Respectful Insolence

CAM, placebos, and the new paternalism

Three and a half years ago, I bought a new car. The reason why I mention this as a means of beginning this post is because that car had something I had never had in a car before, namely Sirius XM satellite radio preinstalled. Curious, I subscribed, and I now barely listen to regular radio anymore. A couple of years after I had bought the car, a new channel was added to the lineup, a channel called Radio Classics. I don’t know how I discovered it, but I rapidly became hooked on what’s commonly referred to as old time radio. Basically, that’s classic radio of the sort that was broadcast between the 1920s until around 1962, when the last of the scripted radio dramas and comedies that were so popular went the way of the dodo with the final broadcast of a couple of my now favorite old time radio shows, Suspense and Yours Truly, Johnny Dollar. (For any other geeks like me, my favorite episodes were the ones starring Bob Bailey as Johnny Dollar.) It’s true that some of these shows were truly cheesy (how on earth anyone could think The Shadow anything other than pure silliness, I don’t know, but I was shocked to learn that Orson Wells played Lamont Cranston, a.k.a. The Shadow, in quite a few episodes), but some were really, really good, such as the aforementioned Yours Truly, Johnny Dollar, as well as Gunsmoke, Dragnet, The Six Shooter, The Adventures of Sam Spade (the Howard Duff episodes, of course), and The Whistler. I also learned that Abbot and Costello had a hilarious radio series in the 1940s and that Jack Benny was actually quite funny as well.

Another thing I learned as I explored this decades-old world is how much medicine has changed. Primarily I learned this from listening to old episodes of The Story of Dr. Kildare, a radio show that ran in the 1950s. The way medicine is practiced these days might well have many, many problems, but listening to how Dr. Kildare was represented one thing I learned was that paternalism was far more prevalent in the 1950s than it is now. Yes, I know, big surprise (although it was refreshing to hear physicians call a quack a quack), but listening to some of these episodes is very jarring to a physician practicing in 2012. For instance, I recall one episode where a patient was not told she had a terminal cancer until the end was near and there was no choice. The other aspect of the series that’s amazing to a physician practicing in 2012 is how little concern is given to the discussion of alternatives, informed consent, or anything else having to do with patient autonomy. In general, doctors told patients what needed to be done and they did it, with little questioning. How much of this was due to how the writers perceived how medicine was practiced and how much of this was a seemingly accurate portrayal of how medicine was practiced is hard to say (after all, how much of Grey’s Anatomy is accurate?), but there is other evidence. For example, until around 40 or 50 years ago, it was considered ethical to prescribe placebos. In general, it no longer is.

Which brings me back to “alternative medicine,” “complementary and alternative medicine” (CAM), “integrative medicine” (IM), or whatever you want to call non-science-based medicine that has infiltrated scientific medicine and academia over the last couple of decades. Last week, I mentioned how we’ve seen a rash of credulous reporting about placebo responses over the last month or so. I singled out one article in particular, but that was not the only article. In any case, what I lamented was the “rebranding” of pseudoscientific CAM remedies as means of “harnessing the placebo effect,” noting that one shouldn’t need pseudoscience to maximize placebo effects if they are real. There is, however, another consideration that I see, and that’s paternalism. And I’m starting to agree with Kimball Atwood when he proclaims that CAM is the “new paternalism.” I’ve already alluded to such concepts before, such as when I countered an attack against science-based medicine as being paternalistic because of its reliance on science or when I pointed out the “misinformed consent” that antivaccine activists and CAM boosters seem to be advocating in the name of a false “health freedom” that actually subverts patient autonomy. A couple of weeks ago, there was a rather interesting study published that led me to think on these matters again.

Power and authority versus empathy in placebo effects

All too often, “placebo” seems to mean exactly what people choose it to mean, no more, no less (apologies to Lewis Carroll). In reality, a placebo is nothing more than “a substance or procedure a patient accepts as medicine or therapy, but which has no specific therapeutic activity” or, as Wikipedia now defines it, “simulated or otherwise medically ineffectual treatment for a disease or other medical condition intended to deceive the recipient.” This strikes me as a better definition than the old definition because it emphasizes that placebos are medically ineffectual and that they involve deceiving the patient. Indeed, the necessity of deception is part and parcel of placebo use, which is one key reason why using placebos has fallen out of favor. Using placebos outside of a clinical trial is now generally considered at best paternalistic and at worst downright unethical, because it violates informed consent and patient autonomy. Sixty or seventy years ago, it was considered acceptable for physicians to deceive patients that way. in 2012, not so much.

In any case, what we call the “placebo effect” is not a single effect, and it has many components. Placebos are actually best viewed as a rather artificial tool used in clinical trials to control for nonspecific effects. There are expectation effects, in which patients experience what they are led to expect to experience. There are effects due to observation. Patients in clinical trials almost always do better than those not in clinical trials, thanks to the closer attention and more rigorous treatment protocols. This has sometimes been referred to as the “clinical trial effect,” and both patients and doctors often unconsciously modify their behavior based on their knowledge that they are being observed, an effect known as the Hawthorne effect. Then there are effects due to reporting, which can introduce bias. There are effects due to regression to the mean, which describes how patients interact with the natural waxing and waning of their symptoms. When their symptoms are at their worst is when patients will tend to try a treatment. Because most symptoms will wax and wane, even if nothing is done there’s a good chance that a patient’s symptoms will “regress to the mean” on their own even if the patient does nothing. However, if a patient has taken a remedy, even a placebo like homeopathy, at a time when their symptoms are at their worst, it’s very common for them to attribute their improvement to the medication. Correlation, of course, does not equal causation. In any case, depending on the timing of the clinical trial’s measurement, regression to the mean can play a role in placebo effects.

Given how complex placebo effects are and how many different variables determine the magnitude of placebo effects, it should not be surprising are a whole host of other factors that determine how strong a placebo effect will occur in any situation. Surgery and invasive procedures are more powerful placebos than pills, for instance. More expensive placebos tend to produce stronger apparent effects. Indeed, there’s a whole hierarchy of placebos, and placebo effects can be enhanced by things like empathy and the doctor-patient relationship. Traditionally, it’s been believed, based on a number of lines of evidence, that practitioner empathy has a major effect on placebo effects.

Just last month a group out of the University of Southhampton published a rather intriguing study that somewhat challenges that paradigm. The study, which was published as an E-pub ahead of print last month is entitled Practice, practitioner, or placebo? A multifactorial, mixed-methods randomized controlled trial of acupuncture. Its conclusions are a mixture of the provocative and the mundane (i.e., in line with what we already know). It’s a rather complicated study to explain because its design is rather complex, which opens it up to concerns on my part that it’s a bit too complicated to draw firm conclusions from. Let’s start with the abstract:

The nonspecific effects of acupuncture are well documented; we wished to quantify these factors in osteoarthritic (OA) pain, examining needling, the consultation, and the practitioner. In a prospective randomised, single-blind, placebo-controlled, multifactorial, mixed-methods trial, 221 patients with OA awaiting joint replacement surgery were recruited. Interventions were acupuncture, Streitberger placebo acupuncture, and mock electrical stimulation, each with empathic or nonempathic consultations. Interventions involved eight 30-minute treatments over 4 weeks. The primary outcome was pain (VAS) at 1 week posttreatment. Face-to-face qualitative interviews were conducted (purposive sample, 27 participants). Improvements occurred from baseline for all interventions with no significant differences between real and placebo acupuncture (mean difference −2.7 mm, 95% confidence intervals −9.0 to 3.6; P = .40) or mock stimulation (−3.9, −10.4 to 2.7; P = .25). Empathic consultations did not affect pain (3.0 mm, −2.2 to 8.2; P = .26) but practitioner 3 achieved greater analgesia than practitioner 2 (10.9, 3.9 to 18.0; P = .002). Qualitative analysis indicated that patients’ beliefs about treatment veracity and confidence in outcomes were reciprocally linked. The supportive nature of the trial attenuated differences between the different consultation styles. Improvements occurred from baseline, but acupuncture has no specific efficacy over either placebo. The individual practitioner and the patient’s belief had a significant effect on outcome. The 2 placebos were equally as effective and credible as acupuncture. Needle and nonneedle placebos are equivalent. An unknown characteristic of the treating practitioner predicts outcome, as does the patient’s belief (independently). Beliefs about treatment veracity shape how patients self-report outcome, complicating and confounding study interpretation.

It’s probably easier to borrow the figure in the paper that explains how this study was laid out (click on the image to enlarge):

i-2865610bb0e60f5ed0e5c452199fdfc8-fig1-thumb-480x454-71825.jpeg

Note how this design results in eighteen different experimental groups, based on three practitioners treating patients either with the “empathic protocol” or the “non-empathic” protocol, each of which is further divided into groups of real acupuncture, sham acupuncture (Streitberger placebo acupuncture technique), or mock electrical stimulation. It is these groups that were analyzed in different combinations (for example, empathic versus non-empathic, sham versus real acupuncture, practitioner 1 versus practitioner 2 versus practitioner 3). In the end, there were 221 patients randomized, and each small experimental group ended up with between 5 and 20 subjects, for a total of 221 patients. To assess for possible confounding factors, investigators also recorded “attitudes towards complementary medicine holistic complementary and alternative medicine questionnaire (HCAMQ),” empathy consultation and relational empathy (CARE) questionnaire, analgesic intake (tablet count), and needling sensation. Patients were also given a daily pain diary (100 mm visual analogue scale VAS) to complete for 7 (pretreatment) days and during treatment. Finally, patients were asked at treatment completion, “Do you think the treatment you had was real” and required to give a simple yes or no answer. One strength of the study is that high percentages of subjects believed (75% to 96%, depending on group) that they were receiving “real” treatments.

Let’s start with the unsurprising result of the study. Basically, it was found that all three main groups, real acupuncture, sham acupuncture, and mock electrical current, all experienced a decrease in pain and that there was no difference between them. This result is, of course, completely consistent with what studies have found time and time again about acupuncture, namely that it performs no better than placebo. Similarly, the observation that belief in the therapy (i.e., belief that the subject was receiving “real” therapy and that that therapy would be effective) was correlated with improved outcomes in pain was expected and consistent with previous literature about placebo responses. The result that was surprising was that there was no reported difference between patients receiving empathic and non-empathic treatment. This finding the authors reported, was unexpected. But what does it mean?

In this study, empathic treatments were described thusly:

Empathic (EMP) consultations were deemed to be normal pragmatic treatment sessions. Patients were greeted in a friendly, warm manner and were free to enter into conversation with their practitioner, who in turn would willingly do so. Practitioners did their utmost to comply with participants’ wishes, providing detailed answers to questions and emphasising patient comfort and well-being.

Non-empathic interactions consisted of this:

This encounter was more “clinical” in nature. Patients were greeted in an efficient manner and quietly shown to the treatment cubicle. Practitioners would only discuss matters directly relating to the treatment to enable them to effectively carry out that treatment, e.g., pattern of pain and side effects. Necessary explanations were kept as short as possible, and if patients attempted to enter into any discussion, the practitioner would respond using the words “I’m sorry but because this is a trial I am not allowed to discuss this with you.” Between needle stimulations, patients were left on their own in a curtained cubicle.

Based on previous results, we would expect beforehand that patients receiving the empathic consultations would report more pain relief, but such was not the case in this study. The authors speculated quite a bit about why this was, from their questionnaire not reflecting empathy adequately to a rather interesting potential confounder in which patients made excuses for the non-empathic interactions:

Participants in empathic consultations described practitioners as caring, friendly, and communicative. Those in nonempathic consultations undertook a little more work to explain their similarly positive views of their practitioners. Thus interviewees who had received nonempathic consultations talked about how they colluded with the practitioner to obey the study rules and have limited personal interactions. They suggested that the practitioners were not really nonempathic, they were just acting that way for the sake of the trial. For example, “I had the feeling that she sort of felt that you know, not being able to converse properly, that she felt a bit awkward about it” (Betty, nonempathic).

To me this suggests that patients really, really want to believe that their practitioners care about them and will go to great lengths to align their interpretations of observed behavior with that belief so that perhaps empathy isn’t as powerful an inducer of the placebo effect as we might expect.

Another intriguing result of this study was the observation of a definite practitioner effect independent of consultation type. Specifically, one practitioner (Practitioner 3) produced consistently better outcomes across all treatment and consultation types. The investigators report that this was observed “in spite of all the meticulous care and planning taken to ensure consistency of treatment delivery among the three practitioners.” Why was this? It wasn’t empathy, but rather it was something that wasn’t being measured in the study design, something unknown. The authors couldn’t identify it, but they did speculate that it has to do with patients viewing Pracitioner 3 as being more authoritative, expert, and confident:

The qualitative data suggested that the interviewees perceived practitioner 3 as a paternalistic male authority figure. Practitioner 3, as the primary investigator, might have been seen by patients as the expert, consequently establishing higher expectations of success, which in turn influenced outcome. Although this is consistent with previous research [10] and [29] a larger explanatory study involving many practitioners is needed.

This was in contrast to Practitioner 1:

Interviewees referred to Practitioner 1 by her first name and as a “girl” and a “young lady,” and some described her using affectionate terms such as “sweet.” Practitioner 3 was referred to as “Doctor,” was never referred to by his first name, and was typically described in more respectful than affectionate terms, including “courteous” and “formal but friendly.” Participants seem to have seen practitioner 3 as more authoritative than practitioner 1.

This is, of course, an observation that opens a can of worms that will be very difficult to deal with. Clearly, more research needs to be done to confirm and expand on these results, but it shouldn’t be surprising that a more authoritative practitioner, who can project an air of confidence and expertise, might be better at affecting a patient’s perception of his or her illness. As I mentioned above, Kimball Atwood once referred to integrative medicine and patient-centered care as the “new paternalism.” I chuckled when I read Atwood’s take on the issue, but I have to admit that he is probably more correct than I had wanted to admit. Certainly, the “health freedom” movement, as much as it cloaks itself in rhetoric suggesting that it is trying to “empower” patients to “take control” of their health, in actuality denies them the most important tool to do that: An honest, science-based appraisal of the rationale behind a proposed treatment, along with an assessment of its potential benefits and risks based on science, not fantasy. Instead, it substitutes tooth fairy science, pre-scientific vitalism, and utter faith in the practitioner for science and reason.

It’s hard not to wonder whether the more modern constructs in medicine that involve truly informed consent and respect for patient autonomy are now coming into direct conflict with the apparent vision of proponents of “harnessing the placebo effect,” such as Ted Kaptchuk and Daniel Moerman, who apparently see physicians as shamans whose interactions with patients are as powerful at healing as the medications and procedures they have at their disposal. Their vision of what medicine should be would fit quite nicely in an old episode of The Story of Dr. Kildare.

Comments

  1. #1 emanuelmulkey
    January 9, 2012

    My brother recently had a car accident and his premiums sky rocketed, and he heard about “clearance auto” and now his premium is lower with same coverage. If anyone is interested search online and find them.

  2. #2 alex
    January 9, 2012

    Very cool article! Thanks

  3. #3 tom gardner
    January 9, 2012

    “Old time radio” isn’t dead. It is a term that I haven’t heard before, but the equivalent is alive and thriving in the UK. It is called “BBC Radio 4″ and is available via the ‘net.

    The best way to describe Radio 4 is “NPR on steroids”. Along with marmite, it is the aspect of UK life that is most missed by ex-pats.

    There’s even a variant, Radio 4 Extra, which includes many reruns of programs from the 60s and earlier.

  4. #4 Anj
    January 9, 2012

    :(

    I interviewed for a job. I’ve gardened most of my life. I attend CENTS, which is a green industry convention. I enjoy the research studies they do and do my best to understand what is presented. I consider myself above average in terms of plant knowledge.

    During the interview, I was told very plainly that some people think men know more than women. Customers. Clients. That people would ask a woman a question, and THEN find a man to ask the very same question to.

    Oh, the person who was in charge of the perennials for this (large, well known) nursery was a woman. The idea that someone would ask her a question and then turn around and ask a man the same question was absurd to me. (This was anecdotally reported to be more common among men, but women would also do this.)

    This study points out a similar skewed perception – men are seen as having more Authoritay than women. Are there any major woo pushers who are female, outside of childbirth? I’m not counting the spokespersons like Jenny McCarthy.

    Need new study: Given the opportunity to get a second opinion on suggested course of treatment – does the gender(/age/…) of the doctor and/or patient affect the patient’s decision to do so?

  5. #5 anarchic teapot
    January 9, 2012

    I see I’m not the only one whose fists start to clench at the use of the word “empower” by the woo touts.

    You’re right, it is paternalism. These people often infantilise their marks, wrapping them in a cocoon of false security and “wellness” (another word that they abuse incessantly). Isn’t it ironic how they systematically use tactics the medical profession grew out of long ago – to a great extent – yet still accuse doctors of this behaviour?

  6. #6 Will
    January 9, 2012

    I’m intrigued by your take on placebo vs. Ben Goldacre’s. You seem to imply that placebo doesn’t work, whereas he’s more interested in the ethics of misleading people. My understanding (although I’m not a medical professional) is that it does work (e.g. see the wikipedia article which is quite well referenced (although I didn’t check them)). (And to be more specific, I’m talking about expectation effects here, not the other ‘placebo-like’ effects you mentioned.)

  7. #7 Ruth/STL
    January 9, 2012

    I remember thinking when I read Solzhenitsyn’s “Cancer Ward” about how much of the doctor’s paternalism was due to the time (1953) and how much the place (Soviet Union). I recommend the book for anyone interested in history and medicine and politics.

  8. #8 Mephistopheles O'Brien
    January 9, 2012

    FWIW, medical paternalism was a plot point in The Bells of Saint Mary’s as well.

  9. #9 Smugspergers
    January 9, 2012

    Clearly an asperger is the best kind of person for practising medicine. Lack of empathy makes no difference and the paternalistic delivery of the aspie would increase the placebo effect.

    Great article, thank you Orac :)

  10. #10 Interrobang
    January 9, 2012

    Don’t forget, it was also fairly common practice for doctors to treat women extra paternalistically during that period, often not even discussing their diagnoses with them, preferring to tell their husbands or fathers instead. Paternalism with tasty misogyny sauce!

  11. #11 Denice Walter
    January 9, 2012

    @ Anj:

    There are a few women, not as well-known as the woo-meisters I follow ( *Les maitresses de woo*?) Give them time. Some I’ve run into in my “travels”: Rima Laibow gets involved in suits through her Natural Solutions Foundation; Carolyn Dean, a struck-off Canadian doctor who went ND, wrote with Null – infamously about iatrogenetic death, in “Death by Medicine”- and purveys her nonsense in Hawaii. Dr Christiane Northrup has been seen on television on women’s issues. There is an HIV /AIDS denialist, Dr Banks, now in Mexico, antivax doctors Suzanne Humphries and Sherry Tenpenny ( much quoted). NY physician, Serafina Corsello and Quackwatch fave, Lorraine Day. Non-physicians like Susun Weed toss out natural plant woo, Staninger on Morgellons, anti-vaxxers Loe Fischer, Habakus,etc; the late Hulda Clark, now channeled by Tim Bolen, sold cancer woo while the late Adelle Davis wrote nutritional faery tales. Gone but not forgotten, unfortunately.

    As women gain in social power I imagine the list will expand: there’s no reason to believe that women are naturally immune to folly and the lure of chicanery. I hear many up-and-comers, courtesy of the Progressive Radio Network.

  12. #12 Denice Walter
    January 9, 2012

    @ Anj:
    I have a post in moderation about the women of woo – and not just DietGurlz!

  13. #13 Jarred C
    January 9, 2012

    What was the age difference between Practitioner 1 and 3; or more importantly, what was the perceived age difference?

    I’m 31 years old, with two B.Sc. degrees and a Masters degree. I’m a veteran of two foreign wars with a lot of combat experience. Yet I look like I’m about 20-22 years old, and I’m treated like it by about everyone I know, including my academic peers, my coworkers, my friends, and my family.

    A few years ago I worked in an Emergency Room, and all the Nurses, Docs, Clerks, and Techs treated my like I was an uneducated old boy/young man, because I looked like I was about 20-21, even though I was 28. I would mention that I nearly had two B.Sc. degrees and I was a veteran, and always they would express surprise; especially at the veteran part. And rarely would they believe that I was in two different wars or that I was in a combat unit. I was once even told not to lie.

    No matter your experience or how you view yourself (I speak and walk with confidence, according to others), if you look young, you will be treated as such.

  14. #14 Susan
    January 9, 2012

    My grandmother had breast cancer in 1930 at age 48. She was was diagnosed by her brother, a physician in a very small town in Ohio. He sent her to Columbus (about 100 miles away) for radiation treatment. My Dad had to drive them there – he was 16 – every week for about 6 weeks. On the last treatment, the doctor removed both her breasts. That was the first any of them knew there was going to be any surgery. He sent her across the street to stay in the hospital for few days. My point is, yes, they didn’t have much consent, informed or otherwise, at the time.

    Good news is that she lived to be 89 and saw me (her only grandchild) graduate from high school.

  15. #15 dreamer
    January 9, 2012

    Is this study legit to any degree? For my friends, it appears to confirm her anti-vax bias,
    via FB: “So it looks as if the Pertussis vaccine is probably the cause of the increase in pertussis cases. Of course, according to the medical machine, the answer is to add another component to the vaccine.
    http://www.cidd.psu.edu/research/synopses/acellular-vaccine-enhancement-b.-parapertussis

    Acellular pertussis vaccination enhances B. parapertussis colonization — CIDD
    http://www.cidd.psu.edu
    An acellular whooping cough vaccine actually enhances the colonization of Bordetella parapertussis in mice; pointing towards a rise in B. parapertussis incidence resulting from acellular vaccination, which may have contributed to the observed increase in whooping cough over the last decade.”

  16. #16 dreamer
    January 9, 2012

    Dr.Phil, summary for tomorrow, Tue Jan 10. It bugs me how the summary itself appears so positive towards the psychics. Last time I watched Dr. Phil and a psychic, he had a very very mild skeptic rebuttal (and a few more very mild in there) I’m pretty sure tomorrow will be the same … if not worse!

    Tuesday
    Psychic Investigations
    Can the living really communicate with the dead? In a daytime television first, world-renowned intuitive mediums John Edward and Char Margolis team up on Dr. Phil’s stage and pull back the curtain to the other side! Watch as the mediums perform LIVE in-studio readings on audience members. What messages do their loved ones have from beyond the grave? Then, a skeptical Dr. Phil sits down for his first-ever psychic reading from Char. Will he become a believer? Plus, the spirit world reveals something Robin would rather keep secret! Then, numerologist Glynis McCants explains how numbers can lead to a love match. Whether you’re already a believer or still on the fence, you won’t want to miss this spirit-filled show!

  17. #17 cervantes
    January 9, 2012

    “The other aspect of the series that’s amazing to a physician practicing in 2012 is how little concern is given to the discussion of alternatives, informed consent, or anything else having to do with patient autonomy. In general, doctors told patients what needed to be done and they did it, with little questioning.”

    Alas Dr. G, this is still true. It’s no longer the ideal — we’re supposed to be practicing “patient centered medicine” and people are supposed to be making “informed choices,” but the reality is otherwise. There’s plenty of evidence to this effect, based on recordings of actual clinical encounters. Basically, most of the time, doctors just tell people what to do.

  18. #18 Prometheus
    January 9, 2012

    I wonder if what this study implies about the desire for paternalism among acupuncture subjects is truly generalisable to the population at large. It may be that people interested in fantasy-based medicine (e.g. acupuncture) are those who are attracted to the authoritarianism of “alt-med”.

    Without a base of data to support it, fantasy-based medicine relies entirely on authoritarian statements by its practitioners for support, e.g. “I know [fill in the therapy] works because I know it works.” (or, “…because of my vast clinical experience.”).

    This, obviously, leads to a more paternalistic approach to medicine, even if they couch it in “health care freedom”. After all, saying that the patient can choose whichever unsupported fantasy-based therapy the practitioner feels inclined to offer them (e.g. “You can try chelation first, or we can start with homeopathy or you might opt for a trial of aura manipulation. Which would you like?”) isn’t exactly the same as presenting all of the options with their supporting data (which, as I already mentioned, is nil for fantasy-based therapies) and asking the patient to make a truly informed choice.

    What fantasy-based practitioners are offering, in the guise of “informed choice”, is actually “misinformed choice”, because they don’t have any data to support their recommendations. And what data is available is rarely presented in an unbiased manner. I wonder how many of the “vaccine-avoidant” paediatricians’ patients are informed of the true risks of vaccines vs the risks of non-vaccination – not many, I suspect.

    My personal experience with science-based physicians, both for myself and for my children, has led me to conclude that – perhaps – the pendulum has swung too far from the 1950′s. Physicians – again, in my experience – often don’t give enough direction, so that I find myself asking them “If you were in my situation, what would be your choice?”. I suspect that real physicians (i.e. science-based medical practitioners) have been brow-beaten so often about their “paternalism” that they bend over backwards to avoid even the appearance of trying to choose for their patients. For any physicians reading this – I’d like a bit more direction; tell me what you think is the best choice and then let me decide.

    Prometheus

  19. #19 Anne Pierce
    January 9, 2012

    I don’t miss the days of doctors lying to patients (esp. women) about their disease, but for some the pendulum has swung too far. I had to convince my (wonderful) family practitioner that, since he had gone through med school and residency, I wanted to know what he thought was the best option for treatment. I wouldn’t necessarily have to agree to follow it, but I want a professional of ANY type to say “The problem seems to be X. Options include 1, 2, and 3. I favor 2 and here’s why.”

    Flu1918

  20. #20 Calli Arcale
    January 9, 2012

    I have to agree with Prometheus and Anne Pierce — sometimes I find it’s gone too far the other way. I can think of two occasions when I came in to get a recommendation and came out with “well, there’s three things you can do, and they’re all equally valid”. Well, since they ranged from “do nothing” to “minor surgery on a four-year-old”, no they were not equally valid! We ended up going with “do nothing” but had to see an orthopedist first, who did an x-ray and then gave us the actual “if it were my kid, I’d do nothing” recommendation. It was a waste of resources, honestly.

    I found the orthopedist took a very good approach. Told us what all the options were, as well as what he’d pick if it was his kid, then let us pick.

  21. #21 Beamup
    January 9, 2012

    A related issue which drives me bonkers is the reluctance to quantify anything, even in general terms. “The main risk of choice A is X, the main risk of choice B is Y.” “What are the odds of X or Y actually happening?” “I can’t say.”

    Well, gee. Kind of hard to make any kind of informed decision without at least a general sense of the relative likelihood of each.

  22. #22 Narad
    January 9, 2012

    Indeed. I was referred to orthopedics several years ago for pretty bad ulnar nerve symptoms in one arm. It’s a teaching hospital, so I was first seen by the resident/fellow and then the attending came in. It was a great show, including the latter’s holding up my arm and exclaiming to the fellow, “I could pluck this nerve like a violin string!” (I.e., CUT!)

    After the fellow left the examination room, I asked the attending if this was really necessary. His reply was along the lines of “Well… when I had this problem in med school, I just took a small pillow and Ace-bandaged it in the crook of my arm at night.” The candor proved helpful.

  23. #23 Jarred C
    January 9, 2012

    Beamup,

    My doc gives me fairly useful likelihoods, but without the numbers. She says things from “This side effect is extremely unlikely to happen, but if it does, call us immediately” to “You will probably experience this side effect, and here’s how to counter it if you do.” Of course, that was after surgery, so perhaps it was a little more pressing that I knew the differences.

  24. #24 Beamup
    January 9, 2012

    I wish I could get anything like that out of mine. And it’s been a string of several.

    I’ve also had one who basically decreed what treatment option I would be going with, was offended that I would even ask whether there were other options, and CERTAINLY wouldn’t talk about possible pros and cons. Ultimately I agreed, but it was like pulling teeth to get any information. EXTREME paternalism there – I shudder to think what a woman’s experience would have been.

  25. #25 anna
    January 9, 2012

    What is so wrong about this statement?
    “Then comes the great disconnect: our country will spend $2.6 trillion on medical care this year yet virtually nothing is spent on prevention and there is no condemnation of diet contributing to disease. The only admonitions that we hear are “don’t smoke” and “drink in moderation.” Any evidence demonstrating that a disease may stem from processed foods and beverages, environmental chemicals, stress, or a lack of exercise is either not discussed or downplayed. As a result, the average American doesn’t pay a great deal of attention to what they feed themselves and their children; nor do they bother to devote much time in their daily lives to exercise or meditation.”

  26. #26 Calli Arcale
    January 9, 2012

    Anna,

    Mostly the fact that it’s wrong. It’s true that the average American doesn’t pay a great deal of attention to their diet or exercise habits, but this is not because of nothing being spent on prevention and no discussion of diet’s contribution to disease. Quite the contrary. Large sums of money are spent on educating the public, at all stages of life, how they can improve their health and reduce the risk of certain illnesses (especially some of the really expensive ones, like diabetes) by eating well and getting good exercise. That this is largely ineffective speaks more to human nature than it does to any supposed medical conspiracy against good health.

  27. #27 anna
    January 9, 2012

    @Calli-
    Most internists do not ask what their patients eat – I’ve yet to talk to anyone
    who has been questioned about their diet-except diabetics. When they reach
    a disease state it’s usually too late.
    As for public education just look at the TV ads for drugs-their side effects message
    is laughable.

  28. #28 Prometheus
    January 9, 2012

    Anna (#24):

    “What is so wrong about this statement?
    ‘Then comes the great disconnect: our country will spend $2.6 trillion on medical care this year yet virtually nothing is spent on prevention and there is no condemnation of diet contributing to disease. The only admonitions that we hear are “don’t smoke” and “drink in moderation.”’”

    What wrong? Two things: the statement is misleading, for another, and it’s incorrect, for another.

    To begin with the first problem – “it’s misleading” – one of the things we’ve been told for decades (if not forever) is that prevention is vastly cheaper than treatment (“An ounce of prevention is worth a pound of cure.”). As a result, even if equal effort was expended on both, the money spent on prevention would be far less than that spent on treatment.

    Moving on to the “it’s incorrect” part, the statement that “…there is no condemnation of diet contributing to disease.” is demonstrably false, unless you want to quibble about using the word “condemnation”. Ever heard of the connection between obesity and diabetes, heart disease, etc.? My doctor has, and she reminds me at every visit. And it’s not just nagging me to “don’t smoke” or “drink in moderation” (I’ve never smoked and don’t drink alcohol – it gives me migraines).

    However, if Anna is going on about how “mainstream” medicine doesn’t agree that the “proper” diet can prevent or cure all disease, that’s because that statement hasn’t been shown to be true. In fact, there are loads of data showing that a lot of diseases can’t be treated or prevented by diet alone.

    Anna continues:

    “Any evidence demonstrating that a disease may stem from processed foods and beverages, environmental chemicals, stress, or a lack of exercise is either not discussed or downplayed.”

    Again, all of these – with the possible exception of the nebulous “processed foods” (does that include cooking?) – are widely accepted as causes of certain diseases, where supporting data are present. I begin to suspect that Anna should change physicians, if hers isn’t up to date on these issues.

    Anyway, it was a nice selection of baseless canards about modern medicine and I thank Anna for putting them all into a concise format for rebuttal.

    Prometheus

  29. #29 Jarred C
    January 9, 2012

    Anna,

    I can’t speak about the diet part (apart from the fact that my doctor cares about my diet, and has assigned me a dietician. So has my parent’s doc, and my grandparent’s doc), but I can shed some light on the TV ads.

    When clinical trials are run for drugs, the researchers are required to report any and all effects which take place during the trials, even if they do not have anything to do with the drug. Those are now labeled as potential side effects, and those are the “side effects” you see during the TV commercials. They may or may not have anything to do with the drug, and there’s no comment to how common or rare they are.

  30. #30 anna
    January 9, 2012

    @Prometheus-
    Processed food primer-
    “Processed foods” that may be bad for your diet:
    canned foods with large amounts of sodium or fat, breads and pastas made with refined white flour instead of whole grains, packaged high-calorie snack foods such as chips and candies, frozen fish sticks and frozen dinners that are high in sodium, packaged cakes and cookies, boxed meal mixes that are high in fat and sodium, sugary breakfast cereals, processed meats

  31. #31 Calli Arcale
    January 9, 2012

    Anna:
    Prometheus and Jarred have both already provided counterexamples. The fact that you haven’t spoken to anybody with a competent doctor is not evidence that competent doctors don’t exist. Of course, you’re specifying internists; I haven’t seen an internist myself. But my GP certainly discusses diet with me.

    About the TV ads….

    Seriously, do you really think that’s the sum total of patient education? Frankly, that’s not even patient education. That’s *advertising*. I’m talking about the real education stuff. Maybe you don’t pay attention, like the bulk of Americans, but it’s out there. The recent modifications to the Food Pyramid are one example; that’s the federal government trying to get people to eat better. I’m not sure it’s really their fault we’re mostly lazy asses who mostly swear we’ll eat right . . . starting tomorrow, which of course never comes. But it’s not just the federal government. Check out Blue Cross/Blue Shield’s “Go” campaign. They’ve got a whole ad series where this middle-aged guy with a bit of a paunch just starts getting up, wherever he is, and starts dancing. It’s to get *regular folks* moving. They also have things like the lady who’s gardening, and pulling up little dumbbells from her garden — the point being that hey, gardening is exercise to, so if you think exercise has to be unproductive or require expensive equipment, you’re wrong, so ditch that excuse and get moving. It’s a fun ad campaign — and it’s been running for a while, so I’m surprised you haven’t noticed it yet.

  32. #32 Anton P. Nym
    January 9, 2012

    Anna (#24): “What is so wrong about this statement?”

    It implies that I and virtually everyone I see or speak/write to have hallucinated the food pyramid(s), repeated calls by various organisations (Heart & Stroke Foundation, College of Physicians and Surgeons of Ontario, the White House, etc) for better eating habits including cutting down on convenience/junk foods, all the diet obsession you see on TV and hear on radio, the food packaging itself… and every doctor and nurse I’ve dealt with, and I work in an office packed with people in the real-world health practitioner circles.

    And that’s just for starters, but I’m out of time.

    — Steve

  33. #33 Narad
    January 9, 2012

    I’ve yet to talk to anyone who has been questioned about their diet-except diabetics.

    You must not get around much.

  34. #34 Mephistopheles O'Brien
    January 9, 2012

    Most internists do not ask what their patients eat

    How do you know that? Where are the statistics? If I say that my internist asked me what I eat, does that disprove it?

  35. #35 Mephistopheles O'Brien
    January 9, 2012

    frozen fish sticks and frozen dinners that are high in sodium

    Just so I understand, is it the fact that they are high in sodium, are frozen, or are fish sticks that you find offensive?
    FWIW, I haven’t had fish sticks or frozen dinners in some time, so have no ax to grind here.

  36. #36 lsm
    January 9, 2012

    I blame those potential side effects listed on ads as a major reason that the gullible turn to alternative medicine. It’s certainly fodder for woomeisters–those potential side effects sound really scary.

    On the flip side, I wish that alt med practitioners were required to list the potential side effects of their more dangerous enterprises.

  37. #37 lilady
    January 9, 2012

    What is so wrong about this statement?
    “Then comes the great disconnect: our country will spend $2.6 trillion on medical care this year yet virtually nothing is spent on prevention and there is no condemnation of diet contributing to disease……”

    Really Anna?

    For one thing it is copy pasta from a self-styled investigator:

    Investigative Blogger-Crystal L. Cox-Industry Whistleblower

    It is considered “good form” to credit a source you found on an internet site.

    I’ve been to Crystal L. Cox website and she is crackers.

    Anna, where else do you get you copy pasta from?

  38. #38 alison
    January 10, 2012

    Sort of on-topic – one of the big dailies down here in NZ is running a rather credulous series on ‘alternative therapies’. Certainly today’s story had no indication of any critical thinking on the issue of whether blood-letting by leech might really be beneficial for people with hepatitis… (click on my name for a link with my take on this nonsense.)

  39. #39 Narad
    January 10, 2012

    FWIW, I haven’t had fish sticks or frozen dinners in some time, so have no ax to grind here.

    The Ecofish pollack nuggets are quite good, just by the by.

  40. #40 lilady
    January 10, 2012

    @ Alison:

    Demi Moore uses leeches in addition to other beauty secrets/enhancements. She claims she learned about the benefit of leeches while undergoing some sort of alt therapies in Austria. Preparation for leech therapy includes bathing in turpentine, shaving certain areas of her body and then letting the leeches suck your blood. “These are not swamp leeches, they are ‘highly trained’ medical leeches. The therapy detoxifies me.”

    Here is what two celebs have to say about treatment of hepatitis C and the benefits of another alt treatment:

    Pamela Anderson: Ozone Therapy

    In an effort to reduce the symptoms of Hepatitis C, the former Baywatch star and mother of two admitted to using ozone therapy — a controversial treatment in which ozone gas is administered in measured doses to a patient. The practice is also supported by fellow actor Nick Nolte, who stated on Larry King Live that ozone therapy makes the brain “more metabolized.”

    Source “10 celeb moms who swear by alternative medicine”

    If these celebrities say these alt treatments are beneficial, it must be so.

  41. #41 TBruce
    January 10, 2012

    “Highly trained” medical leeches?

    Makes the brain “more metabolized”?

    Don’t these people have PR flacks who could tell them that they sound like idiots – or doesn’t that matter?

  42. #42 Smugspergers
    January 10, 2012

    Aww, it’s not magic after all. Now I know how it’s done.

    If someone posts in favour of alt-med (that includes diet now!), and they are dumb enough to handle, their posts remain. If they are too clever, Orac deletes their contributions.

    If they start off looking unclever then turn clever, Orac cries ‘sockpuppet’!

  43. #43 lilady
    January 10, 2012

    Is training a leech similar to training fleas for a flea circus? What constitutes a “highly trained” leech rather than a “trained in the basics” leech?

    Nick Nolte ought to know what a “more metabolized” brain acts like…his mug shot after an “under the influence” arrest is a classic.

    -Bad publicity is better than no publicity.

  44. #44 alison
    January 10, 2012

    “highly trained medical leeches” – hahahaha (well, it’s either laugh or cry!). Thanks, lilady – obviously I should have searched more widely in writing my piece :-)

  45. #45 Puppetsox
    January 10, 2012

    “If someone posts in favour of alt-med (that includes diet now!), and they are dumb enough to handle, their posts remain. If they are too clever, Orac deletes their contributions.

    If they start off looking unclever then turn clever, Orac cries ‘sockpuppet’!”

    That pretty much nails it :)

  46. #46 Smugspergers
    January 10, 2012

    Yes, someone posted something about comparing vaccine preventable deaths to safer painkiller preventable deaths and then it disappeared!

    Can’t these pussies handle real hard science debate?

  47. #47 lilady
    January 10, 2012

    Alison I enjoy reading your informative blog and you are doing a great job of teaching “the science”.

    You would be amazed how many pregnant women, foreign born and born in the United States as well, who are uninformed about their chronic hepatitis B status.

    When I worked in public health I was the perinatal hepatitis B prevention program coordinator…in addition to other duties in the division of communicable disease control at a large county public health department.

    I would always supply good information to these women and also question them about any supplements or herbal “remedies” they were ingesting…and caution them that many of these substances are no benign and could alter liver function.

    It was a very rewarding position for me because they were my “cases” for ~ 18 months; from first trimester, through the births of their infants and until their babies were tested for immunity, following the completion of their hepatitis b vaccine series.

    I was always impressed with the role of community resources such as places of worship and other organizations that were quite active in educating their membership about the increased risk-by-nature-of-their-heritage of being chronic carriers. They ran free testing programs and free counseling and would arrange for uninfected partner immunizations, through referrals to public health clinics.

    I firmly believe if you can get respected leaders of any vulnerable group “on board” with preventive health…you have accomplished a major feat to dispel ignorance and fear of modern medicine.

  48. #48 Andreas Johansson
    January 10, 2012

    I confess myself to be baffled by the more processed = worse thing. If you’re a raw foodist, well, okay, but most people using the line would agree raw meat is worse than cooked, and typically advocate whole grain bread, not unprocessed grains. So why are they using the line at all if they’re only objecting to some kinds of processing?

  49. #49 Calli Arcale
    January 10, 2012

    Andreas — while we are probably straying from the topic a bit, I have run into a lot of people railing against “processed food” who don’t seem to have a very clear idea of what, exactly, that means. (Including a lady who didn’t want me to buy Iams because it was processed, and instead wanted me to buy her company’s “all natural” kibble. Which is, of course, also processed — it’s kibble!)

    The hidden costs of fresh produce are ignored by the “processed food is bad!” crowd. It’s January, and I’m in Minnesota. It’s been unseasonably warm, but there’s still not a lot growing up here. Traditionally, any plants eaten this time of year had been preserved. (With the exception of root crops, stored in a root cellar, and apples, which keep quite a long time if you can keep the skin intact.) Canned tomatoes. Canned fruit. Dried fruit. Dried veggies. Milled flour. Pickled everything, not just cucumbers. Sauerkraut. Meat would be preserved as well, perhaps salted, perhaps smoked, often dried. Lutefisk. ;-) Our ancestors survived on processed and preserved food for thousands of years. They had to. They would have died otherwise. It is only in the last few decades that we’ve had the technology and the global infrastructure to have fresh produce 365 days of the year. Honestly, people who complain about processing as a sign of modern decadence have no idea whatsoever.

  50. #50 Chris
    January 10, 2012

    I also have a hard time with the “processed food” is evil bit, especially from people who have no problem with tofu or miso. I had a laugh when some raw food proponent linked to her cite with recipes, and right there on the page were “raw food” recipes that included miso and tofu.

    I am not sure if she knew that both required a great deal of processing and cooking to turn soy beans into each product (one is very salty).

  51. #51 Mephistopheles O'Brien
    January 10, 2012

    “Processed food” is used these days as shorthand for food that is higher in various undesirable components (sodium, fat, sugar, etc.) and lower in other, more desirable components (e.g. fiber) than equivalent foods prepared fresh might. For instance, a can of hominy I happen to have in my pantry has 570mg of sodium per serving (about 1/4 of the can), or 24% of the recommended daily allowance. A can of “no salt added” whole kernel corn, on the other hand, has 10mg of sodium per serving. The issue is not the processing (or at least should not be); it’s making intelligent choices about how much of which foods to eat and encouraging producers and stores to have products with less salt, sugar, starch, and fat (and let us add it at the table).

  52. #52 Karl Withakay
    January 10, 2012

    Anna,

    Processed foods primer.

    Processed foods (foods that have been modified from their original form for consumption) includes any food that has been cooked, chopped, peeled, frozen, dried, pasteurized, homogenized, or supplemented, as well as those that have been canned, smoked, or otherwise preserved, etc.

    Bread made from whole grains is still a processed food.

  53. #53 TBruce
    January 10, 2012

    Don’t forget one of my pet peeves – “juicing”!

    What could be more natural and unprocessed than squeezing out and drinking the water and fructose, and tossing the fiber and complex carbohydrates?

  54. #54 Karl Withakay
    January 10, 2012

    Thanks TBruce,

    I forgot blending, juicing, mixing, etc! There’s a reason why those small kitchen appliances are called food processors.

  55. #55 Andreas Johansson
    January 10, 2012

    “Processed food” is used these days as shorthand for food that is higher in various undesirable components (sodium, fat, sugar, etc.) and lower in other, more desirable components (e.g. fiber) than equivalent foods prepared fresh might.

    It has to be possible to communicate that in a less confusing way. Calling that “processed” is actively misleading.

  56. #56 Calli Arcale
    January 10, 2012

    Andreas — I’d go so far as to call it lying, but most of the people who use the term in that sense really, genuinely have no idea what they’re talking about. At least, most of the one’s I’ve met. It’s sort of a vague bogeyman, associated with images of industrialization, “chemicals”, and the idea that the food thus produced is somehow counterfeit.

  57. #57 Mephistopheles O'Brien
    January 10, 2012

    Andreas,
    I agree with you. They’ve used a term as a shortcut. It takes time and energy to review food facts on every package you buy. If you take, say, corn in four degrees of processing (on the cob, frozen, canned, and fried into tortilla chips) then the degree of processing is a rough guide to the relative healthfulness of the product. But it doesn’t always follow – treating corn with lye, I’m told, makes it more digestible. The same is, of course, true for cooking.

  58. #58 Denice Walter
    January 10, 2012

    I think that the juicing/ raw food-fadists may have unusual ideas about nutrition -one of them being that plant materials contain a species of magical *elan vital* that will transfrom your chi or suchlike as well as using medicinal plant substances as a replacement for pharmaceuticals . There is an entire “green foods”( chlorophylll as chelator of toxins and heavy metals )school of thought that echoes these sentiments- “living foods” and “high vibrational foods” ( see Adams, today);

    An additional factor is that it’s hard to consume many calories if you subsist on raw foods and juices. The idiots I survey have interesting ideas about what percentage of adult body weight should be fat (*way* less than what SBM would estimate): I’ve heard that a female at 20% is well over the limit ( whereas she might actually be nearly low enough to disrupt cycles). The DSM V may include “Orthorexia” – over concern about “correct nutrition” – in the case of raw and juice, I wonder how far this is removed from more classical eating disorders.

  59. #59 lilady
    January 10, 2012

    I try to use local produce in season, but rely on frozen veggies…plain, no salt…at times for various recipes.

    One of the best purchases I ever made was the non-defrosting upright freezer that I purchased close to 40 years ago. That original freezer served me well and I readily replaced it 10 years ago. It is very efficient and I only have to manually defrost it every two years, usually in late April.

    Even when I was working, I managed to prepare large amounts of stews, soups and sauces for other meals. Now that I am retired, it has become our weekly pleasure to prepare meals in advance…hubby is always willing to peel, chop and shred and then do some of the clean up tasks.

    FWIW…I have never eaten a frozen fish stick or a commercial frozen dinner. Occasionally, I indulge in fish and chips at three favorite restaurants that are co-located in fishmonger shops. I like my fish fresh and they all use canola oil for deep frying.

    BTW…Big Government is responsible for the extensive ingredients list on all commercially packaged food items.

  60. #60 Chris
    January 10, 2012

    lilady:

    One of the best purchases I ever made was the non-defrosting upright freezer that I purchased close to 40 years ago.

    I have a thirty year old non-defrosting chest freezer. It contains the peeled and sliced apples from my yard, and a few bags of applesauce I made from some of those apples. Yes, they were processed, all I did was cut them up and cook them down. Then put them in the large size muffin tins to freeze, and them moved those into bags.

    If I have time this evening, I will be processing some of bunches of basil leftover from making pizza sauce this weekend. I am going to turn it into pesto using (wait for it) a food processor.

  61. #61 alison
    January 10, 2012

    Goodness me, I hadn’t thought about this before. I suppose this means that my breakfast smoothie (kiwifruit, banana, blueberries/raspberries/whatever’s in the garden, allbran & milk) must be teh ebil processed food as well! Who’da thunk it?

  62. #62 Narad
    January 10, 2012

    Are you kidding? I’ll bet dollars to donuts that All-Bran is extruded.

  63. #63 lilady
    January 10, 2012

    Yum, pesto made with pignoli nuts frozen whole in the deep freeze alongside chimichurra for grilled steaks…”processed” in the 2 cup Oskar purchased 35 years ago for preparing baby food.

    I always made homemade fruit “sauces” (apple, pear) for my babies…using teh ebil food processing methods.

  64. #64 Chris
    January 10, 2012

    Two great books: A history of the world in 6 glasses and An edible history of humanity.

    The first drink that humanity invented was beer, which is essentially liquid bread. First the processing included boiling which killed pathogens, and second it provided some nutrients. Of course it caused a wee bit of a buzz (though the early beers were really not very alcoholic).

  65. #65 Chris
    January 10, 2012

    lilady:

    I always made homemade fruit “sauces” (apple, pear) for my babies…using teh ebil food processing methods.

    So did I. It is how I learned pears go with broccoli. Being over enthusiastic I tried pureed broccoli on my son, the first time he turned his nose up to food (honestly, it smelled very bad). The next day I mixed it with pears and it was actually quite good. Pears also work with brussel sprouts and roasted root veggies.

    And yes, I have my pine nuts in the chest freezer, plus there are almonds, walnuts and pecans. OOoh, another really good pesto can be made with walnuts, oregano and parsley (the latter two grow like weeds here). I learned about it in The Herbfarm Cookbook.

    Though I’m not getting to the pesto tonight. I spent the day running around, and only managed to make a pear tart and getting the rest of the pears into the freezer. They were from my four-in-one tree, they did quite well being refrigerated since October. Pears are funny. They need to ripen off the tree for a while (time dependent on variety), and they start rotting from the core outward. I have cut into what was a beautiful firm pear, only to have all but the outer quarter inch rotted. This year, there were only four rotten pears out of dozens.

    I just took a bite out of the pear tart (store-bought puff pastry, almond paste made by daughter that was in the freezer, some cornstarch, a sprinkle of sugar, and topped with ground almonds that were also in the freezer with some dots of butter). It is very yummy.

    I did not use much sugar because the pears are very sweet. When I peeled and sliced apples and pears everything gets sticky. They are full of fructose!

  66. #66 lilady
    January 11, 2012

    “Of course it caused a wee bit of a buzz (though the early beers were really not very alcoholic).”

    But, the beer my grandfather made during prohibition, had a wicked “kick”…according to my mom. They got the yeast from the local bakery, but I’m not certain where they got the malt and hops.

  67. #67 Chris
    January 11, 2012

    Ooops, the html did not quite work with the book note:
    A history of the world in 6 glasses
    and
    An edible history of humanity

    There is also one is Catching Fire: How Cooking Made Us Human, which describes how processing food with heat made it easier to digest. The author tries to explain why the human digestive system is so much smaller than any other ape species.

  68. #68 anna
    January 11, 2012

    @lilady,alison, Chris-
    Yum- sounds like you’re all eating well-Delish!
    Using the term “Processed is misleading”.

  69. #69 Chris
    January 11, 2012

    anna:

    Using the term “Processed is misleading”.

    Then you must use a term that is better defined, or exactly explain what you mean.

    Often when I see someone using the term “processed” like you do, it reveals that you know little about food and how it is made. I expect you would be one of those who would be surprised that tofu started out as raw soy beans, or that miso requires lots of salt just to be created.

    Perhaps you are one who would gladly buy blue corn tortillas, but not know that to release certain nutrients it has to be alkaline treated (soaked with wood ash). Or that cassava root needs to be treated with lots of water soaking to remove cyanide, so that we can have safe tapioca pudding.

    Just by using the phrase “processed foods and beverages” you revealed that you do not have a clue. You have no idea how food is made edible, nor how it gets to your table.

    I am only couple of generations from those who had to provide their own food for an entire year. My parents made the mistake of getting acquainted and loving the creature that provided their relatives’ bacon, ham and sausages for a year. My father can describe how his grandfather made his peach orchard survive the Great Depression by actually removing most of the fruit his peach trees and creating huge pampered peaches that were sold a big premium to those who could afford it.

    Anna, have you ever preserved food? Do you know how sauerkraut is made, and why it was created? Or that it has versions all over this planet, like kimchee? Have you ever tried to keep food for any length of time without refrigeration? Do you know what that actually involves?

    Also, are you aware that those of us who actually cook can create those evil dishes from scratch that are actually worse in terms of fat and salt? I know how to make pasta Alfredo, and it involves lots of real butter, cheese and cream… which must be eaten in moderation. I also make very good and wicked breaded fish and chicken… to the point that baking the frozen version might be healthier (first dip in seasoned flour, then in egg that has some Tabasco sauce mixed in, then dip in ground up bread crumbs or panko, fry in butter and olive oil).

    By the way, yeast bread needs a balance of both sugar and salt. It is disaster if either one is skimped on. I know this from very sad experience (it was a pizza dough).

    Anna, I suggest you learn how to cook, and not just the basics (include canning, salting, creating stock, etc). That might help get rid of some of the myths you have created about food.

    Here are some books to help you:

    The Joy of Cooking (only those editions from before 1980! … especially the edition on how to deal with squirrels)

    On Food and Cooking by Harold McGee

    And despite what Calli Arcale said, lutefisk is quite tasty. Well, truthfully, it does not have much taste. It is kind of like jelled fish, the taste comes from the white sauce and allspice. But I actually like it. Which makes me, according to my father, a damn Norwegian. Uff da!

  70. #70 Chris
    January 11, 2012

    Grumble, grumble, grumble. I now have two comments in moderation. The last one deals with the fact that Anna does not know what food processing entails. Plus I reveal I like lutefisk. Really, I do!

  71. #71 Chris
    January 11, 2012

    Woot! My comments are out of moderation. This means that Orac is up past midnight. To which I say as someone two time zones west of him: go to bed!

  72. #72 lilady
    January 11, 2012

    “Here are some books to help you:

    The Joy of Cooking (only those editions from before 1980! … especially the edition on how to deal with squirrels)”

    My 1964 edition of the Joy of Cooking has recipes for rabbits and hares, squirrels, opossum, bear, raccoon, muskrat, woodchuck, beaver, beaver tail, peccary, wild boar and venison…not that I actually ever used these recipes. My “edition” has excellent pastry recipes that I have used for the past 45 years.

    I’ve had lutefisk and fiskeboller and cardamom flavored cookies prepared by my aunt for Christmas holidays.

    anna, other great “contemporary” cookbooks are the America’s Test Kitchen series, which actually delve into the “science” of food preparation and the “art” of cooking and baking.

    Also try looking up “mise en place” to learn how to develop a system of having chopped, sliced and diced ingredients at hand to caramelize veggies for sauces, soups and stews, so that you do not resort to “processed” chemical-infused flavorings

  73. #73 alison
    January 11, 2012

    An edible history of humanity sounds like another one for the pile of bedside reading. Thanks, Chris :-)

  74. #74 alison
    January 11, 2012

    An edible history of humanity – yum! Sounds like my kind of book, & another candidate for the pile of bedside reading. Thanks, Chris :-)

  75. #75 Calli Arcale
    January 11, 2012

    I gave a wink about lutefisk; I didn’t say it was *bad*. I’ve eaten it too. It varies widely. If prepared well, it retains the flakiness of the original whitefish (traditionally cod, but these days it is more likely to be pollock due to depletion of the North Atlantic cod stocks). If prepared badly, it’s goo. Sauce is important too. I originally had it with drawn butter, but then one year I got to have it with cream sauce, and that was a different experience altogether.

    My point was merely that it started out as a way of reconstituting preserved fish. We Scandinavian-Americans have ancestors who migrated from a heavily fish-oriented culture to the middle of North America, where fish are available, but not the cod that was such a staple of their diet. To preserve that taste of home, their only option was salted, dried cod. Now, eating salted, dried cod can break teeth, so you need some way of reconstituting it. Thus, lutefisk was invented, waaaay back when it was how you kept protein available in the winter, when the fjords were frozen and you couldn’t take your boats out into the sea to drop your nets. Oh, you could cut a hole and do some ice fishing, but you can’t get the same quantity that way. You might feed yourself, but you won’t feed a village that way.

    So I wasn’t knocking lutefisk; it’s an example of a food (albeit one about which many jokes are made) which is a) heavily processed, b) traditional, and c) vital to our ancestors’ survival.

    I love those traditional Scandinavian-American foods. Lefse is fantastic. (I’ve recently become hooked on lefse with hummus, which is sort of a cultural mishmash, but it’s fantastic!) Pickled herring are awesome. (I’ve heard it called “Scandinavian sushi”, and that’s not a bad description.) Julekage. This year, because I was doing a lot of travelling in December, I didn’t bake a kransekake — first time in years that I skipped it. Krumkake. Fattigman. Swedish meatballs and swedish sausage, preferably that sold at Ingebretson’s in Minneapolis. (Theirs really is better. I know folks like Ikea’s meatballs, but it frankly doesn’t come anywhere near Ingebretson’s.) Gjettost. I hated that when I was a kid, but I can’t get enough of it now; it’s a carmelized goat cheese. Jarlsberg. Havarti. Rommegrot. (Oh, rommegrot! You are so sinful, and so wonderful!) Rice pudding. Flatbrod. Lingonberries. *Cloudberries*. (Those are a taste of heaven, surely.) Luciakatter. I’ve made my own lefse (though didn’t this Christmas, for the same reason i didn’t make a kransekake — I did manage to get the luciakatter made, though). Much of this isn’t particularly healthy, but oh, it is good! I do believe in the occasional feast; you should try and make sure your regular meals are healthy, but a feast with family and/or friends is good for the soul.

  76. #76 Andreas Johansson
    January 11, 2012

    Gjettost. I hated that when I was a kid, but I can’t get enough of it now

    I’m the reverse; loved it as a kid, can’t stand the stuff now.

    (I do believe the Norwegian spelling is “Gjetost” BTW. On the right side of the Keel, we call it mesost.)

  77. #77 Chris
    January 11, 2012

    Calli Arcale:

    Gjettost. I hated that when I was a kid, but I can’t get enough of it now; it’s a carmelized goat cheese.

    I’ve made it. After making some homemade ricotta cheese (using white vinegar instead of rennet), I simmered down the whey. What remains is gjetost.

  78. #78 LW
    January 11, 2012

    “An edible history of humanity”

    By the authors of “To Serve Man”!

  79. #79 Calli Arcale
    January 11, 2012

    Sorry about the typo; yeah, I’ve only ever seen it spelled gjetost.

    My dad made some last year. It was fabulous! I’ve tried making cheese before, but have not been successful; I decided some years ago to leave it to the experts. ;-)

  80. #80 anna
    January 11, 2012

    @alison-lilady-
    Good grief, I know how to cook-My grandfather made wine, my mother canned
    delish fruits and vegs. I make a great pesto, low fat shepherd’s pie etc etc etc-
    I hate tofu.
    Will never post again. Write a cookbook.

  81. #81 Chris
    January 11, 2012

    Well, anna, that is what you get with your preaching using such a broad term as “processed.” Next time, try being a bit more clear, and it helps if you actually back up what you say with evidence.

  82. #82 anna
    January 11, 2012

    @lilady,@alison-
    Also my uncle owned a 70 acre farm-raised all their own vegetables -slaughtered their own chickens and beef. I loved picking blueberries from their bush, ate too many
    plums while picking them, loved eating fresh pears and apples etc.

  83. #83 lilady
    January 11, 2012

    @ anna: You came here with “your” first post (#25), which was lifted in its entirety from a self-styled whistle blower…Crystal Cox.

    Your second post (#27), was a screed directed at physicians describing “your” experience and your disgust and distrust of doctors, as well as their incompetence.

    You do realize, don’t you, that Orac is a breast cancer surgeon and the director of a breast cancer research center?

    Many of the posters on this blogs are doctors, nurses, scientists, researchers, college professors who teach the sciences and other well-educated-in-the-science people.

    Speaking for myself, I was given you a “taste” of your own medicine and dishing out your “just desserts”.

  84. #84 DLC
    January 13, 2012

    I caught the old “Dr Kildare” movies from the 30s. They’re weird watching the old outdated movie medicine compared with modern day medical dramas. In one, Brave Maverick Dr Kildare uses “unproven insulin shock therapy” on a patient. . . In another one, cranky curmudgeon Dr Gillespie (the “Dr House” of his day? ) tells one married couple that they’ll stop having marital problems as soon as the wife gets pregnant.
    Yes, that was his prescription. “Go get pregnant and have babies !”

  85. #85 anna
    January 13, 2012

    @DLC-
    Better yet are the doctors advertising different cigarette brands (from the 50′s).
    http://www.nytimes.com/2008/10/07/business/media/07adco.html

  86. #86 anna
    January 13, 2012

    @DLC
    My post on doctors advertising cigarettes in the 50′s is in moderation. Great link!
    Even said which brand was least irritating to the throat!

  87. #87 alison
    January 14, 2012

    um, Anna, I don’t recall giving you any cooking advice :-) But I’ve had a great time reading everyone else’s recipes!

  88. #88 herr doktor bimler
    January 14, 2012

    My post on doctors advertising cigarettes in the 50′s is in moderation.

    I hate to be the bearer of disillusioning news, but advertising agencies in the 1950s often hired *actors*, to *pretend* to be doctors. Sometimes those agencies even made up false claims for the products, like “9 out of 10 doctors prefering Brand X”! So the appearance of someone wearing a white coat and a stethoscope in a 1950s advertisement does not mean that they were actually doctors.

    Also, not everyone with a white beard and a red costume is really Santa Claus.

  89. #89 Chris
    January 14, 2012

    herr dokter bimler:

    hate to be the bearer of disillusioning news, but advertising agencies in the 1950s often hired *actors*, to *pretend* to be doctors.

    Which is clearly pointed out in the article that Anna linked to. Here some quotes:

    “The very best artists and copywriters that money could buy” would work on cigarette accounts, said Dr. Jackler, who is also chairman of the department of otolaryngology, head and neck surgery.

    and Dr. Jackler further says:

    “This era of over-the-top hucksterism went on for decades,” he added, “and it was all blatantly false.”

    Further down the article:

    “Some of the claims being made in the ads, you did not have to be a scientist in a laboratory to dispute,” Ms. McDonough said, citing ads that smoking certain brands “does not cause bad breath” or “can never stain your teeth.”

    Radio Seti, now “Big Picture Science” interviewed Dr. Jackler about the exhibit in Skeptical Sunday: I’ll Buy That!. He becomes visibly shaken when he talks how the advertisers blatantly lied, and his mother dying from lung cancer.

    I made a longer comment on this on March 1, 2011 8:11 PM in the article Orac posted on February 28, 2011 titled “Naturopathy versus science.” Go check it out, Anna. Perhaps in the future you might check if a canard you invoked has already been addressed by using the handy dandy search box in the upper left hand part of this page. It might save us a bunch of time.

  90. #90 Chris
    January 14, 2012

    Ugh, stupid moderation. I noted that Anna did not even read the NY Times article, which actually said what herr doktor bimler said: they were lying.

    If Anna had bothered to check on the doctor and tobacco ad myth using the handy dandy search box on the top of this page she would have found where I addressed that myth on March 1, 2011 at 8:11 PM, on the article called “Naturopathy versus science” posted on February 28, 2011 3:00 AM, by Orac.

  91. #91 anna
    January 14, 2012

    @Chris,Herr D-
    Obviously-just commenting on the “Zeitgeist” of the times. I guess you need to constantly misinterpret other people to feel your “Mensa” qualifications.

  92. #92 Chris
    January 14, 2012

    Again, do try to be more clear on what you write. You said “Better yet are the doctors advertising different cigarette brands”, when the article clearly said those were not doctors, but falsehoods created by the by the add companies.

    Um, that was not the “Zeitgeist” of the times, that was advertizing companies lying. That has not changed in sixty years, they still lie.

  93. #93 Narad
    January 14, 2012

    Obviously-just commenting on the “Zeitgeist” of the times.

    Zeitgeist, eh? Tell me, when did Jack LaLanne start appearing on television?

  94. #94 anna
    January 14, 2012

    @Chris-not about cigarettes.
    The post was not addressed to you- do you always butt in on posts?

  95. #95 Chris
    January 14, 2012

    Because you are not using email, but are posting on a blog that allows comments.

  96. #96 Travis
    January 14, 2012

    Anna, you should probably learn about how blogs work. Anyone can comment on the statements you make. You can address them to certain people, but anyone can comment on what is written by anyone else. That is a feature and not a flaw.

  97. #97 Krebiozen
    January 14, 2012

    I’m never quite exactly sure what people like Anna are trying to say. There is plenty of good information on a healthy diet and lifestyle available, and there has been for decades. Why is it somehow the medical professions fault that so many people are unable to resist the unhealthy foods marketed by multinational companies? It is doctors who have to try to patch up the damage done.

    I worked for years with a doctor who spent a large portion of her time running a lipid clinic, giving diet and lifestyle advice that people largely ignored and seeing her patients end up in the coronary care unit with angina or a heart attack. I don’t know what else she could have done, apart from warning her patients what the likely consequences of their actions would be. Was she supposed to follow them home or to the supermarket?

  98. #98 lilady
    January 14, 2012

    Anna: You were the one who first came on this post, with your flamethrower remarks…about processed food and the incompetence of doctors to provide patients with preventive information about diet. “Your” remark (#25) wasn’t even your own original posting…it was unattributed copy pasta.

    You then proceeded to discuss “in your experience” how incompetent physicians are to educate their patients in preventive lifestyle choices. It also seems that you equate television advertisements as the sum total of information about healthy lifestyle choices.

    Stop watching television anna, stop visiting “nutritionist’s” websites and think about going to a reliable website for starters, such as the American Dietetic Association website. By simply registering at the adajournal.org website, you can have access to their abstracted articles and some of their full-length articles on diet.

  99. #99 herr doktor bimler
    January 15, 2012

    I seem to recall that there are some Dorothy Sayers readers out there, who are probably reminded of “Murder Must Advertise” every time someone pops up about “doctors advertising different cigarette brands”.

  100. #100 alison
    January 15, 2012

    Ah, yes, “whiffle your way around England”. I had a real thing for Lord Peter Wimsey when I was younger :-)

  101. #101 Marry Me, Mindy
    January 16, 2012

    Recall that the “doctors don’t care about nutrition” accusation. Idoes not really mean that doctors don’t care about nutrition, but that doctors aren’t doing things like recommending a buttload (sometimes literally) of worthless supplements. Oh no, doctors aere only recommending diets low in fat and sugar with moderation in portions and lots of fruits and veggies. Those ignorant bastards! Don’t they know you should be taking 50 supplement pills?

  102. #102 Chris
    January 24, 2012

    Orac:

    A couple of years after I had bought the car, a new channel was added to the lineup, a channel called Radio Classics. I don’t know how I discovered it, but I rapidly became hooked on what’s commonly referred to as old time radio.

    When I was in college I used to listen to the CBS radio station’s “Mystery Theater” while writing reports. I love radio plays, and usually listen here:
    http://jimfrenchproductions.com

    I believe there are others around, but I happen to like Sherlock Holmes and they have one about once or twice a month.

  103. #103 Witch
    March 6, 2012

    The placebo effect is alive and well, as is discussed in the article below (excerpt):

    The fact that an increasing number of medications are unable to beat sugar pills has thrown the industry into crisis. The stakes could hardly be higher. In today’s economy, the fate of a long-established company can hang on the outcome of a handful of tests.
    Why are inert pills suddenly overwhelming promising new drugs and established medicines alike? The reasons are only just beginning to be understood. A network of independent researchers is doggedly uncovering the inner workings—and potential therapeutic applications—of the placebo effect. At the same time, drugmakers are realizing they need to fully understand the mechanisms behind it so they can design trials that differentiate more clearly between the beneficial effects of their products and the body’s innate ability to heal itself. A special task force of the Foundation for the National Institutes of Health is seeking to stem the crisis by quietly undertaking one of the most ambitious data-sharing efforts in the history of the drug industry. After decades in the jungles of fringe science, the placebo effect has become the elephant in the boardroom.

    http://www.wired.com/medtech/drugs/magazine/17-09/ff_placebo_effect?currentPage=all

  104. #104 Antaeus Feldspar
    March 6, 2012

    Unfortunately, necromancing spam is also alive and well, as Witch keeps demonstrating.