture woo with TENs treatment and calling it electroacupuncture.

    He’s off for a camping trip (foraging for food?) and off another topic…CMEs. Just feel free anytime to segue into another topic Jonathan; I think your vegan diet is skewing your thinking processes.

  77. #77 lilady
    August 21, 2011

    “Too bad I have a long comment stuck in moderation about Jonathan’s mentor at U Penn, Dr. Mao…”

    Well the long comment is out of moderation now and posted at # 73…thanks Orac.

  78. #78 Chemmomo
    August 21, 2011

    @Denise: I believe we agree.
    @Jonathan: thank you for elaborating your position. But I do disagree with your solution. As I’m not a physician, I can’t comment on your assessment of CME programs. But from my own point of view as a patient, “physician, heal thyself” is just a saying. It really doesn’t matter to me whether or not my doctor is also overweight when I’m trying to find time in my schedule to exercise, or get to the grocery store to pick up fresh produce.
    Educating the physicians isn’t going to get to the root of the problem. It’s far more complex than that. It’s a societal issue. Educating the physicians isn’t going to do much good when the average American doesn’t actually have consistent access to healthcare. Spending research dollars on coming up with better selling points isn’t going to fix that. There’s no point in improving credibility unless you also improve access.

    Just to make this clear: I don’t think your ideas won’t help fighting obesity. But I do think that they don’t go far enough.
    We’ve only touched the tip of the societal iceberg, but I think we’ve gotten far enough off topic.

  79. #79 pk
    August 23, 2011

    When science isolates and does not integrate, it becomes blind. People suffer and die daily from the overdosing of the isolated drug therapy used by traditional medicine. Traditional medicine is full of quackery, so why is that not discussed here? Medicine is lost in a model of disease and has nothing to do with health. It’s sad to see a mind so lost in trying to disprove the benefits of integrating what is known from many traditions. When you can prove there is no such thing as love, then I will believe the ravings of this lost website.

  80. #80 Chris
    August 23, 2011

    pk:

    Traditional medicine is full of quackery, so why is that not discussed here?

    There have been discussions similar to that here. If you have something specific you wish discussed, then please present it.

    and

    When you can prove there is no such thing as love, then I will believe the ravings of this lost website.

    What does that have to do with anything?

  81. #81 Calli Arcale
    August 23, 2011

    pk — the pitfalls of what you’re calling traditional medicine are indeed discussed here. Just not in every post; each post has its own topic, depending on what has piqued Orac’s interest at a particular moment.

    It’s untrue that medicine has nothing to do with health. If you think that, you can’t possibly have been seeing a doctor regularly for preventative care (i.e. physicals). Or, if you have, you may need to fire him/her and get a better one. Maintaining health is a major goal of primary care practitioners; that a lot of people refuse to listen to them, or don’t see them until they’re very severely ill, isn’t really their fault and it wouldn’t be fair to blame them for it.

    As far as your comment about proving there being no such thing as love, I have no idea what you’re getting at there. It seems you’re setting an arbitrary and impossible task before you will believe anything said on this website, which is a puzzling thing to do if you are really concerned about not becoming blind. Who is blind? The ones who want to study and test and find out what is true, or the one who sets an impossible and pointless task (disproving love) before he will believe anything?

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