I read this book a month or so ago, but we’re having a Chicago Skeptics Book Club for it tonight, thus a fire was lit under me to write this. As someone whose favorite skepticism subject is medicine, I’ve read or consumed a number of similar books/blogs/podcasts (Trick or Treatment, Mark Crislip’s work, Science Based Medicine, and Neurologica). I’ve also read (nay, DEVOURED) a couple of Paul Offit’s vaccine or autism-related books though, and took his online vaccine course last year; so this seemed to be a natural choice. And a good use of my large Amazon certificate coffers that my brother and his wife keep filling. I didn’t know whether it was going to be a rehashing of what Simon Singh, Edzard Ernst, Mark Crislip, Orac, and Steven Novella et. al. had written (and oh well if it was, I like his writing), but it turned out to be quite a bit more.
Offit’s impetus for writing the book was an incident after his knee microfracture surgery when an orthopedic surgeon recommended chondroitin sulfate and glucosamine to reduce inflammation and encourage cartilage growth. He was befuddled that a seemingly orthodox doctor (and an orthopod!) was recommending something Offit thought trials had definitively declared useless. He did a literature search and confirmed this, which led him to the conclusion that “we [medicine] had crossed over.”
I had a similar experience with an HMO-assigned physician recommending acupuncture for my crunchy, poorly tracking knees. Similarly befuddled, I saw a placard near the reception area telling of her education at both medical school and an “Oriental medicine” school. If only I’d though to mention something like “[i]n mainland China…where both traditional and modern therapies are available…only 18 percent of the population relies on alternative medicine…acupuncture is embraced almost solely by the rural poor.”
There is the familiar run down of the history of snake oil and patent medicines in America (which includes the original Coca Cola, described here and recently on Drunk History!), Upton Sinclair, and the subsequent birth of the FDA. There are explanations of the other alt med usual suspects that I have read/heard about elsewhere; including homeopathy, coffee enemas, antineoplastons, and Susanne Somers’ “bioidentical hormones” and laundry list of pills and potions. Of course, Offit’s unique explanations and tidbits made this still something I wanted to read. He devotes an entire chapter to cancer cure charlatans throughout history, and Burzynski gets his own chapter.
The biggest surprise of the book was a preponderance of bad news about supplements. I’m sure we’ve all heard that “they can’t hurt, may as well take a multi” or “you only need to care about the fat soluble ones” or “those population studies might be showing a correlation and not a causation since sick people may be taking more supplements to make up for their crappy lifestyles.” OR (and I find this to be a shaky, patronizing argument) “most people have terrible diets, they need supplements.” The truth turns out to be far worse.
Offit describes a number of studies and metanalyses in which cancer patients were assigned either a placebo or megadoses of antioxidants. This is kind of ironic since we often call the supplement industry “Big Placebo,” though placebos are harmless by definition. Megadosed patients either had no benefit, increased morbidity and mortality, or so much harm that the trials had to be halted. I’ve never seen this much evidence that supplementation can be harmful stacked up in one place. And it’s not like there were huge benefits to these sort of therapies to justify such a risk.
Good ole Linus Pauling had gotten this crazy idea in our heads that vitamins (yes C, but others as well) could cure everything from colds to aging. Public consciousness got a hold of the “a little is good, so a lot must be better” mentality, which even now seems entirely impossible to shake thanks to the likes of Dr. Oz, Andrew Weil, and the powerful, politically connected supplement industry. “Antioxidant” is right up there with “natual,” “organic,” and “gluten-free” these days. They are nice marketing terms, but don’t back their promises up with much science.
This is the antioxidant paradox. Yes, we need them to repair damage to DNA. But pour too much into a biological system, and you get an economist’s favorite thing: unintended consequences. Oxidants play a role in killing bacteria and cancer cells, among other things. Marsha Cohen, in a 1975 attempt to prosecute William Proxmire’s bill to protect the supplement industry, lined up 8 cantaloupes to demonstrate the how many one would need to eat to equal 1,000 mg of vitamin C. This is a standard dose that you can take in two pills. It is not to give credence to the naturalistic fallacy; but the fact that it’s not natural (or maybe even physically possible?) to consume 8 cantaloupes presents “the opposite of what manufacturers had been promoting.” Eating that much fruit sounds like some sort of hazing ritual if you ask me.
Of course, the supplement industry peddles minerals and plenty other substances as well. We’ve seen the argument over and over that supplements and herbs are natural and to be trusted over everyone’s favorite boogeyman, Big Pharma. It delights me to no end how this is entirely false on all counts. First of all, Big Pharma has no trouble wetting its beak in the supplement market and many manufacturers are, in fact, owned by pharma companies. Yes, I just linked to Fox News, but you can easily see the other reliable Google entries on this out for yourself. Supplement factories are the Swiss banks of pill manufacturing, in that they are super under-regulated and don’t need to prove safety or efficacy. It’s a multibillion-dollar industry with far less overhead than prescription drug production. Minerals can have dangerous levels of heavy metals and have no standard for quality control. Herbs are drugs without listed warnings, interactions, standardized doses, or efficacy for whatever condition they are touted to treat. Or they may just do nothing, like saw palmetto and echinacea. Scratch that, echinacea can give children a rash. I spose that’s a use.
In other words, the supplement industry is not that guy you met at Burning Man grinding up a root with a mortar and pestle. It’s Gerald Kessler, the founder of Nature’s Plus, who lives in Ray Kroc’s old estate, complete with wandering ostriches and trumpeter swans. It’s enough to make Jack Donaghy shed a tear.
As with any complex subject, there are caveats and grey areas. Offit includes a chapter about which supplements have proof of efficacy. While of course testing isn’t a requirement for supplements and herbs, the NCCAM is the body that has wasted about $1.6 billion studying these and other alt med modalities. The problem is that if they find evidence of harm or lack of benefit, there’s no recall or change on the supplement or herb’s label in your local herbalist or GNC. You can dig through medical literature (if you are so inclined), but how likely is that to catch someone’s attention when there are people like Oprah and Oz or posts on message boards about how saw palmetto cured someone’s uncle’s enlarged prostate?
As for those supplements with some hope of efficacy or usefulness, Offit names 4 (maybe 4.5 if you count the weak effect of St. John’s Wart). But that’s 4/4.5 out of ~51,000. The “winners” include omega-3 fatty acids (which are not without risks for men), calcium and vitamin D for certain populations, and folic acid for pregnant women to prevent birth defects. But 4 out of 51,000? There obviously aren’t many people keeping score.
Offit goes into detail about Steve Jobs’ unfortunate demise. As if that weren’t bad enough news, the book is peppered with stories of child cancer patients (often a type that is usually curable) who were also victims of quack gurus. He reviews the dubious, unproven, and often harmful treatments for autism that our buddy Jenny McCarthy and others promote and subject unfortunate children to. Sure, that includes fairly innocent things like special diets, but there are also bleach enemas, for crying out loud. Offit’s past books dealt with the history of vaccines and autism treatments, so this is his wheelhouse and the source of much of his hate mail. He has a slightly sunnier attitude towards the uses of placebo than similar writings (I’m looking at you Crislip and Novella!), but it’s more that he has a more positive attitude towards the known limits of placebo.
So, now that I’ve written my first TLDR post, I’d say the takeaway is that all skepticism should be a form of consumer reporting, and what commodity is more valuable than your health? But I bet you hated swallowing all those horse-pill-sized multivitamins anyways. And though this phrase is getting to be a bit of a broken record, it bears repeating:
There is no alternative medicine. There is only scientifically proven, evidence-based medicine supported by solid data or unproven medicine, for which scientific evidence is lacking.
P.B. Fontanarosa, JAMA (1998).
Note: I am interested in *reasonable* criticism regarding this book, but please no Big Pharma rants or vaccine rants or anecdotes please. Stick to science.