White Coat Underground

Plumbing the depth of quackery at HuffPo

One of the questions addressed in this space is, “what makes a particular condition susceptible to quackery?”  Some of the common features we’ve seen over time are:

  1. Diverse and protean symptoms: fatigue, “brain fog”, diffuse pain, and other vague symptoms are often used as diagnostic criteria for controversial entities such as morgellons and chronic Lyme disease.
  2. Lack of diagnostic certainty: there are no definitive tests to make the diagnosis of chronic Lyme disease or morgellons (or fibromyalgia for that matter) making objective diagnosis difficult. 
  3. Children affected: autism affects children (and of course their parents) and our natural desire to protect children makes us vulnerable.

There are a number of ways that quacks can churn out their product using just these three trends.  When a patient suffers from generalized fatigue or malaise but a good work up fails to reveal a specific problem, a real doctor will listen carefully and take a cautious wait-and-see approach.  A quack will rush into action, applying unproven treatments and even making up their own diseases. 

Making up a disease may sound easy but if you want people to really buy it, you need to follow a few principles.  You have to make it sound plausible to lay people, and you have to create the best kind of lie—the one based on a nidus of truth.

It helps if you have tests—everyone loves tests.  Diagnostic testing is a complex field.  Tests need to be validated in several different ways so that any test’s characteristics are well understood.  For example, if I want to use a hemoglobin A1C level to diagnose and follow diabetes, I need to know how results are distributed across the population of interest, I need to know how well the test itself technically works, and I need to know how well it works statistically.  Without this information, the test result is meaningless.  Quacks get around this in a few different ways: they make up their own tests; they misinterpret tests by, for example, re-define the normal range in proven tests or giving a result meaning that it does not have; they send tests to labs with less “stringent” quality controls; they use tests that have not been proven to show what they claim.

All this is by way of introduction to another crappy piece in the Huffington Post.  The piece, “Why Lead Poisoning May Be Causing Your Health Problems,” is by Mark Hyman, a doctor and non-toxicologist.  The title seems to imply that lead poisoning is common and causes just about everything.  Hyman claims that “[n]early 40 percent of us have toxic levels of lead in our bodies.”  If this is true, this is potentially one of the greatest public health problems we have ever faced.   

Lead exposure affects children and adults unequally.  The reason so much effort is focused on young children and lead is that lead has a devastating affect on a growing, developing child.   Lead intoxication in kids leads to all sorts of serious problems including anemia and abnormal cognitive development.  Although childhood lead levels in the U.S. are declining, there is still reason to be concerned. In the last reporting period (1999-2004)  about 1.4% of American children had lead levels above 10 mcg/dL, the level usually considered problematic.  Recent research is giving us reason to be less sanguine about lower lead levels as well (see references). Even blood levels below 7.5 mcg/dL are correlated with decreased intellectual function, although the data are a bit murky. 

In adults, the effects are less clear.  Leaving aside occupational lead exposures, there is some evidence that environmental lead exposures cause cognitive problems in adults and may also contribute to hypertension and other common problems, but it’s hard to draw conclusions about causation.  Differentiating chronic and acute lead exposure and its effects is a significant problem in adults.  States are responsible for collecting data and use different cut-offs but according to the data that are available (2005), the average rate of elevated blood lead levels in U.S. adults is about 8.7/100,000.  To get a more complete picture, we would have to use other measurements for adults in addition to blood.  But even a worst-case scenario of adults plus children brings us nowhere near the 40% figure cited by asserted by Hyman. 

While Hyman’s alarmist statistics may not be anywhere near accurate, one of his basic premises is: lead is dangerous to children and too adults, even at levels lower than traditionally measured.  After that, he flies right off the rails.

He describes very much overplays the state of the research into adult lead toxicity.  It appears to be correlated with a number of common health problems, but that’s where it ends for now.  There is not yet convincing data to show a strong causal relationship between low lead levels and common health problems.  The data is certainly concerning enough to continue reducing human lead exposure, but beyond that, things are murky.  For some reason, after describing the potential damage caused by lead exposure he states seemingly out of nowhere:

Wow! Take a moment to digest that. Chelation therapy saves lives and billions of dollars. But your doctor probably isn’t offering this as standard treatment, because, as I have said many times, doctors don’t learn two of the most important things in medical school: How to help people improve their nutrition and how to deal with environmental toxins.

Chelation for lead poisoning is indicated only when lead levels are very high.  At lower levels, avoiding the source of the lead is the treatment of choice.  There is no evidence that chelating adults or children with low lead levels leads to positive outcomes.  With avoidance alone, children with elevated lead levels get better.  There is no evidence that, as Hyman enthusiastically suggests, chelation “saves lives and billions of dollars.”  I’m also not sure what his medical education was like, but we certainly learned about nutrition and environmental toxins.  What I learned, however, was based on actual evidence.

Hyman then gives six tips to “getting the lead out” which are also curiously devoid of evidence.  While I won’t torture you with all of them, I do suggest you read it for the giggle-inducing shoe suggestion.  His first suggestion is the worst of them.  He recommends to be screened for lead toxicity through chelation-provoked testing.  The American College of Medical Toxicology specifically recommends against this practice:

It is…the position of the American College of Medical Toxicology that post-challenge urinary metal testing has not been scientifically validated, has no demonstrated benefit, and may be harmful when applied in the assessment and treatment of patients in whom there is concern for metal poisoning.

Hyman has done a good job of using a kernel of truth around which crystalize  and entire diagnostic and treatment fiction.  He encourages people with vague symptoms to undergo unproven medical tests and to then subject themselves to potentially dangerous treatments.  He should be ashamed.

But of course, he has no shame.

References:

Jusko, T., Henderson, C., Lanphear, B., Cory-Slechta, D., Parsons, P., & Canfield, R. (2007). Blood Lead Concentrations Environmental Health Perspectives, 116 (2), 243-248 DOI: 10.1289/ehp.10424

Lanphear BP, Hornung R, Khoury J, Yolton K, Baghurst P, Bellinger DC, Canfield RL, Dietrich KN, Bornschein R, Greene T, Rothenberg SJ, Needleman HL, Schnaas L, Wasserman G, Graziano J, & Roberts R (2005). Low-level environmental lead exposure and children’s intellectual function: an international pooled analysis. Environmental health perspectives, 113 (7), 894-9 PMID: 16002379

Hu, H., Shih, R., Rothenberg, S., & Schwartz, B. (2006). The Epidemiology of Lead Toxicity in Adults: Measuring Dose and Consideration of Other Methodologic Issues Environmental Health Perspectives, 115 (3), 455-462 DOI: 10.1289/ehp.9783

Shih, R., Glass, T., Bandeen-Roche, K., Carlson, M., Bolla, K., Todd, A., & Schwartz, B. (2006). Environmental lead exposure and cognitive function in community-dwelling older adults Neurology, 67 (9), 1556-1562 DOI: 10.1212/01.wnl.0000239836.26142.c5

Liu X, Dietrich KN, Radcliffe J, Ragan NB, Rhoads GG, & Rogan WJ (2002). Do children with falling blood lead levels have improved cognition? Pediatrics, 110 (4), 787-91 PMID: 12359796

Comments

  1. #1 Adam_Y
    June 14, 2010

    If I’m not mistaken aren’t the tests he recommending the same ones criticized in the Chicago Tribune (In an autism article) as having no real baseline which means that the tests will probably always read positive. Also, if I am not mistaken didn’t the NIH also stop a chetelation trial after evidence surfaced that chetelation without any overt cause causes may lead to cognitive problems?

  2. #2 Donna B.
    June 14, 2010

    Your post title is awesome!

    You may have typed “low” when you meant “high” in two places. Or maybe my reading comprehension is worse than usual.

  3. #3 KWombles
    June 14, 2010

    What is really frightening is the idea that Huff Post’s medical editor approves this crap.

  4. #4 T. Bruce McNeely
    June 14, 2010

    So Canadians should have a lower incidence of lead poisoning:

    http://www.howtospotacanadian.ca/2009/01/they-take-their-shoes-off-indoors.html

  5. #5 G
    June 14, 2010

    Why is it giggle inducing to suggest taking shoes off inside?

  6. #6 Marcia
    June 14, 2010

    A new study finds a NON Inherited genetic source for a minority but growing percentage of children having been diagnosed with Autism. This likelihood is already explained in a recent book based on Systems Theory rather than statistical study. The book is called Xzenobia. (available USA Amazon) At the end it also predicts that autism incidence will rise slowly but exponentially as a result which is what we are seeing.
    Xzenobia surmises that this learning preference is a net result of standard human progression during high survival times such as humans enjoy now and is not restricted to Autism but includes various forms of learning and cognition such as Dyslexia.

    The book is elegant and positive thinking as well as practical. Written for regular fathers to encourage them to act early but totally brilliant and touches on a lot of subjects germane to learning disabilities which is not commonly found else ware.
    Worth a look-see. You will get a new view and also a perspective of the medical profession you may not expect.

  7. #7 PalMD
    June 14, 2010

    @DonnaB

    My only editor is me…and attentive readers. I’m checking now.

  8. #8 PalMD
    June 14, 2010

    Ah…yes. “Low” means lower than the traditional cutoff. The usual cutoff for “high” lead levels is 10mcg/dL. More recent studies have found correlations between even lower lead levels and harm (IOW, there is no real “normal” lead level, so “low” means “low but still abnormally high”).

  9. #9 Anonymous_Psych
    June 14, 2010

    >Diverse and protean symptoms: fatigue, “brain fog”, diffuse pain, and other vague >symptoms are often used as diagnostic criteria for controversial entities such as >morgellons and chronic Lyme disease.

    You’ve just described every psychiatric diagnosis.

  10. #10 Pascale
    June 14, 2010

    Reading HuffPo health stories induces brain fog for me… So is HuffPo the ultimate cause of chronic lyme disease?

  11. #11 PalMD
    June 14, 2010

    No, but hyperemesis is still up for grabs.

  12. #12 Donna B.
    June 14, 2010

    “so “low” means “low but still abnormally high”

    Okay, that makes sense, but it sort of worries me that it does :-)

    Against my better judgement, I read some of the comments at Huffpo… and they are way more scary than the original post.

  13. #13 Logan
    June 15, 2010

    I appreciate what you’re saying, but are there alternative tests you’d recommend? I agree on the general state of HuffPo’s “medical” articles; but while you admit there are risks to lead/heavy metal toxicity, you offer no alternatives. Perhaps you could point in the direction of a non “quack” article with more reliable suggestions? Thanks.

  14. #14 PillowCaseLaw
    June 15, 2010

    Regular blood tests should work just fine, Logan.

  15. #15 PalMD
    June 15, 2010

    “Screening” and “diagnostic” tests are two different things. Kids are screened regularly with blood tests. Screening is not recommended for low risk adults AFAIK. The most important thing aside from childhood screening is minimizing environmental and occupational exposures.

  16. #16 Vicki
    June 15, 2010

    Not directly related, but just before coming over to this blog today, I read an article on a real, serious cluster of lead poisoning cases. Serious as in over a hundred deaths.

    The cause is gold mining in which men working in the mines bring the ore home, where their wives process it. This produces very high levels of lead in the home and in the village soil.

    I just hope people don’t react to this with “oh, god, see, lead is horribly dangerous!” without recognizing the orders-of-magnitude difference in the exposure levels there and the levels we’re mostly concerned about in the U.S.

  17. #17 Dangerous Bacon
    June 15, 2010

    “I just hope people don’t react to this with “oh, god, see, lead is horribly dangerous!” without recognizing the orders-of-magnitude difference in the exposure levels there and the levels we’re mostly concerned about in the U.S.”

    That would require knowledge of what a “toxin” actually is, and the realization that “the dose makes the poison”.

    It’s a lot simpler (especially for practitioners who take advantage of public fears about chemicals and contaminants) to raise alarms about “toxins” independent of dose.

    For anyone who recommends chelation, supplements or other therapy to “flush out” “toxins”, there are several key points they need to address:

    1) Does the substance they warn you about actually have toxic properties in mammalian systems?
    2) At what dose is it toxic, and are you likely to encounter that dose in everyday living?
    3) Does the “toxin” cause defined signs/symptoms that can be objectively appraised/tested for?
    4) What’s the evidence that their treatment/product removes the “toxin’ in question?
    5) If so, what’s the evidence of clinical improvement with the treatment/product?
    6) What are the hazards/side effects of using the treatment/product?

    It is rare to the point of non-existent for promoters of “toxin” removal to address these questions.

  18. #18 PalMD
    June 16, 2010

    I apologize. There was a comment above by “E” that I have unpublished. As much as I may question the content of Dr Hyman’s piece, I am a bit wary of allowing a comment that makes assertions that are not clearly supported by external data.

  19. #19 E
    June 16, 2010

    Understandable. Obviously, this person has a closer familiarity to me. I’ve being coming across items by and about him for a period of time now. As well as hearing the personal accounts of those who’ve had dealings with him. But I have not always cataloged all those references and should I find time I will repost my comment with such. On the other hand, since he’s a rather transparent personality the subjects I touched upon either are or probably will become evident to all one way or the other.

  20. #20 Militant Agnostic
    June 16, 2010

    Plumbing the depth of quackery at HuffPo

    I see what you did there (if it was intentional).

  21. #21 Mike
    June 17, 2010

    PalMD,

    Martin McKee wrote a paper Titled “Denialism: what is it and how should scientists respond?” In this paper she references David Michaels from his book “Doubt is their product: how industry’s asssult on science threatens your health.” Below are two quotes from David Michael’s book that Martin Mckee referenced in his or her paper about denialism.

    The first quote implies that we should question the pharmaceutical industry and the medicines/drugs/vaccines that they try to sell us. Is he an alarmist/quack/denialist and is this bad advice?

    The second quote suggests that the science and policies regarding lead have been manipulated in the favor of the lead industry. Now is David Michaels an alarmist/quack/denialist since his book contadicts what you have said about lead or are you an alarmist/quack/denialist? I am so confused and I don’t know who to listen to anymore because if you are right and David Michaels is wrong, that means that Martin Mckee wrote a paper about denialism and referenced a denialist to help support his or her arguement which makes matters even more confusing when it comes to knowing who to believe. Would you be able to help me sort things out and clarify this for me so I can better understand who to believe and what information is accurate?

    First quote by David Michaels from Doubt is their product.
    “The power of companies to influence and distort research
    is also strong in the pharmaceutical industry.”

    Second quote by David Michaels from Doubt is their product.
    “Industry groups have tried to manipulate science no matter which political party controls the government, but the efforts have grown more brazen since George W. Bush became
    president. I believe it is fair to say that never in our history have corporate interests been as successful as they are today in shaping science policies to their desires. In 2002, for example, the Bush administration remade a committee that advises the CDC on the issue of childhood lead poisoning. Secretary of Health and Human Services Tommy Thompson replaced prominent researchers with individuals more likely to side with the lead industry. (One new member had testified on behalf of the lead paint industry in a suit brought by the state of Rhode Island to
    recover the costs of treating children with lead poisoning and cleaning contaminated homes.) Since then, the CDC has not moved to strengthen the federal standards for lead poisoning despite research showing that even very low levels of lead in the blood can sharply reduce a child’s IQ.”

  22. #22 Blah
    June 17, 2010

    Dude, this should totally answer your questions.

  23. #23 Mike
    June 17, 2010

    Blah,

    Are you trying to use an ad hominem strategy to discredit an opposing position by attacking its proponent? It really seems that way.

    From Wikipedia:
    Application of the term troll is highly subjective. Some readers may characterize a post as trolling, while others may regard the same post as a legitimate contribution to the discussion, even if controversial. The term is often used as an ad hominem strategy to discredit an opposing position by attacking its proponent.

  24. #24 PalMD
    June 17, 2010

    ck/denialist since his book contadicts what you have said about lead or are you an alarmist/quack/denialist? I am so confused and I don’t know who to listen to anymore because if you are right and David Michaels is wrong, that means that Martin Mckee wrote a paper about denialism and referenced a denialist to help support his or her arguement which makes matters even more confusing when it comes to knowing who to believe. Would you be able to help me sort things out and clarify this for me so I can better understand who to believe and what information is accurate?

    Ad hom is only a fallacy if it is untrue or irrelevant. The obvious fact that you are presenting yourself in a disingenuous way pretty much absolves Blah.

  25. #25 Mike
    June 17, 2010

    PalMD,

    Would you be able to please let me know what I wrote that is untrue and how I am presenting myself in a disingenuous way?

  26. #26 PalMD
    June 17, 2010

    I’ll try to make it simple, and give you a chance to restate your point, such as it is. Your comment, lengthy as it is, says nothing. It gives a few short quotes of quotes of quotes and even after several readings it’s hard for me to decipher exactly what point you are trying to make.

    If you are saying that science and medicine have been and can be influenced by politics and industry, you’ll find few who would argue against that. If you are saying that this invalidates all of science and medicine, you’ve lost most sane folks.

  27. #27 PalMD
    June 18, 2010

    You do realize that the above comment makes you sound a bit unstable, don’t you? You may wanna dial it back a bit. Just a friendly suggestion.

  28. #28 Isis the Scientist
    June 18, 2010

    Did that dude really just cite Wikipedia as an authority?

  29. #29 PalMD
    June 18, 2010

    Well, so did I, as an illustration of sorts, being too bored to explain what a concern troll is. But when i did it, it didn’t seem as lame.

  30. #30 PalMD
    June 18, 2010

    Dude, I’m trying to help you out here by deleting comments that make you sound totally fucking over the top nuts. I’ll do it once more as a favor but after that you’re on your own.

  31. #31 JP
    June 18, 2010

    I think being perceived as difficult to treat might also make a condition susceptible to quackery. Treatments for obesity comes to mind.

    PalMD: did you choose the coffee mug or the beach towel as your free gift for joining the Darwinist-Humanist Cabal?

    Cheers,

    JP

  32. #32 PalMD
    June 18, 2010

    Sigh…

    Sorry, Mike. Don’t say I didn’t try.

  33. #33 JoeB
    June 20, 2010

    While it may be a service to Mike and those like him, deleting comments for being batshit crazy is a disservice to readers like myself that enjoy reading unhinged responses in the comments almost as much as the great content provided in the post.

    I have no issue with deleting comment that violate rules the blogger has laid down for commenting, but it’s not your job to make them look reasonable, and you doing so takes some of the fun out of reading the comments.

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