Sometimes things just fall into your lap. This evening I was working on a different piece, and not getting very far, when an email arrived in my in-box.
You see, when you write for the 21st most influential science blog, you get a lot of unsolicited mail (OK, fine...I get spam in my blog-related inbox. But my spam is cool.)
What's great about a lot of this spam is that it is usually written by an actual person, and directed at me by name, which means they had to at least glance at the blog. In this case, a "glance" was all, or perhaps the writer simply suffers from poor reading comprehension. My latest correspondent is selling an herbal extract for diabetes. It seems unlikely that she's read my writing about this particular topic. See, as an internist, I'm very well-trained in the management of diabetes. It's what I do. And I hate, HATE, people who interfere with the treatment of this very serious disease with a bunch of cult medicine bullshit.
First, a little background (this bit is basically a cut and paste job from an old post, so if it seems familiar, it means you're a loyal reader).
There are two main variants of diabetes: Type I (juvenile) and Type II. Type II accounts for about 95% of the 20 million cases of diabetes in the U.S. Diabetes is can be a disabling and deadly disease, but not because of the blood sugar fluctuations per se. High blood sugar damages blood vessels, which in turn damages the organs they supply.
We generally divide diabetic complications into two categories: microvascular (small blood vessel), and macrovascular (large blood vessel). For the sake of discussion, I'll simplify things a bit more.
Microvascular complications include things like kidney failure, blindness, and nervous system damage (such as painful peripheral neuropathy).
Macrovascular complications include the big baddies like amputation, stroke, and heart attacks. Heart disease and stroke account for about 65% of deaths in diabetics.
Prevention of these complications has been the goal of diabetic treatment for years. Large-scale studies of type I and type II diabetics have shown that better control of blood sugar levels reduce the incidence of microvascular complications (DCCT and UKPDS ) . Control of cholesterol and blood pressure have been shown to prevent macrovascular complications in type II diabetes. Studies haven't yet shown whether or not tight blood sugar control can prevent the biggest killers of diabetics---heart attack and stroke.
In sum, proper, evidence-based treatment of diabetes prevents death and disability. Improper treatment does not, and that's where I start to get a bit angry (and you wouldn't like me when I'm angry).
There are about 2.4 gazillion unproven herbal products available to treat diabetes. I find this one interesting for a few reasons, though.
Introducing Glucocil!
If you look way down at the bottom of the webpage linked above, you'll see a Quack Miranda Warning. Normally I'd stop right there, but the claims made by the company's PR hack are so over the top, that I must go on.
According to "Rachel":
"We are excited to share this news with your readers, as we believe mulberry can help save the lives of the millions of Americans struggling with Type 2 diabetes."
Well, I'm excited, too. She graciously offered to send me clinical studies, but I have my own MedLine and PubMed access, and their website gives references as well. The study of which they are particularly proud was published in the American Journal of Clinical Nutrition (full citation below). This study of 20 people established that some of these plant extracts may inhibit carbohydrate absorption in the human gut. Another study in Diabetes Care (to which I do not have electronic access) looked at mulberry extracts' effects on after-meal blood sugar levels.
Here is the real deal.
There are several classes of pharmaceuticals used in the treatment of diabetes (along with non-pharmacologic interventions). One of these classes is the alpha-glucosidase inhibitors (primarily acarbose). Acarbose essentially slows the absorption of sugar derived from ingested carbohydrates. In other words, the mulberry tea functions similarly to acarbose. In studies of acarbose, it had some minimal but significant effect on blood sugar levels. In some studies as many as a quarter of all participants stopped the drug due to severe gas, a symptom that was observed in the mulberry studies as well. Most internists and endocrinologists find these drugs to be of minimal use in treating diabetes.
So, this company is offering you a bottle of an unproven treatment that works very much like a minimally effective drug that is already available.
Cost? A one month supply is forty bucks. This same amount can buy you a four month supply of glyburide, a standard diabetes drug with similar or better efficacy and better tolerability as compared to acarbose.
As usual, they're selling you something you don't need, in this case an untested and unregulated version of an already-available drug that most doctors and most patients don't like.
So, in response to your letter, Rachel, I'm quite happy to share this information with my readers.
References
Zhong L, Furne JK, Levitt MD. An extract of black, green, and mulberry teas causes malabsorption of carbohydrate but not of triacylglycerol in healthy volunteers. Am J Clin Nutr. 2006 Sep;84(3):551-5.
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I was surprised to find that the Metformin I take to control my blood sugar is derived from French lilac, and that lilac has been prescribed for diabetes practically since Galen's day.
Yet I don't see lilac tinctures when I walk past the supplements aisle in the grocery store. I certainly understand about controlled dosage and quality, but why is it that I don't see lilac in the herbal supplements aisle?
Similarly, cinnamon has been prescribed as an herbal for diabetes for millenniums (real cinnamon, not cassia). And one of the herbalist diagnostics for diabetes is a craving for it. But you're not going to sell it for $40 a bottle.
I think the problem here is *quack* herbalists, not the entire genre.
Ringo:
As opposed to whatnon-quack herbalists? "Honest" herbalists exist only in abstract. They are a hypothetical, a "what if" dangled by woosters to distract from the fact that they are all hucksters.
You guys are just way too cynical. Now, if you will excuse me, I have an email from Joe Mercola that says he can tell me how to avoid sudden death like what happened to Tim Russert. Gotta go check that out.
Bill, that would be the same Mercola who says that you can avoid catching smallpox by cleansing your system of "toxins", because of course smallpox isn't a contagious disease...because there is no such thing as infectious microbes, dontchaknow.
Ringo: As opposed to what�non-quack herbalists? "Honest" herbalists exist only in abstract. They are a hypothetical, a "what if" dangled by woosters to distract from the fact that they are all hucksters.
Radioactive:
An "honest" herbalist will send you to a "real" doctor if your condition is life threatening, and will do everything in their power to prevent it from getting that far.
Do you have any idea how many drugs in the modern pharmacopia come from plant sources? Do you know any ethnobotanists?
Knee-jerk dismissals are the worst form of fundamentalism.
I love how herbalists and such like to classify drugs as "unnatural" and their treatments as "natural", since of course "natural" arsenic, amanitas, and snake venom won't hurt you.
My partner is a synthetic chemist. He finds molecules that other people have isolated from plants. He then builds them in his lab, from scratch. When he's done, he can quantify exactly how much he made and how pure it is. And what these herbalists don't seem to get is that the molecule he builds is EXACTLY the same molecule that was isolated from the plant. The only difference is that it's cheaper to make than isolate, and we know exactly how much of it people are going to ingest.
PAL,
This is a good post. I have your whitecoat e-mail address; if you want a copy of the article in Diabetes Care, I'll send it.
Because there is an animal model, it seems the active ingredient is a prime target for isolation. If my friends at BigPharma aren't developing this stuff, they probably have concluded that it would not compete (financially) with what is already available; as you say is true for the herb, itself.
I don't know what pharma is or is not working on, but the equivalent available drug isn't very useful or tolerable.
Pal,
My point was that an animal model allows for isolation of the active ingredient(s), if any, in mulberry. Most herbal claims (e,g, St. Johns Wort) can only be studied in human subjects; and one cannot (practically) screen herb fractions under those conditions.
If an isolated, herbal component (e.g., mulberry) is insufficiently active, medicinal chemists may find a way to extend it's activity. Perhaps we can develop a drug that is useful and tolerable. That is what we do.
Too many herbal "treatments" leave us in the (impractical) position of testing them, and there fractions, only in human subjects. That's why I found this case (with small-animal models) especially interesting.
@Ringo, the evidence for cinnamon is feeble http://www.mskcc.org/mskcc/html/84132.cfm Herbalists tend to "throw everything against the wall and take credit for what sticks."
Consider the case of the antimalarial drug, artemisinin; more than 100 herbs, traditionally used for malaria, were examined to find one that actually worked. http://www.ncbi.nlm.nih.gov/pubmed/16722826?ordinalpos=21&itool=EntrezS…
And this begets the question- "How many, otherwise, useful drugs have been missed in those plants that failed the malaria screen?" Perhaps they have something useful for multiple sclerosis. If the ancients didn't know about MS, it won't be found in ethnobotany.
The artemisia story provides another lesson- it turns out that the herb only produces the drug (artemisinin) when grown under certain conditions. Herbal providers can never know if their products have any activity.
Clearly- "there" fractions should be "their" fractions.
Joe: are we looking at the same website?
A significantly higher reduction in fasting plasma glucose was demonstrated in the cinnamon group (10.3%) versus the placebo group (3.4%). But no significant differences were noted in HbA1C, LDL, HDL, total cholesterol or triglyceride levels. There was a significant correlation between the reduction of plasma glucose and baseline concentrations suggesting that patients with higher initial plasma glucose levels benefitted more from the cinnamon extract. No adverse effects were reported. The authors conclude that cinnamon extract may be of moderate benefit in reducing plasma glucose in type 2 diabetics with poor glycemic control.
(and that's without specifying the most active species)
Ringo asked "Joe: are we looking at the same website? ..."
I am not psychic, how can I tell?
joe: you provided a link to memorial sloan kettering's web page on cinnamon, to support a "feeble" comment. "Moderate benefit" is not "feeble"
They do say (in the other tab) that findings on cinnamon are "mixed". After looking at pubmed, I'm not surprised. Any study that doesn't specify the actual species tested should never have made it through peer review.
Re: the cinnamon link. You've got it backwards; it's cassia that was studied in the trials, not real cinnamon. However, in the US, the vast majority of cinnamon-flavoured items are actually cassia, so go for those cinnabons :-)
I have a lay question on drugs & herbs. I keep on reading that all sorts of compounds in fresh fruit & veg are good for you in preventing all manner of cancers and heart diseases. Yet I also hear that studies using just those individual compounds as supplements find it hard to show any value to their use.
It seems obvious to me that you're getting a cocktail of chemicals in your fruit, along with water and fibre. But wouldn't that also be an issue for herbs, as well? A combination of active ingredients, rather than a single chemical, might be the trick?
Type 2 diabetics should worry less about which herbs they are eating and worry more about how much they are eating. The disease comes primarily from too much unused belly fat. For most diabetics, we would not have to worry much about it if they would eat a balanced diet (how unamerican!) and exercise for a half hour a day.
Buying a woo-woo product seems like such an easy way out. The truth is not easy. Justification for such woo comes from pseudoscience that sounds baffling enough to convince the common man.
P.T. Barnum once said (something like), "Nobody ever went broke underestimating the intelligence of the public". The herbalist take that point all the way to the bank.
Cath - there are actually three different species (roughly, from India, Sri Lanka, and China). It's interesting that most of the published studies have been done on cassia (the Chinese species), since herbalists warn against using that one. Don't know what the underlying story is here.
The cocktail of chemicals idea is right on (more likely, active ingredient and another compound that makes it bioavailable). Also true in "native" food recipes (that lime water in the tortilla isn't just for taste).
Also interesting is the similar notion of one herb treating multiple associated syndromes. Cinnamon is used as an herbal to promote weight loss (in particular, that stuff around the middle), and to treat stomach ulcers, which we now know are caused by H. Pylori. Both apple-fat and H. Pylori infection are risk factors for (or, at least correlated with) diabetes. Hmm.
http://www.ncbi.nlm.nih.gov/pubmed/18500972?ordinalpos=1&itool=EntrezSy…
http://www.ncbi.nlm.nih.gov/pubmed/16437723?ordinalpos=2&itool=EntrezSy…
id stick with proven medications and not on those unproven herbs.
Ringo, "feeble" referred to the quality of the evidence favoring use of cinnamon. In other words, the claim for benefit is not well-supported. This is typical for herbal claims.
Cath, dietary claims that are hyped to capture your money are, like herbal claims, often poorly supported. There are a number of reasons that more careful studies fail to find the claimed benefit. Herbalists are quick to claim the benefits of combined ingredients; but they supply little data to support that claim. The simpler explanation is that the original claim was wrong.
The study linked by Ringo is too small for one to draw a firm conclusion. It is a "pilot" study and it only suggests that a proper clinical study is warranted.
Kayleene is right.
Dr. Kimball Atwood has an excellent article with a rather long, side-by-side comparison of the enthusiastic endorsements for several herbs (by herbalists) vs. scientific assessment of their safety and efficacy.
http://www.sciencebasedmedicine.org/?p=151
Joe: any article that uses the phrase "pseudoscientific cult" in its *title* is probably not written from a position of pure objectivity. It also appears that the author has a beef with a particular organization, not the field in general.
Ringo wrote "any article that uses the phrase "pseudoscientific cult" in its *title* is probably not written from a position of pure objectivity."
That is like saying staunch opposition to child abuse is not objective. Dr. Atwood made a thorough study of n'pathy, using their own literature, and there is no basis for most of what they say and do. (Some of their dietary advice is okay; but only when they match the ADA.)
www.naturowatch.org
And, no less a celebrity nutritionist and authority that Dr Jonny Bowden (PhD in holistic nutrition from Clayton College of Natural Health) said it so that should settle the matter: The 11 Best Foods You Aren't Eating. Or, it has in his and Tara Parker-Pope's mind, as they make clear in the comments where they reject criticism of the quality of evidence for this recommendation and that for other items.
I find this discussion of cinnamon in these comments and in this overview to be of considerably higher quality than anything offered by TPP and Jonny Bowden.
Given its influence, the NYT should be more careful of its reputation and those to whom it lends the 'imprimatur of respectability'.
The only difference is that it's cheaper to make than isolate, and we know exactly how much of it people are going to ingest.
Actually, it's very often a *lot* cheaper to let the plant make it, then extract it. Of course, the plant breeders also produce strains with high and consisent yields, too.
This has exactly SFA to do with "woo".
Joe: there is no "they" here. There are multiple traditions in multiple cultures. A Chinese herbalist doesn't go to the once-a-month meeting in a basement somewhere with an Ayervedic consultant. Unless Atwood reads fifteen different languages, the phrase "using their own literature" is meaningless.
Ringo wrote "Joe: there is no "they" here."
I don't understand that. The best I can determine- it is an un-artful dodge. Dr. Atwood researched n'pathy in the US, that does not require reading 15 languages.
Whence do you bring in Ayurvedic consultants, and Chinese herbalists, to Atwood's survey of n'paths and their herbal nonsense?
Joe - all "naturopaths" may be "herbalists", but all "herbalists" are not "naturopaths". Researching naturopathy in the US tells you nothing about the validity of Chinese, Indian, or any other non-Western practice.
And this guy clearly has a beef - just look at his rhetoric (not to mention that he seems to think all doctors are male. How old is this dude?).
Here's an interesting variation of the Quack Miranda Warning, found on the Emotional Freedom Techniques site:
Which raises several questions:
* Does calling something "experimental" reduce liability?
* EFT has been offered for over a decade, and according to Wikipedia has been the subject of three (inconclusive at best) peer-reviewed studies; when might it be past the "experimental" phase? (The EFT site asserts: "This common sense approach draws its power from (1) time-honored Eastern discoveries that have been around for over 5,000 years and (2) Albert Einstein, who told us back in the 1920's that everything (including our bodies) is composed of energy. These ideas have been largely ignored by Western Healing Practices and that is why EFT can work where nothing else does." Quite a long period of "experimentality", not to mention a bold, if carefully worded, claim...)
* What liability shield does a "ministry" or "coach" status confer?
* How about transferring liability by dragging in a patient-chosen "professional"'s "consultation"?
Offering an actual physical substance to treat any sort of problem is just so, like, materialist, y'know?
I did a little piece on this a while back..
http://whitecoatunderground.com/2008/02/05/a-whole-new-woo/
Ringo,
The typical response: "no True Scotsman" would do that." I take it you agree, then, that the list of ineffective herbs is accurate.
As for Dr. Atwood's "rhetoric," that is an ad hom fallacy. You have to show us where he is wrong; but you can't.
Joe: Congratulations, you have destroyed the strawman. Bad strawman. Bad. Bad. Joey wins.
Cath, There is another explanation of why all the long duration, large, double blind, placebo controlled trials of supplemental antioxidants have completely failed to show even the slightest positive effects (most have shown slight negative effects). I discuss some of that in my blog with links to relevant literature.
http://daedalus2u.blogspot.com/2008/05/is-secret-to-good-health-in-bowl…
If supplemental antioxidants dont improve oxidative stress, then dietary antioxidants are not regulating oxidative stress in the slightest bit.
The explanation is that the association of good health and a diet rich in fruit and green leafy vegetables isnt because the diet causes the good health, but that the good health causes the healthy individual to self-select the healthy diet.
Oxidative stress is a very important physiological parameter. Cells learned to regulate that billions of years ago. It is too important to allow to be controlled by haphazard quantities of dietary antioxidants. If it is setpoint issue, then physiology will adjust what ever it needs to adjust to bring the state of oxidative stress back to the setpoint. The body has an unlimited capacity to generate superoxide. If you eat more antioxidants than your setpoint calls for, your body has to destroy them by generating more superoxide. I think that is why supplemental antioxidants make some of these diseases worse.
If this hypothesis explaining the observation is correct, then any source of dietary antioxidants above what the individuals physiological "setpoint" calls for will be problematic, whether they are from supplements or from diet.
There have been no randomized prospective studies of the effects of diet on these diseases. All the studies have been using a self-selected diet. If diet choice is a control parameter that physiology uses, then diet choice is an effect, not a cause of the state of oxidative stress.
Thanks for all the replies. I never knew there were 3 types of cinnamon. Cool.
I am not a big proponent of herbalism. I do think that since herbs contain potentially active ingredients, there's a chance that some of them do actually work. Unlike obvious woo like homeopathy or reiki, there may be some genuine, albeit pre-scientific, wisdom in herbal remedies.
I do wish science blogs had a good quack-busting nutrition writer. There is an unbelievably large amount of quackery in the diet industry; it's very hard for a lay person to tell the good from the bad.
There are a number of resources. I occasionally blog on them (as I have here), and you may find this interesting.
Cath, it is hard for many scientists and MDs to tell also. That is the nature of reality and trying to figure it out. It is complicated and humans have a lot of cognitive structures that are useful for communicating with other humans, but are terrible for trying to understand reality. There is a lot of conventional wisdom that is actually wrong.
The tendency of humans to anthropomorphize everything tells us about human cognition, not about reality.
Remember this book http://www.librarything.com/work/5197214
"There is a Cure for Diabetes," the one that claimed to "cure" diabetes in a matter of weeks? You'll be proud to see that the reviewers who received advance review copies from the publisher have unanimously slammed it as unscientific and unsupported.
Not that this keeps it from being published, but at least it appears that patient education is succeeding to the degree that the people who have seen it so far know better than to believe this nonsense over what their own doctors have explained and demonstrated.
Yes, and thank you Liesele for the tip. My original post on the killer quack is here.