Terra Sigillata

Yesterday, the real-life mailbox brought the Pharmboy household the Fall 2009 issue of DukeMedicine connect, a biannual publication on current news from the Duke University Health System. Produced by DUHS Marketing and Creative Services, it “strives to offer current news about health topics of interest” to its readers. This issue is not yet online but you can see the Spring 2009 issue here.

What caught my eye was a cover teaser titled “Detox Delusion” and an article on detoxification diets focusing on an interview with Beth Reardon a nutritionist with Duke Integrative Medicine.

(Note added 17 Nov 2009 – the article is now available online here. The author is June Spence, a freelance writer, author, and blogger at Unshelved)

The article focuses on the fallacy of detoxification diets, extreme and sometimes dangerous regimens of purges, enemas, supplements, herbs, with the misguided goal of clearing one’s body of “toxins.” These amorphous toxins are never named, much less denoted with an IUPAC chemical name, but prey upon the fears of our “chemical” environment.

The article refers to the current “Master Cleanse” craze, known also as the Lemon Cleanse or Maple Syrup Diet. Not mentioned in the article is that the diet was developed in 1941 by an unlicensed practitioner named Stanley Burroughs and popularized most recently in the 2005 Peter Glickman book, Lose Weight, Have More Energy and Be Happier in 10 Days and his MasterCleanse/Raw Food website.

So, I was very pleased to see this:

The evidence supporting detox diets is slim to none, but they’re often touted as holistic and popularized by celebrities small and smaller. Scores of slender starlets can’t be wrong – can they?

Beth Reardon, MS, RD, nutritionist for Duke Integrative Medicine, gives us the skinny on a recurring diet craze:

It’s not merely the lure of plummeting pounds that draws people to detox diets. There’s powerful appeal in the promise that these diets will cleanse our body of toxins, observes Reardon. “We are bombarded by our food supply, what’s in it, what’s not. We hear about additivies, preservatives, dioxins, carcinogens; we see horrific pictures on the Internet of something that supposedly came out of a colon; and we’re just overwhelmed. The fear factor is pretty convincing. People are grasping to do what makes sense, and the notion of detoxifying the body sounds right. But there just isn’t good science behind detox diets.

Fear. The propagation of fear – fear of the unknown or fear propagated by faulty risk/benefit considerations – drives much of the market for these approaches. Fear also even drives other areas of pseudoscience and denialism

From the article, again:

Most detox diets are awash in fluids; the Master Cleanse’s liquid-only regimen includes, in addition to six to 12 eight-ounce daily servings of lemon drink, a quart of water with added sea salt – the “saltwater flush” – as well as herbal laxative teas to combat the constipation that can result from the lack of food intake. Reardon warns that overuse of these electrolyte mixes or laxatives can “disturb our natural balance, causing dehydration, nausea, cramps, dizziness. And excessive fluid intake can lead to hyponatremia: low sodium in the blood.” She says that people who are taking medication for their heart or to regulate blood sugar are at great risk for this serious complication.

BINGO! We are often critical of so-called alternative or integrative medicine programs at our most-revered academic medical centers, but this may be where such centers are truly legitimate: by bringing in patients who want to use alternative approaches but who are protected from doing so by people trained and licensed in science-based medicine and allied health professions.

Here’s how I think about it, without being privy to any of the discussions at such institutions: large health systems like Duke’s pay a collective price if one of their heart disease or diabetes patients suffers complications from use of alternative practices like Master Cleanse, as alluded to in the last sentence of the above quote. By having an “integrative medicine” arm, these patients are attracted by the philosophy in such centers but then receive proper medical treatment. With Ms Reardon, diabetic patients who wish to lose weight will then be counseled and prescribed a dietary regimen that won’t complicate their disease.

Of course, I’m not giving carte blanche to all integrative medicine centers – Duke’s center was endowed by a reiki master – a very wealthy reiki master – and continues to offer other unsupported practices such as acupuncture. There are many more examples of where such organizations are buying into practices not supported by science – Orac keeps a nice list entitled, “The Academic Woo Aggregator.”

However, I’m seeing that major health systems have realized that integrative medicine programs supported by science-based medicine can mitigate patient risk and improve health by intervening with healthy practices under the rubric of something perceived as alternative.

Finally, here is where Reardon closes the deal in garnering my utmost respect: she points out how we have evolved Phase I (e.g., cytochrome P450 monooxygenases) and Phase II (e.g., UDP-glucuronyltransferases) xenobiotic-metabolizing enzymes as our body’s natural detoxification mechanisms:

Finally, says Reardon, you just don’t need to go to extremes to cleanse your body of toxins. “Give your body more credit. We have evolved over two-and-a-half million years with highly effective detoxification systems – such as the liver and the kidney. We naturally detox most substances that could be harmful. Our bodies are designed to do this – if we give them proper food and hydration and don’t stress out our systems by eating a diet that includes a disproportionate amount of processed foods.”

In fact, Reardon’s suggestion of a plant-based, whole-foods diet means that one will be exposed to naturally-occurring chemicals known to induce the activity of some Phase II detoxification enzymes.

Once the Fall 2009 issue of DukeMedicine connect is online, I’ll put up a link so you can read more.

Disclosure: For eight months in 2001, the author drew 50% of his salary from the organizational precursor to Duke Integrative Medicine as a dietary supplement educator and consultant.

Comments

  1. #1 disgusted
    November 8, 2009

    You are nothing but a shill for BigPlacebo – taking money from this industry that cares only about profits and deception of patients under a psoition of trust from well-known universities.

    I’ll tell you why integrative medicine really exists – did you see today’s L.A> Times?

    They spent about $33.9 billion on these practices in 2007, accounting for about 11.2% of the public’s total out-of-pocket health expenditures. In 1997, the last time such a survey was taken, the figure was $27 billion.

    “Whatever this amount of the population is doing is no longer fringe,” says Dr. Tracy Gaudet, executive director of Duke Integrative Medicine, part of the Duke University Health System. “We have to figure out what they are looking for that they can’t find in conventional medicine.”

    Integrative medicine doesn’t even have to bother with insurance! Don’t be so naive!!!

  2. #2 stewart
    November 8, 2009

    I’m glad that there are some oases of sanity. Popular things can kill, after all. True integrative medicine should be evidence-based and not rely on a charismatic guru. Behavioral health, nutrition, and warning people why fads are dangerous all seem to be good parts of this.

  3. #3 anon
    November 8, 2009

    Thank you for an excellent post!

    The guy calling you a pharma shill makes me laugh…Disgusted, are you a shill for “master cleanse.”

  4. #4 becca
    November 8, 2009

    Yep, nothing like the UGTs to detoxify stuff. Like morphine. Oh wait. Did our bodies not evolve with morphine?

  5. #5 David Estlund
    November 8, 2009

    Thanks for a great article. Comment #1 is amazing. People with views like that just make me think of the movie The Road to Wellville. “All it takes is a few gallons of yogurt up the tokhes and you’ll be right as rain. Oh and a few dozen other forms of torture that have never been proven to do anything at all. But we’ve got testimonials!”

  6. #6 Abel Pharmboy
    November 8, 2009

    Actually, if I understand comment #1 correctly, “disgusted” is charging me with being an altmed apologist, not a pharma shill. I think their point is that altmed draws in a lot of cash. Am I reading this properly?

    I loves me some Sunday afternoon @becca smack. shoulda known you’d catch me on glucuronidation – yes, morphine-6-glucuronide is several hundred-fold more potent than the parent drug but that is by far the exception. The predominant role of UGTs is, of course, to conjugate aromatic hydroxyls of plant compounds, steroids, bilirubin, bile acids, and Phase I-generated hydroxyls. Yes, it may increase the potency of selected drugs like morphine or prolong the action of some steroids (e.g. oral contraceptives) via enterohepatic recirculation. Remember also that glucuronide conjugates can be actively secreted into the renal filtrate/developing urine in the distal tubule (i.e., against a concentration gradient), making it a more efficient process for renal excretion via glomerular filtration. So, by and large, wouldn’t you agree that glucuronidation is vastly more important as a detoxification mechanism?

  7. #7 David Estlund
    November 8, 2009

    Oh wow, you’re totally right about #1. Amazing how misreading
    “BigPlacebo” as “BigPharma” can change the whole tone of the comment. It can also make it seem a lot crazier. Apologies to “disgusted.”

  8. #8 anon
    November 8, 2009

    ah,you’re righ…I misread it– Im so used to the Big Pharma conspiracy theorists rants!!

  9. #9 Ian Musgrave
    November 8, 2009

    Becca wrote:

    Did our bodies not evolve with morphine?

    No, not really, the plant from which the modern morphine containg opium poppy was cultivated from is restricted to the shores of the Mediterranean, modern Humans didn’t enter the Mediterranean until between 100,000 and 50,000 years ago, so there would have been very little co-evolution with morphine per se.

    However, morphine is a particular example of a broad chemical class of compounds called alkaloids, many of which are toxic (eg solanine, harmaline, ergotmine etc. etc.). It has been estimated that around 15% of the plant materials chimpanzees eat have potentially toxic alkaloids in them, and the human (primate/vertebrate) body has evolved a wide variety of enzymes to detoxify them. The UDP-glucuronosyltransferases evolved as broad specificity detoxification enzymes. Their ability to detoxify a wide variety of natural alkaloids means that alkaloid-like chemicals that the body has not come into contact with before can be acted on (like morphine some 100-50,000 years ago, modern pharmaceuticals like zidovudine within the past decade).

    Of course, while these enzymes have evolved to detoxify chemicals (mostly by increasing their water solubility so they can be rapidly excreted), occasionally due to quirks of chemistry the glucuronide can be more active than the parent (digoxin and midizolam are other examples where the glucuronide is more potent than the parent).

  10. #10 Joseph j7uy5j
    November 8, 2009

    She says that people who are taking medication for their heart or to regulate blood sugar are at great risk for this serious complication.

    I would like to add that radically altering your salt-water balance can cause problems for those taking lithium, as well. This is something that is so obvious to doctors, that they may fail to mention it to their patients.

  11. #11 Jordan
    November 10, 2009

    I love the point from this article: STAY AWAY FROM PROCESSED FOODS. Great point. I’ve been a lifestyle educator for three years and try my best to instill those values. Either way, I still believe everyone would benefit from a detox (there’s toxins even in the air we breath, afterall). Here’s a site that explains why we should detox and how to adapt your detox so that its right for you: http://www.nut-dyntv.com

  12. #12 foodsmarty
    November 10, 2009

    Although you have a point about the body’s innate enzyme detoxification system, this system can be overloaded. That is the amount of toxic load entering the body can exceed the enzymatic capacity of body. This can perhaps be more likely to occur in individuals with genetically lower concentrations of Phase 1 and II enzymes. I personally became very ill after prolonged exposure to formaldehyde in medical school. Western Medicine did not have an answer to why I felt ill on a daily basis. After detoxification, by less radical measures than a 10 day fast, I am gradually returning to normal. But even now, I am liable to become ill for days if I consume to large of an amount of non-organic food. If people did not have great improvements in health by alternative medicine, especially by being frustrated by western medicine, this “fads” would not exist.

  13. #13 Chemgeek
    November 17, 2009

    Jordan- Please, please, please identify the ‘toxins’ and representative concentrations you are referring to.

    foodsmarty- causation/correlation. look into it. Also, please describe your control experiments.