I realize I've said it before, but I still can't believe as many people read what I like to lay down on a daily basis right here on this blog. Believe me, it has nothing to do with an sort of false sense of modesty. After four years at this, I know I'm good at blogging. Real good. But good isn't always enough to make much of a difference or even to garner an audience. Whether I've done the first, I don't know. I like to think that I have. As for the second, I've done pretty well for myself. Indeed, after a year of stagnant traffic, January and February were the best months, traffic-wise, in the history of this blog. What that means, I guess, is that sometimes people whom I would never have expected to give a rodent's posterior about what a nobody like me writes actually sometimes take note. Sometimes famous people, certainly far more famous and renowned than your humble pseudonymous blogger, are moved to leave a comment. Not surprisingly, these responses, on the fairly uncommon occasions when they appear, are usually provoked by something I've written that has--shall we say?--displeased the target of my insolence, be it of the respectful or not-so-respectful variety.
Such was the case late Tuesday night, when one of the Four Horsemen of the Woo-pocalypse himself, upon whom I had laid a bit of a smackdown in the course of lambasting Senator Tom Harkin (D-IA) for his plan to piggyback the legitimization of quackery onto any health care reform legislation that President Obama might try to get through the Congress. Because Harkin is a very senior and very powerful Senator, one who nearly single-handedly birthed the legislation that produced the Office of Alternative Medicine in the NIH, which later begot the monstrosity that has become the National Center for Complementary and Alternative Medicine (NCCAM), his intentions are very important, as he very well might succeed if President Obama is insufficiently serious about the promise he made in his Inaugural Address to restore science to "its rightful place." A few of you know of whom I speak, as you took up the slack when I couldn't respond right away due to yesterday being a travel day to the SSO Meeting in Phoenix. I'm referring, of course, to Dr. Dean Ornish, the Founder and President of the Preventative Medicine Research Institute, who left a comment that, because it got held up for moderation (I know not why), I did not see until very late. Suffice it to say, he is not particularly happy with me.
Although I can totally understand why Dr. Ornish might not appreciate my criticism, he should actually know that, of the Four Horsemen of the Woo-pocalypse, I consider him (probably) the least objectionable. Certainly he would not be Death (that would be Andrew Weil). Smart-ass that I am, maybe I'll consider Dr. Ornish to be Famine, given that his claim to fame is the use of very low fat diets, along with major lifestyle alterations, to effect changes in health. The reason that I find Dr. Ornish perhaps the least objectionable is that at least he tries to do science. It's preliminary science, and usually the controls aren't the greatest, but it is for the most part science. My main beef with him is how he represents that science to the public. For his claims for dietary treatment of prostate cancer at least he tends to take preliminary studies of highly select patients and make way too much of them. Indeed, he often says one thing in his papers, where peer-reviewers force him to remain tentative and keep him from going too far off into the deep end with his claims, but quite another thing to virtually everyone else, including the aforementioned Senator Harkin and, even worse, to the recent Institute of Medicine/Bravewell Collaborative conference on alternative--excuse me "integrative" medicine--from which he hopped over to the Senate to do a two-fer of woo promotion in our nation's capital.
My post about him and his fellow horsemen led him to respond in the comment section thusly (comment reproduced in its entirety), after which I will provide my response:
For someone who prides himself on attention to detail, it's surprising that you haven't done your homework. My testimony that comprehensive lifestyle changes may affect the progression of early-stage prostate cancer was not based solely on the paper that my colleagues and I published in the Proceedings of the National Academy of Sciences last year (Proc Nat Acad Sci USA 2008; 105: 8369-8374. Ornish D, Magbanua MJM, Weidner G, et al. Changes in prostate gene expression in men undergoing an intensive nutrition and lifestyle intervention. Proc Nat Acad Sci USA 2008; 105: 8369-8374).
It was based on a randomized controlled trial that I directed in collaboration with Peter Carroll, M.D. (Professor & Chair of Urology, School of Medicine, University of California, San Francisco) and the late William Fair, M.D. (Chief, Urologic Surgery and Chair, Urologic Oncology, Memorial Sloan-Kettering Cancer Center) which was published in one of the leading peer-reviewed urology journals (Ornish DM, Weidner G, Fair WR, et al. Intensive lifestyle changes may affect the progression of prostate cancer. Journal of Urology. 2005;174:1065-1070). Other subsequent studies have shown similar findings.
In September, we published a pilot study in The Lancet Oncology in collaboration with Dr. Elizabeth Blackburn, who was awarded a Lasker prize for discovering telomerase, showing that these comprehensive lifestyle changes increased telomerase by almost 30%. This is the first study showing that any intervention may increase telomerase.
Our earlier studies showing that comprehensive lifestyle changes may stop or reverse the progression of coronary heart disease were published in several peer-reviewed journals, including:
â¢ Ornish D, Scherwitz L, Doody R, et al. Effects of stress management training and dietary changes in treating ischemic heart disease. JAMA. 1983;249:54-59
â¢ Ornish D, Brown SE, Scherwitz L, et al. Can lifestyle changes reverse coronary atherosclerosis? The Lifestyle Heart Trial. The Lancet. 1990; 336:129-133.
â¢ Gould KL, Ornish D, Scherwitz L, et al. Changes in myocardial perfusion abnormalities by positron emission tomography after long-term, intense risk factor modification. JAMA. 1995;274:894-901.
â¢ Ornish D, Scherwitz L, Billings J, et al. Intensive lifestyle changes for reversal of coronary heart disease Five-year follow-up of the Lifestyle Heart Trial. JAMA. 1998;280:2001-2007.
You can do a medline for more references.
Although you dismiss this statement as "nonsense," we are, in fact, more than just genes and germs, microbes and molecules. You might begin by reading some of Leroy Hood's work (no slouch as a scientist) who described systems biology and the concept of synergy. I cited his work in my keynote talk at the recent Institute of Medicine's "Summit on Integrative Medicine" at the National Academy of Sciences that will be posted later this week (http://www.iom.edu/integrativemedicinere) in which I describe the studies of those such as Sheldon Cohen in JAMA showing that not everyone who is infected with rhinovirus develops the signs and symptoms of a cold, and found a direct relationship between the degree of social support and immune function.
The best scientists are open to new ideas, not glibly dismissing them just because they don't agree with their preconceptions.
Dean Ornish, M.D.
Founder and President, Preventive Medicine Research Institute
Clinical Professor of Medicine, University of California, San Francisco
Ow. That's gonna leave a mark.
Well, not really. In fact, I'm rather disappointed that Dr. Ornish played the "close-minded" gambit so vociferously. Whether consciously or not, Dr. Ornish appears to have missed the broader point I was making about how pseudoscience had coopted what should be the very science-based interventions of diet and exercise as a "wedge strategy" designed to open the way for the entry of all manner of quackery in order to focus like a laser on the much narrower point of my criticism of his work. When I first saw Dr. Ornish's response, I was half-tempted to ignore his complaints about my criticism of him, because even if each and every point he makes about his diet and lifestyle interventions were 100% perfect science with overwhelming support and I really were a close-minded, lousy scientist, it wouldn't change one whit my annoyance with him for allying himself with supporters of pseudoscience to support Senator Harkin (the broader point of my broadside against Weil, Hyman, Oz, and him), as I'll explain a little later. However, when someone throws down the gauntlet like Dr Ornish, I have a tendency to pick it up and slap him across the face with it, accepting the challenge. Even if I end up losing badly, better to go down honorably than to slink away. So let me deal with a handful of the specifics of Dr. Ornish's complaints before I move on to finish this post addressing the broader point of why Dr. Ornish drives me crazy.
First off, Dr. Ornish is mistaken to assume that I have not read or was not aware of his other papers testing his diet against prostate cancer. I've read them all, although I've done a detailed deconstruction of only the microarray paper that I mentioned. I've even obliqulely alluded to his telomerase paper before, and I've read several of his others. Consequently, it's probably my fault that he got the impression that the microarray paper was the sole basis of my criticism. However, my post was long and a detailed discussion of all of Dr. Ornish's work in prostate cancer was beyond the scope of the post; so I picked one example that I had already discussed, which you can read again right here if you so desire. In the meantime, let's look at a couple of the other papers Dr. Ornish cites as evidence that I am a close-minded, careless dolt, as well as a brief look at the microarray paper again.
The telomerase study, which did indeed appear in The Lancet Oncology in September, was entitled Increased telomerase activity and comprehensive lifestyle changes: a pilot study, is very interesting in that Dr. Ornish reported telomerase activity results on the same patients upon whom he did his microarray experiments. This is what Dr. Ornish said about this problem in the discussion section of the PNAS microarray paper:
...our analysis was limited to normal prostate tissue because tumor tissue was present on the biopsy specimens of only a minority of patients. Thus, the implications of this study are not limited to men with prostate cancer. Because of the microfocal nature of low-risk prostate tumors and the limitations of ultrasound biopsy guidance, we were unable to precisely match pre- and postintervention tumor samples for individuals in our cohort...Because only one-third of patient biopsies in our study included tumor tissue, we were limited to examining the response of the normal prostate tissue (stroma and epithelium) to the intervention. It will be very important for future work to examine tissue molecular responses to determine whether the normal stroma, tumor stroma, normal epithelium, tumor epithelium, or a combination of these tissues respond to diet and lifestyle changes.
I will admit that it is fair enough to point out that, if the results are validated, that the changes in gene expression occurred in normal prostate cells does imply that his diet might be useful for prevention. However, given that he missed cancer epithelium 2/3 of the time, it's really difficult for him to conclude anything whatsoever about his microarray experiment. In fact, what I'd be interested in is a comparison of the array results of tissue samples with no tumor tissue versus those with tumor tissue. All it would take is a couple of patients whose pre-diet biopsy had tumor tissue but whose post-diet biopsy did not to significantly affect the results. That was the main basis of my skepticism over whether the PNAS paper meant much of anything.
Moving on, I have to admit that the telomerase paper led me to scratch my head. In cancer, telomerase is generally a bad thing. To put it simply, telomeres are repetitive DNA sequences at the end of chromosomes. They serve to keep chromosomes from degradation. The reason chromosomes degrade during replication is that the enzymes that replicate the chromosome cannot replicate the DNA all the way to the end of the strand. Consequently, during each round of cell division and chromosome replication, some DNA sequence is lost. With telomeres at the end, what is lost is noncoding repetitive DNA, and no important DNA sequences that code genes or regulatory regions are lost. In most eukaryotic organisms, an enzyme known as telomerase adds these DNA sequences to the end of the chromosomes. However, in the adult telomerase is generally active only in cells that need to divide a lot, such as stem cells and immune cells but only expressed little, if at all, in most normal cells. In immune cells, which is where Dr. Ornish looked, decreased telomerase activity has been associated with an increased risk of atheroclerosis, although, as he himself points out in the paper, telomerase length is not.
In any case, I went back and looked at the telomerase paper again. To boil it down, what Dr. Ornish found was that his diet is associated with an increase of about 25% in telomerase activity in peripheral blood monocytes (PBMC). The standard deviations are quite large and overlapping, and the statistical significance is there, but not impressive. I looked at the table that showed all the telomerase activity values "before and after" (statistical significance tested, appropriately, with Student's paired t-test) and saw huge variability, with telomerase activities actually decreasing slightly in some patients. This leads me to concede that there is probably a difference in telomerase activity, but to wonder whether the difference is clinically relevant. Moreover, that increased telomerase activity appears to be associated with Dr. Ornish's diet in PBMCs makes me wonder something. If his diet does definitely increase telomerase activity in PBMCs (something that remains to be demonstrated), then could it be possible that it does the same thing in cancer cells? Remember, many cancers have high telomerase activity, and telomerase inhibitors are being developed for various cancers. Just a random thought. I went back to look at the microarray paper to see if telomerase gene expression levels increased or decreased in prostate tissue as a result of the Ornish diet, but couldn't find anything.
Finally, there are the two papers, one in Urology and one in the Journal of Urology, reporting that the Ornish diet is associated with slower progression of early stage prostate cancer in men who choose watchful waiting for their tumors, and a longer time to progression, all of which is very interesting, although pretty preliminary given the few numbers of men. In addition, I won't go into the cardiovascular papers (much), because (1) I'm a cancer surgeon and (2) no one is arguing, least of all me, that diet and exercise don't play a very important role in contributing to (and potentially preventing) cardiovascular disease. I'm not even that skeptical that diet and exercise might be preventative for prostate cancer and other cancers--or even mildly therapeutic. It's a straw man to say otherwise. My sole purpose in mentioning some of the papers that Dr. Ornish cited is to emphasize that they are all pilot studies and that their results are tentative at best. Moreover, what I have been arguing is that Dr. Ornish has willingly and enthusiastically allied himself with the "alternative" medicine movement, many of whose leaders are boosters of pseudoscience, when the use of diet and exercise, the very health interventions he champions, are not and should not be in any way considered "alternative." Worse, Dr. Ornish is overselling his results to Congress, the medical profession, and the public in order to champion them as "alternative."
Which brings me back to my main complaint about him, the complaint that he completely ignored, which is why I'm going to e-mail him and make sure he sees this response, given that he was kind enough to comment.
As an example, let's go back to his article in the Washington Post in January, in which in addition to Dr. Weil, Dr. Ornish teamed up with, of all people, Deepak Chopra and Rustum Roy. Let's get one thing straight. Deepak Chopra is a booster of pseudoscience. There's no other scientifically accurate way to describe him. Indeed, he is so full of pseudoscience that I can take credit for coining a term that has spread through the blogosphere for the nonsense that he regularly that he regularly lays down: Choprawoo. I and others have deconstructed the nonsense about medicine, evolution, and other "quantum" nonsense. His contortions of science are legion (and legendary). The same is true of Rustum Roy, who has become known above all else for his support for the quackery that is homeopathy.
This leads me to ask: Does Dr. Ornish think there is anything at all to homeopathy or the "memory" attributed to water by homeopaths? If so, he has left the path of science, as homeopathy is quackery. Period. If not, then why on earth did he associate himself so publically with a booster of such quackery? Rustum Roy is one of the most famous current supporters of homeopathy. Talk about shooting oneself in the foot, scientifically speaking! Let's put it this way: Palling around with Deepak Chopra and Rustum Roy--and even going so far as to write an article on alternative medicine with them to be published in the Washington Post--do not exactly constitute a sound strategy to enhance one's scientific credibility, if you know what I mean. An analogy would be hanging out with Bernie Madoff as a strategy to enhance one's cred as an honest investment guru.
Given Dr. Ornish's obvious distress at my criticism, though, I had considered apologizing for having gone a bit far and getting a bit too testy (although I take back absolutely nothing that I said about Senator Harkin and the rest). Truly, sometimes I do get a bit carried away when I'm on a roll, particularly after coming up with a pithy phrase like "the Four Horsemen of the Woo-pocalypse," which, if I do say so myself, is one of my better ones. Then I saw Dr. Ornish's slide set from his presentation to the Institute of Medicine/Bravewell Collaborative woo-fest last week, which, not-so-coincidentally, overlapped Senator Harkin's woo-fest.
Now I'm half-tempted to conclude that I may not have been hard enough on him.
The first thing that bugs me is that Dr. Ornish invoked Leroy Hood. Since he told me in his comment, in essence, to "go read some Leroy Hood," I can't resist pointing out that I have, in fact, "read some Leroy Hood" and that I have, in fact, attended talks by Leroy Hood. It can even be said that I rather admire Leroy Hood. In fact, I have even blogged about Leroy Hood and exactly why I like his systems biology approach. I am even currently striking up a collaboration with a systems biologist at my own institution who's very big on network analysis. Nonetheless, I still have a great many reservations about whether the hype over systems biology as epitomized by Leroy Hood is an accurate reflection of its ability to deliver truly "personalized medicine" (very much like the dubious "individualization" of medicine claimed by CAM advocates, which is, in most cases, a synonym for "making it up as I go along). I won't rehash my comments here, but rather refer readers to my post on the issue. I will, however, reply to Dr. Ornish by saying, "You, sir, are no Leroy Hood." Nor is Dr. Hyman, Dr. Oz, Dr. Chopra, Dr. Roy, or Dr. Weil, for that matter. The reason is that Leroy Hood, for whatever faults he may have in perhaps overselling his work a bit, does not represent his approach as "alternative," nor does his approach embrace pseudoscience along with his science, as apologists for "alternative" and "integrative" medicine all too frequently do. Invoking Leroy Hood as a supporter of the kind of arguments that Dr. Ornish made at the IOM is akin to Deepak Chopra's invoking Einstein, the only exception is that it is not clear that Hood will have anywhere near the effect on medicine that Einstein had on physics.
Next, Dr. Ornish invokes Dr. Hyman's functional medicine, which is, in fact, nothing more than a mish-mash of a lot of old woo about "balance" (just leaving out the yin/yang or qi) given a fresh "science-y" gloss, as longtime skeptic Wally Sampson has described. Dr. Ornish also cites approvingly a paper that claims that "mindfulness meditation" improves the antibody titer response to the influenza vaccine. I went and looked up that paper to read while I was on the plane to Phoenix. I have to say, I was underwhelmed; indeed, it reminded me of a similar study of Tai Chi that I blogged about in that there was no attempt at blinding, but, even worse, the measures used to control for confounding factors were truly inadequate.
But Dr. Ornish hit the jackpot in provoking my annoyance when cited an acupuncture study thusly:
In patients with low back pain, response rate was 47.6% in the acupuncture group, 44.2% in the sham acupuncture group, and 27.4% in the conventional therapy group.
The medical blogosphere extensively covered this study, as did I. Suffice it to say, the study fell far short of how it was represented. Morever, the most obvious conclusions about acupuncture from the study are that: (1) it's a placebo effect and (2) acupuncture meridians are bunk, given that there was no difference between the sham acupuncture and "real" acupuncture group. In all fairness, I don't know what Dr. Ornish said about the slide, because the video of the conference hasn't been posted yet, but his slide sure does lead me to suspect that, when it comes to science-based medicine, he just doesn't get it, as does his comment to me remonstrating with me for taking him to task for saying that we are "more than just genes and germs, microbes and molecules." Indeed, if he thinks that Leroy Hood's work indicates that to be true, he is more misguided than I thought. Nothing in Leroy Hood's work indicates that we are "more" than these things, only that how these things work in human physiology and disease is likely to be far more complicated than we had previously thought. It does not imply any sort of dualism, which is what Dr. Ornish seems to think that it does. He can correct me if I'm wrong.
Finally, Dr. Ornish truly buried himself when he finished up with a series of slides that concluded:
With all due respect, I ask: Transformation into what? One does not have to embrace pseudoscience to "transform" healthcare. Indeed, the best transformation of health care would be to make it more science-based. If science shows that lifestyle alterations are the best treatment for some conditions, bring it on! I'll be all for 'em, as they say. If science bears out Dr. Ornish's results, I would happily recommend his diet to men with early stage prostate cancer. To me, there is no such thing as "alternative" or "integrative" medicine. There is medicine that has been validated by science as effective and safe, and there is medicine that has not. In fact, I would happily recommend even something that I now think as ridiculous as homeopathy if science could show that (1) it works significantly better than a placebo and (2) provide an reasonable scientific mechanism by which it could work. Indeed, I'd even scratch #2 if someone could show me that homeopathy could cure an incurable disease like pancreatic cancer.
In the end, the problem is that Dr. Ornish has yoked his science to advocates of pseudoscience, such as Deepak Chopra and Rustum Roy. Why he's done this, I don't know. The reason could be common philosophy. It could be expedience. It could be any number of things. By doing so, however, Dr. Ornish has made a Faustian deal with the devil that may give him short-term notoriety now but virtually guarantees serious problems with his ultimately being taken seriously scientifically, as he is tainted by this association. Let me yet again reemphasize that this relabeling of diet, exercise, and lifestyle as somehow being "alternative" is nothing more than a Trojan Horse. Inside the horse is a whole lot of woo, pseudoscience and quackery such as homepathy, reiki, Hoxsey therapy, acid-base pseudoscience, Hulda Clark's "zapper," and many others, all contradictory, virtually all pseudoscientific, but all intentionally hidden within the Trojan horse of diet and exercise. Once the horse is within the fortress of scientific medicine, the quackery will leap out and take over. Thus, as far as I'm concerned, the answer is not to blindly accept diet and exercise as "alternative," but rather to smoke out the quackery from within the Trojan horse constructed by CAM advocates and then return diet, exercise, and lifestyle interventions to where they were before they became "alternative" and to where they should be: In the realm of scientific medicine. Dr. Ornish could be a huge help in accomplishing this. Indeed, one of my commenters put it very well:
You're doing science-based preventive medicine. Prevention and health care maintenance have always been core concerns of medical science. Nothing "alternative" about it.
So what do you need CAM for?
Why sit with that army of anti-science quacks on their side of the table when you could be over here with us? (Srsly. Take a look at Weil. Dude knows his way 'round a bong and a sandwich LOL.)
We try not to lie to the people, even though it might be fun. We don't like to over-state our data, unless we're really drunk. We don't like getting called on our bullshit, but we accept that this might sometimes be necessary for the greater good.
We are tough. We are rockin'. Chicks dig us!
So get yer ass over here!
I echo the sentiment, and say to Dr. Ornish: "Get your ass over here, back on the side of science- and evidence-based medicine." Or, channeling Luke Skywalker trying to persuade Darth Vader, "I know you can still turn away from the Dark Side."
What do you need "alternative" medicine for, Dr. Ornish? Really? Think about it. What has it done for you other than lump you together with the crystal gazers, shamanic chanters, and purveyors of quackery? I do not say "unfairly lump you," because you yourself chose this association, and you yourself can choose to end it.
You have the potential to be a pioneer in showing scientifically just what dietary and lifestyle interventions can really do, but instead, you're letting a bunch of opportunistic apologists for quackery coopt you and your work for their own purposes. They're using you, and your diet is nothing more than a convenient tool, a "foot in the door," if you will, behind which quackery will follow.
Stop it. Please.
Dr. Ornish is also a member of the Advisory Board for the so-called Physicians Committee for Responsible Medicine (PCRM): http://activistcash.com/biography.cfm/bid/1339
So is Dr. Weil, BTW.
I don't Ornish will be turning from the Dark Side any time soon.
The guy's kinda in a tough spot. Ever been to Marin County?
Imagine you're Obama and you believe in Einstein's God. *cough*
Ornish could leave the dark side for truth, justice, and the American way. But he'll still need to periodically throw an inconsequential-Rick-Warren-at-the-inauguration bone out there for his constituents.
It's do-able. I can overlook a few weasle words of woo in a colleague, provided they're inconsequential.
But what isn't clear to me is how much of a narcissistic hit he can take without feeling really threatened or damaged. Our tribe is pretty vicious toward bad ideas.
I have downed the Kool-Aide myself before, from time to time. I remember when I wanted to be a psychoanalyst how annoyed I felt with "narrow" definitions of so-called "science." LOL.
But the slings and arrows of peer review are really nothing in the grand scheme. Our Kung-Fu is mighty and will not fail to bring us victory in the end.
Only a fool would stand against Team Science.
Dr. Ornish is also a member of the Advisory Board for the so-called Physicians Committee for Responsible Medicine (PCRM).
I didn't know that! That's bad. Very bad. I thought I had a chance to reach him, but maybe it was just a fool's errand.
I think it's safe to say that we've lost him. Anyone who is comfortable sitting on the Board of the "Physicians Committee for Responsible Medicine" (the only honest part being the short word in the middle) with the likes of Andrew Weil and Henry Heimlich has to have left any committment to science far behind.
In fact, I would happily recommend even something that I now think as ridiculous as homeopathy if science could show that (1) it works significantly better than a placebo and (2) provide an reasonable scientific mechanism by which it could work.
Why #2? Arent ther a lot of things that we know work but don't know how it works. Was the mechanisms of the smallpox vaccine understood before we realized that something like smallpox was good enough to immunize us against smallpox?
I'd happily use homeopathy if a) it was shown to work better than placebo and b)shown to work better than an equally safe drug (like tylenol).
Heck, I'd believe in telepathy if someone could show it existed with good tests.
Dr. Ornish appears to be rather uninformed about the deeper implications of telomerase activity in the setting of low-grade prostate cancer.
I am not a cancer biologist per se, but I don't have to be one to say that increasing telomerase activity 25% above pre-treatment baseline (BTW, did he do any controls for patients without cancer in situ?) is not necessarily in the patients' best interest.
Assuming that the baseline telomerase activity (in peripheral blood monocytes?) was adequate to maintain the stem cell lines, a "therapy" that increases telomerase seems to have the potential to "unleash" a cancer that had heretofore been constrained by loss of telomere length.
Of course, this all assumes that increasing the telomerase activity in peripheral monocytes did anything to telomerase activity in prostatic epithelium (or, for that matter, prostate cancer). Does Dr. Ornish not know that telomerase activity is tissue-specific?
So, am I missing something? I'll get the paper later today and look it over, but it sounds like the wrong conclusions were drawn from the data.
Why #2? Arent ther a lot of things that we know work but don't know how it works. Was the mechanisms of the smallpox vaccine understood before we realized that something like smallpox was good enough to immunize us against smallpox?
Edward Jenner didn't have a proven track record of making shit up.
Telomerase is kind of a double-edged sword- yeah, increasing telomerase might help a cancer that's already there, but telomere crisis (uncapping of telomeres because they're too short) is thought to be tumorigenic.
As I understand it, the idea here is NOT that the immune system telomerase levels in the PBMCs are necessarily even correlated with telomerase levels in the prostate, only with overall general health. We know that low blood telomerase is associated with cardiovascular risk and other health problems. This study is trying to show that these lifestyle changes promotes general health and decreases a risk factor (low telomerase levels) that we know predicts other serious health risks. There's no conclusion that this is a cure for cancer.
At least, as a member of Dr. Blackburn's lab (albeit not in the clinical side of it), that's how WE took it- from several months of reading this blog, I wouldn't be surprised if Dr. Ornish tries to spin it to say that it does/is/could be.
"Dr. Ornish is also a member of the Advisory Board for the so-called Physicians Committee for Responsible Medicine (PCRM)."
That may explain absolutely everything here: PCRM and "plant based diet"....
Not a surprise that someone from the "oh no, we're not animal rights based at all, we're into real science and medicine, honest" PCRM is presenting more vastly overstated benefits of lifestyle changes that happen to include "plant based diets" as per the Ornish diet.
This is Cargo-cult science: the few from the PCRM who publish science all use their papers to over-estimate the benefits of veggie or vegan diets and vastly overstate the dangers of meat eating. They'll then self-cite the papers when they're making more overt cases about avoiding animal based diets.
The PCRM do the same with animal testing - they publish poor quality and biased reviews in low-tier journals that say animal testing isn't predictive to humans and then self-cite them as if they are definitive and fully peer reviewed positions.
It's a shame, there are probably real scientific findings and real lessons about diet mixed in with what they publish but you just can't trust any of it.
@Dr. Benway: Yes, I've been to Marin County- and not for the woo.I'm afraid that in Ornish's case it might *be* the woo-ful enterprise that allows him to *afford* being in Sausalito.
Arent ther a lot of things that we know work but don't know how it works.
You can use a couple "what-ifs" in your mechanism in a young science. Example:
- What if (1) something in the pox provokes a lasting defensive reaction in the body and
- What if (2) cowpox might provoke a reaction protective against smallpox?
#1 seems plausible based on the observation that people who've had smallpox seem not to get it again. And #2 seems plausible given the observation that milkmaids who get cowpox don't get smallpox.
What you ought not do: sixteen "what ifs" in your mechanism that you pull out of your ass. That's not science but a mental disorder I have termed, polymaybeosis.
Someone more informed than I might go through Ornish's study to count the "what-ifs." One potential one noted above:
What if telemorase activity in peripheral blood monocytes correlates with the suppression of prostate cancer?
Every "what if" requires a reminder and an apology, as each one is an imposition upon the credulity of the reader, who might assume prior evidence exists when it does not.
...after a year of stagnant traffic, January and February were the best months, traffic-wise, in the history of this blog. What that means, I guess, is that sometimes people whom I would never have expected to give a rodent's posterior about what a nobody like me writes actually sometimes take note.
I think there are two factors. The one you mention is the lessor.
Of course you are adorable in a big-dog kinda way. But that's nothing new.
The medical blogsphere is reacting to "hope and change" aka "fear and trembling." The government is here and it is ready to help.
I'm feelin' it.
Greetings from the belly of the beast, or as I call it, The Axis of Me-ville. Here in northern California, fear of science, especially medical science, is big business. As an advertising creative director, I was paid handsomely to "mainstream" woo into something called "LOHAS" back in the tech-bubble 90s. I have seen the the Chopra and the Weil in their natural habitat and it's not pretty. I've seen them fundraising in the candle-glow, working rooms of neurotic, rich, PC, bourgeois-leftists, gliding soothingly amid the Marin glitterati, slick as eels on teflon. I've seen the money they make from the worried-well, I can only imagine what they make from the actually-sick. By hanging with Chopra and Weil, Ornish gets cred with these wealthy, gullible, self-absorbed folk. I doubt he'll uncouple from the golden tit as long as the money and adulation flow. Being a new-age demigod in the Axis of Me-ville is utterly seductive. I saw fairly decent people turn into high-maintenance, tantrum-throwing divas in that environment. Ironically, it was working directly with these men, who I had once revered for their "wisdom", that scraped the last barnacle of magical-thinking off my hull. Reality is better than woo in every way. Thanks Orac, I'm learning so much here, I hope I can keep it all in my head.
I just wrote a primer for beginners on evidence-based medicine, and it's extraordinarily frustrating to try to explain why it's so rare.
sounds useful, can you share it?
" I doubt he'll uncouple from the golden tit as long as the money and adulation flow."
The analogy I was mulling over last night was being stuck to the tar baby of Woo. Every once in awhile someone with a decent background of science/medical training who's strayed too close to the tar baby reaches out to this blog in what's either a desire for self-justification, an unconscious appeal for extrication or (more ominously) an attempt to drag others into the quagmire.
You have to feel a little sorry for them. Once you've wandered into the land of Chopra, there's a tendency to keep flailing away until you find yourself hopelessly entangled with Mercola and Mike Adams, and there's no getting free, ever.
Save yourself, Doc Ornish!
The Corner, Thursday, March 05, 2009
"News from Iran . . . What the New York Times Missed [Michael Rubin]
The full Iran News Updates are available free for anyone who asks for them (firstname.lastname@example.org), but a few stories from the Iranian press worth mentioning today:
Ahmadinejad praises traditional medicine, attacks modern medicine, which is the product of Zionists."
Gee Orac, now I know your problem. You're a Zionist. You believe in "Jewish medicine." Bet you believe in "Jewish Physics", too. (Pesky things: General Relativity and Quantum Mechanics).
"We try not to lie to the people, even though it might be fun. We don't like to over-state our data, unless we're really drunk. We don't like getting called on our bullshit, but we accept that this might sometimes be necessary for the greater good."
I don't know who this commenter is but over the last couple years I have made a hobby of reading medical journals, several of which I have paid out of my own pocket to subscribe to. I also often peruse science-related websites such as Science Daily. Although I have no background in science and very little background in statistics (2 statistics courses in college and I used multiple regression analysis in my honors thesis) even I can see that researchers frequently, repeat frequently, overhype their results, particularly when issuing press releases or speaking to journalists. There are a number of reasons why they do this, including a natural human tendency to believe in one's own results regardless of whether they are consistent with whatever other evidence is out there.
Don't get me wrong, I am totally with you on the perniciousness of these CAM boosters, but I think it behooves us not to over-idealize scientists and physician scientists. They are human, like anyone else.
Hi Marilyn Mann,
I don't mean to say that on one side of the table sit saints and on the other sinners. Rather, on one side are people who explicitly agree on the rules, and who support a culture where those rules are respected, while on the other are people who are ambivalent about the rules at best.
On my side, anyone who says, "my personal opinion trumps the consensus of the scientific community" gets a kick in the shins. That doesn't happen on the other side.
There are lots of jerks over here on my side, people who try to have their cake and eat it too. But they agree on the rules. You can call them out when they break them. They might be huffy and unreasonable for a time, but they don't try to sabotage the system.
Hi Dr. Benway, I am very glad we are having this conversation because I clicked on your name and discovered your blog. You are very funny -- I read several of your posts.
I think it is hard in comments posted to a blog to convey all the nuances of what one thinks. Probably our views on things would not differ greatly if we could discuss it over a beer.
I think you are generally right that most people who are doing science agree on the rules, but the problem I see is that some do not but it is not always that easy to know who those people are. You have things like ghostwriting, seeding trials (such as the ADVANTAGE seeding trial, which Orac wrote a post on), and publication bias (e.g., negative trials not getting published) that occur fairly frequently. So looking at the literature in a certain area and taking it at face value can sometimes lead you astray.
I am not critiquing the scientific method, but the perversion of the scientific method.
If you would like citations and PDFs I would be happy to provide some. You can contact me at email@example.com. Thanks, Marilyn
Dangerous Bacon comments:
"The analogy I was mulling over last night was being stuck to the tar baby of Woo."
I like to think of it as similar to crossing the event horizon of a black hole. Once you're beyond the event horizon, there's no coming back. And even if you haven't crossed it yet, there is a limit to how close you can get before you are inexorably drawn in.
Most people don't have the "thrust" necessary to break orbit from the "black hole of woo". Once you let yourself drift into the gravity well of the "black hole of woo", there is a limited amount to begin your exit. If you start too late, you'll never get out.
Actually, the black hole analogy works quite well on a number of levels. Like black holes, "alternative" medicine woo emits no light, just a powerful gravitational attraction that sucks in everything (e.g. money) that gets too close.
BTW, I read Dr. Ornish's PNAS paper on gene expression in prostate cancer. It was reminiscent of some of the worst of the early microbial micro-array papers from ten years ago - long on supposition and short on hard data.
They have a bunch of genes listed that are differentially regulated in their study, but no indication of what role these genes play in prostate cancer. For example, the #1 downregulated gene was RAN, which encodes for a GTP-binding protein essential for translocation of RNA and proteins in and out of the nucleus.
Is it good or bad to reduce expression of this gene in the setting of prostate cancer? Is it even relevant?
The #1 upregulated gene was NR2F1, a steroid-hormone receptor-like protein that has no known ligand. What it its relevance to prostate cancer?
They have no idea what most of the differentially regulated genes do, let alone what their role in prostate cancer might be, but that didn't stop them from making guesses that support their pre-chosen hypothesis. That's probably why it had to be a direct submission.
Decided to come back and give a few links:
The ADVANTAGE Seeding Trial: A Review of Internal Documents
Seeding trials: Just Say No
Bias, Spin, and Misreporting: Time for Full Access to Trial Protocols and Results
Reporting Bias in Drug Trials Submitted to the Food and Drug Administration: Review of Publication and Presentation
Why Most Published Research Findings Are False
Selective Publication of Antidepressant Trials and Its Influence on Apparent Efficacy
Guest Authorship and Ghostwriting in Publications Related to Rofecoxib
What Should Be Done To Tackle Ghostwriting in the Medical Literature?
Harlan Krumholz and Joseph Ross, Relationships with the drug industry: More regulation, greater transparency
Marcia Angell, Relationships with the drug industry: Keep at armâs length
Hm . . . Hope I didn't get too carried away.
"...Most people don't have the "thrust" necessary to break orbit from the "black hole of woo". Once you let yourself drift into the gravity well of the "black hole of woo", there is a limited amount to begin your exit. If you start too late, you'll never get out..."
Fortunately Dr. James R. Laidler, see Through the Looking Glass:
My Involvement with Autism Quackery, accomplished getting off of a woo train; maybe Dr. Ornish can do similar if he puts his mind to it.
In the mid 90's I attended a preventive cardiology conference. Just before Dr. Ornish went on, he sat next to me in the back and prepared to be introduced. I quietly said "hello," and then asked, "can't one get the same benefit(reduced LDL cholesterol and possible plaque reversal)by taking a statin as compared to following your 10% fat diet?" He whispered, "probably" and got up from his chair and moved to another before he was introduced.
He had a book, program, way of life to sell. His Ornish program for patients was very expensive. Sure, I'm glad he encouraged a meatless lifestyle (I'm a vegetarian), but he has something to sell.
Money makes the world go 'round, especially in the integrative medicine community.
Dr. Ornish has finally replied:
Fortunately Dr. James R. Laidler, see Through the Looking Glass: My Involvement with Autism Quackery, accomplished getting off of a woo train; maybe Dr. Ornish can do similar if he puts his mind to it.
It's different. Dr. Laidler let himself be pulled for personal reasons. He was hoping those treatments would be useful for his children, and he really thought he was talking to experts who could help him.
You all seem very smart and very concerned about capitalism and its affects on our society. Yet I see no mention of how our consumerism and pollution of our country has resulted in one of the sickest industrial nations. There needs to be some health education of patients and docs who don't fight their 10 minute appointments to give patients some guidance shouldn't be surprised when their patients in frustration turn to alternative medicine. Eating a healthy diet and exercise should be a staple of a traditional doctors advice and education of patients but many docs just don't care enough or know enough themselves. I think government money spent on health education would not be wasted. Health systems, insurers, physicians - none of them have the resources - instead of spending time attacking the alternative side step up to the plate and advocate for giving patients basic wellness information that they need.
There needs to be some health education of patients and docs who don't fight their 10 minute appointments to give patients some guidance shouldn't be surprised when their patients in frustration turn to alternative medicine. Eating a healthy diet and exercise should be a staple of a traditional doctors advice and education of patients but many docs just don't care enough or know enough themselves.
Funnily enough, I was at the doc's a few weeks back trying to blag some temazepam as my sleep's a bit off due to work-related stress. First bit of advice she gave me, before writing a very short prescription: get some exercise.
Taking her words of wisdom to heart, I have since been out for a regular walk... exactly once. (And yes, my sleep pattens still suck. Who'da thunk?)
People don't turn to woo because they aren't getting good advice from their physicians. They turn to woo because physicians aren't telling them what they want to hear. The CAM industry, on the other hand, is only too happy to validate their crappy lifestyle choices and stroke their egos - for a fee and a waiver, of course.
You pays your money, etc.
You need to stop taking the MD approach and discounting patients as stupid - that's why they turn to woo. I have as son with heart defects. I looked at woo because my prominent cardiologists failed on numerous occasion to tell to anything that would help my son short term - other than we would wait for an acute issue. Indeed, despite many published studies no one bothered to advise me that my son had an increased risk of CAD. There is nothing wrong with a doc saying there have been several studies saying this or this you may want to try it. I just don't think docs know or sometimes scarily don't care. To that line I think that Dr. Benway moniker is insulting and goes to show why traditional docs fail.
I, however, did research including looking at Ornish and thought I would not hurt to ensure we adopt every possible heart healthy aspect to our diets. I am smart enough to not agree with the other woo - and its a shame that Ornish does. However, after leaving my big law firm job and spending countless hours cooking and not using packaged products I explained my approach to our Stanford cardiologist. His comment was I wish all my patients would do that!! Well who is going to tell his patients - certainly not him with the 5 minutes he gives us every year. Anyone who has studied "science" knows how complicated and confusing the body is and it gives you a respect that keeps you somewhat healthy. The vast majority of your patients however don't know this. By the way did your doctor take the time to explain why regular exercise might help your sleep or just give you the advice like they know better. If the woo doctors have one skill from not studying as much in med school is how to interact with patients.
I looked at woo because my prominent cardiologists failed on numerous occasion to tell to anything that would help my son short term - other than we would wait for an acute issue.
IANAD, but perhaps there wasn't anything that could be done? Sometimes the best/least harmful course of action is to do nothing at all. Not the answer you'd want to hear as a deeply concerned parent with a powerful need to do something to help your child; alas, reality has never included a written guarantee that it shall never be harsh.
Look at it from another perspective: a hundred years ago a western child with a serious medical condition would likely have died in infancy; even today there are plenty of parts of the world where they still do. By that measure you and your son are already ahead overall, even if medicine and/or medics can't provide you all the solutions that you (and they) might wish for.
If the woo doctors have one skill from not studying as much in med school is how to interact with patients.
Con artists can appear caring and helpful. Doesn't mean they actually are.
BTW, if you want to do anecdotes, then I've had maybe a half-dozen doctors in my life - general practitioners mostly, plus the odd psychiatrist. All have demonstrated vastly better people skills than me, being helpful and informative and readily responding to questions and concerns, so I've no complaints there.
And yes, my doctor patiently explained - without prompting - the reasons for adopting better lifestyle habits and against trying to medicate the problem away. Which I already knew, but I'm just an apathetic slob trying to score a magic bullet fix for my own rash and/or lazy choices, so any problems I have are entirely of my own manufacture.
You need to stop taking the MD approach and discounting patients as stupid.
MDs are sooo stupid, aren't they.
To that line I think that Dr. Benway moniker is insulting and goes to show why traditional docs fail.As Herr Doktor Benway has not yet mastered the art of the humorectomy, I take it you are not a former patient.
You may not have heard: "irony" actually does not mean, "iron-like."
MDs do not think their patients are stupid. What patients tend to be is non-compliant, and doctors see it time and time and time again. I imagine it makes one feel like a broken record when one tells a patient to eat more fruits and veggies and get more exercise every single appointment, and with every appointment said patient comes back not having done so.
My husband went in for a physical-- his trigylcerides came back nearly 400! At his followup appointment, however, he showed the results of four months' adherence to diet and exercise guidelines given him by the doc. He had lost 30 lbs., and his triglycerides were 113. His internist's reaction was shock that my husband had actually followed his advice! Sadly, that is a rarity rather than the rule.
People complain about our pill-based society, but then when push comes to shove, a pill is what most people want. Otherwise, they'd have to make substantive life changes, which is haaaaaaaaaaaaaard.
Eating a healthy diet and exercise should be a staple of a traditional doctors advice and education of patients but many docs just don't care enough or know enough themselves.
Telling people to exercise more, stop smoking, cut back on the booze, and follow the food pyramid doesn't exactly require an advanced degree. The truth is that many docs do lecture their patients on lifestyle modifications, but it's very difficult for many people to follow through on them.
However, after leaving my big law firm job
What to say? No-one I have trained has written as badly as you, and I haven't been at a "big law firm" - although I am in England, and standards may vary.
You have no need to declare an occupation on this blog; your arguments will stand or fall on their merits. If you nevertheless choose to do so, just stick to the facts.
Robin - you're assuming a "big law firm job" involves being a lawyer as opposed to, say, a gofer at a big law firm.
Janitor was my guess...
I'm not a believer in alternative medicine, but I've noticed that sometimes alternative medicine includes accurate observations that haven't been validated by rigorous research, or end up being validated later. Just as some folk remedies have been found to work.
Especially if you have a disease that's a medical no-man's land, you're likely to look into experimental approaches.
For example, I have food sensitivities, probably as a side effect of celiac disease. I have to avoid many different foods, because if I eat them I'll get sick and groggy for days, starting 1/2 hour to 4.5 hrs after eating the food. People don't know much about what's going on with this kind of food reaction. But I've found some real help in some alternative approaches - for example, a "rotation diet" - eating a given food or others that might cross-react with it, only once every 4 days - has seemed to help me avoid developing new food sensitivities. This is pretty much an "alternative" approach. Also, I used to have "reactive hypoglycemia", that is, reactions to high-carbohydrate foods, like jittery feelings, irritability, tension - that went away completely after an elimination diet. I found this described on "alternative" hypoglycemia websites, not in the research on Medline.
So while I'm very cautious and skeptical of "woo", in my experiences some of what woos is right ;)
To all: Ornish's diet advice is basically the same as T. Colin Campbell's advice in "The China Study": plant-based diet, low fat, non-processed foods. Campbell's 40 years of scientific research seem to confirm that animal protein promotes cancer growth, and many other diseases. After all of this evidence, do you believe that this plant based diet Ornish is promoting, regardless of how he promotes it, may actually stop some of these diseases? Campbell says animal-based nutrients promote the development of cancer, heart disease, diabetes, and obesity. He said they could literally "turn off" cancer cells if they removed all animal products from the diet. Is that true? The bottom line: Removing ALL ego and politics, do you believe that Ornish, Campbell and (many) others have NOT adequately proven that these dietary suggestions do indeed HALT disease and save lives? With all of these debates, how are any of us supposed to know what is really best for our health? Some of us are so genetically disadvantaged, with genetic cancer syndromes wiping out our families, that we just need to know if Science has proven that we should eat as Orish advises: entirely plant-based, or not?
The data in the studies are statistically significant within the study period. I hope you know what "statistically significant" means. The result's, albeit surrogate endpoints, pretty impressive given that dietry intervention typically have a slow response and takes long time to show statistically significant results. The results don't need to impress you, Orac. You are not Science.
What's impressive in your opinion? How about 'substance A' that reduces(ARR) major coronary events by 1% in primary prevention, 2% in diabetics, and 4 in secondary prevention and reduces death by 0% (primary prevention, not statistically significant), 0% (diabetes, not statistically significant), and 2% (secondary prevention)?
Are these results impressive or not?
Since it appears that you are pretty hard to impress, I would think you'd answer no. Well, Orac. This substance A is the best science-based drug that we have for CVD. It is statin. Statin has 0.2% ARI rhabdomyolysis.
For those who do not understand: if you give statin to 100 at-risk patients (eg. elevated cholesterol etc) for 5 years continously, you will prevent ONE patient from getting heart attack/stroke, but it does not prevent death. If you give statin to 100 diabetic patients, you will save two patients from getting heart attack/stroke, but will not prevent death. If you give statin to 100 patient who already had heart attack/stroke, you will save four patients from having heart attack/stroke, and prevent death in two patients. Unfortunately statin will cause serious life-threatening muscle breakdown in one of every 100 patients. This is the most cost-effective, proven therapy with one of the LARGEST magnitude of benefit among almost all drugs.
Now, go start writing something for docs prescribing statins for their diabetic/at-risk patients. Feel free to call them what ever nasty name you'd like.
Also in your leisure time, pls go read big meta-analysis on drugs used today (like HTN, osteoporosis) while paying particular attention to the magnitude of benefit. After you've done that, tell me if you are impressed. If not, please start bitching about docs who prescribe those as well.
Oh and one more thing, what's the harm in following Dr. Ornish's diet even if it turns out to be much significantly less beneficial than what you think it claims?
I appreciate your hallucinating comments.