Which is more urgent: military drones or a cure for cancer?

A Global Hawk drone

The U.S. government has an answer: drones. Drones and other weapons of destruction are vastly more important than healing people - or at least that’s what one might think, based on our government’s spending priorities. In the most recent federal budget, we spent $821.6 billion on defense, which includes $636.2 billion for the Defense Department, $138.9 billion for veterans, and another $46 billion on foreign military aid. We spent just $29.1 billion for the National Institutes of Health, the epicenter of all our research on new cures for disease. That’s a decline of $1.7 billion from 2012 (thanks to the sequester). In the big picture, then, we spent 28 times as much on defense as we spent on curing disease.

Does anyone in the federal government ever step back and think seriously about what our overall priorities are? Or do they just think about whether to adjust a particular agency’s budget a few percent up or down? Congress returns from recess next week, and they’ll make lots of noise about the budget decisions, and then they'll pass something that makes at most a few incremental changes.

A big problem with our short-term approach to governing is that the forces that want to keep everything the same are always more powerful than the forces for change. The people and institutions that benefit from the current budget are already in place, and always at the ready to lobby against change. We desperately need to review our priorities, at least once in a while, and make a rational decision about how much to invest in the things that government does. Do I expect this to happen? No. But that doesn’t mean we shouldn’t try to make the argument.

Here are just a couple of examples of how current spending plans just can’t be stopped, even if they have gone wildly out of control. First let’s consider the Global Hawk drone program, which the Defense Department itself would like to terminate: the Air Force says it has better equipment for the same job. Ending the program would save $2.5 billion over four years. (That’s $2,500,000,000. It helps to write these numbers out.) How did Congress respond to the Air Force proposal? The head of the Armed Services Committee, Howard McKeon (R-Calif.) rejected the proposal and added $443 million to purchase three more Global Hawks. Not coincidentally, the manufacturer of these drones, Northrop, builds them in the district represented by McKeon.

A bigger example is the Joint Strike Fighter program, the most expensive plane in history, which is now estimated to cost $400 billion by the time it starts flying in 2018 - if it’s not delayed further. This is more than triple its estimated cost in 2001, when it was first approved for $119 billion. Just recently, the Pentagon itself reported 147 “major” quality issues with the program. 

We won’t even have these planes for another 5 years, so obviously this hasn’t improved our security yet. And once it starts flying, the Pentagon estimates this fighter plane will cost another $850 billion to keep going. Who decided this was worth it? Is anyone seriously considering scrapping the whole project, before we spend another trillion dollars on it?

There are many more examples, such as the $436,000,000 we’ve spent building new Abrams tanks that the Army does not want. The Army may not want it, but it’s built in Ohio, and the Ohio members of Congress (both Democrats and Republicans) have fiercely defended it. 

It’s not just Defense, of course - we are still funding the 1925 federal helium program, which Congress seems unable to kill. The helium program was started after World War I, when the U.S. was worried that it wouldn’t have enough blimps. Lobbyists are keeping the program alive.

Let’s go back to the big picture. The leading causes of death in the U.S., according to the CDC’s latest figures, are:

1. Heart disease (597,689 deaths)
2. Cancer (574,743 deaths)
3. Chronic lower respiratory disease (129,476 deaths)
4. Stroke (120,859 deaths)

You might expect that we would be pouring money into research on the biggest causes of death in the country - at least as much as, say, a new fighter plane. But you’d be sorely disappointed: the entire U.S. budget for cancer research at NIH's National Cancer Institute is $4.78 billion. That’s for every type of cancer (and there are hundreds). This budget covers clinical research on new treatments, long-term research on understanding cancer, and everything in between. The budget for heart, lung and blood disease (the number 1 and 4 causes of death) is even smaller, just $2.90 billion. 

These numbers are little more than round-off errors when compared to the entire U.S. budget, which for 2013 is $3,454 billion.  The NCI budget is just 0.14% of the total.

How much should we invest in cures for all disease each year? How about 5% of our budget? Or maybe just 2%? That doesn’t seem like too much. Ask anyone who has cancer, or who knows someone with cancer, if 2% of the budget is too much to invest in cures. I suspect that most of them will say it’s not nearly enough. 

2% of the federal budget is $69 billion. Let’s put that on the table as next year’s budget for NIH. Rather than building weapons, let's use our tax dollars to build new things and make new discoveries. Rather than destroying infrastructure in other countries, let’s invest in our future, and create new treatments that make our lives longer and healthier. 

In the current issue of The Atlantic, James Fallows interviewed Eric Lander, one of the world's leading genome scientists, and asked him when genomics would lead to a cure for cancer. Lander responded:

“If we invest vigorously in this and we attract the best young people into this field, we get it done in a generation. If we don’t, it takes two generations. That’s a very big difference.”

Think about it. If we invest more now, you might see a cure for most forms of cancer in your lifetime. Two generations, though, will be far too late for most of us. How many more people need to die from cancers that we’ll eventually be able to cure?

Government ranking of U.S. universities: a truly bad idea

The U.S. Secretary of Education, Arne Duncan, has come up with a plan to produce official government rankings of our universities.

The plan was announced this past August, and over the past month, the Obama administration has been holding public forums around the country to get input about its plan.  But it seems like they’ve already made up their minds.

I hope not.  This is such a bad idea I don’t know where to start.  But I’ll start.

First of all, we have multiple rankings systems already, including the highly regarded U.S. News college rankings, which millions of students, faculty, and administrators use every year.  Even though everyone loves to complain about it, U.S. News is pretty darned good: they rank colleges in many categories, by region, by specialty, and more. They also rank graduate programs and professional schools such as law and medicine.

If you don’t like U.S. News, there are several other rankings, including the more recently established World Rankings from Shanghai and The Times Higher Education rankings. These are excellent rankings, well-documented using multiple criteria, and not nearly so US-centric. All these websites are chock-full of useful data about hundreds of universities.

I know, I know: “ratings aren’t rankings” as Ben Miller wrote recently at the Inside Higher Ed site. But I’m not at all confident that the proposed ratings won’t turn into a ranking system, especially with the weight of the federal government behind them.

So we don’t need a federal ranking of universities. That’s the first problem.

Second, this push to create official ratings will inevitably lead to a new bureaucracy within the Education Department, which will then create a constituency that will fight to keep itself in existence. How many staff will Secretary Duncan hire to create these rankings? Dozens? Hundreds?  And how many university employees around the country will then have to be hired to answer whatever questions the government asks?  This seems like it could quickly become a very expensive proposition, running in the tens of millions of dollars annually, or perhaps even more. I haven't seen any estimate of how much this new system would cost, but I'm betting on a lot. What will we cut from the federal budget to create this new system?

Third, a ranking system will likely spawn a host of new requirements that universities will have to satisfy. Why? Well, primarily because federal financial aid to universities will be tied to their ratings. Thus it’s pretty clear that universities will do whatever they can to keep the feds happy. And I’ve no doubt that with a full-time bureaucracy in place, the federal raters will keep moving the goalpost - coming up with new measures that in turn will spur new costs throughout academia. I’m highly skeptical that any of these government metrics will lead to better education.

We’ve already seen what government scorecards do in our public education system. Thanks to the No Child Left Behind program, we now have incessant testing of students, beginning in elementary school, and thousands of hours devoted to teaching students how to take tests rather than learn new material. Schools have not improved as a result. Do we want this trend to creep into colleges too?

I’m not the only one who thinks this a bad idea. Janet Napolitano, the president the University of California system and former Secretary of Homeland Security under President Obama, told the Washington Post that she is “deeply skeptical” of the criteria that a federal ratings bureau would develop.

“It’s not like you’re buying a car or a boat,” said Napolitano.

Secretary of Education Arne Duncan has already criticized the critics of the new rankings system, calling the criticism “premature and a little silly.”  Duncan emphasizes the need to address the alarming number of college students who default on their student loans. This is certainly a problem, but a college ranking (or rating) system is not the solution.

Perhaps the biggest problems with student debt is the rapid rise in mediocre, for-profit online colleges. If the feds want to get the loan problem under control, they should stop funneling money to these Yugos of higher education. As the PBS show Frontline pointed out in 2010, for-profit universities are

 “churning out worthless degrees that leave students with a mountain of debt.”  

And they’re not cheap, either - the GAO found that

“tuition in 14 out of 15 cases, regardless of degree, was more expensive at the for-profit college than at the closest public colleges.”

So yes, we do have a problem with student debt. One solution would be to exclude truly bad colleges, which are responsible for a disproportionate share of student debt, from federal aid. But that would mean naming the bad apples, who in turn will claim that the government is somehow being unfair. Perhaps the new ratings are an attempt to be fair, but it just makes no sense to rate everyone in order to identify the worst universities. Having a federal government agency produce college rankings is just a bad idea.

Controversial GMO corn study being retracted over the authors' objections

Retractions are always interesting. When a scientific paper is retracted, it usually means the authors have found a serious error, and that the major conclusions are no longer valid. The error can be unintentional, but in some high-profile cases, the story is far more interesting.

Reading about a retraction is, for a scientist, kind of like reading about a celebrity divorce. You know something went wrong, and it just might be a bit scandalous.

Last year, I wrote a detailed takedown ("Does genetically modified corn cause cancer?") of a very poorly done scientific study by Gilles-Eric Seralini and colleagues, in which they claimed that genetically modified corn, Roundup Ready® corn, caused cancer in rats.  The study had many egregious flaws, and I explained a few of them after reading the paper.  Hundreds of other scientists criticized the study at the time, and six French science academies took the unusual step of issuing a joint statement that rejected the study's conclusions.

Among the many flaws, the study used far too few rats to make statistically valid conclusions, and it contained self-contradictory results, such as data showing that rats fed the highest amount of GMO corn lived longer than rats fed the lowest amounts.  They also used a strain of rats that is highly prone to cancer.  Basically, it was unconvincing junk science.

Last week, Retraction Watch reported that this paper is being retracted. Particularly interesting was the news that the retraction is being made by the editors of the journal, not by Seralini and his co-authors, who are pretty darned upset about it. The journal conducted a lengthy investigation (much too lengthy, I might add - they should have been able to act more quickly) and decided that the many flaws in the paper mean that its major findings are not valid.  It is very unusual for editors to force a retraction like this, especially when fraud is not involved. The journal, Food and Chemical Toxicology, issued a statement that said:

"A more in-depth look at the raw data revealed that no definitive conclusions can be reached with this small sample size regarding the role of either NK603 [RoundupReady corn] or glyphosate [Roundup] in regards to overall mortality or tumor incidence. Given the known high incidence of tumors in the Sprague-Dawley rat, normal variability cannot be excluded as the cause of the higher mortality and incidence observed in the treated groups."

In other words, the editors concluded that Seralini's results were not supported by the data. Together with the rest of their statement, it seems pretty clear the editors are admitting that they screwed up during the peer review process, and they never should have published the article.

Seralini is very unhappy.  So unhappy, in fact, that he's threatening a lawsuit, as Forbes contributor Jon Entine reported.

But is this grounds for retraction? Lots of bad science gets published, often due to sloppy peer review, and most of these papers aren't retracted. In this case, it's pretty clear that the high-profile nature of the paper played a role.  Seralini is part of an anti-GMO organization, CRIIGEN, which has used this paper as justification for an aggressive campaign to ban GMO crops in Europe and elsewhere.

As bad as this study is, and as much as I'd like to see it retracted, I'm not sure that the justification given by the editors of Food and Chemical Toxicology is sufficient for retraction. Maybe it's because their statement is too carefully worded - wimpy, in fact. If they just came out and stated clearly that the study's conclusions are erroneous, then they would have a much better case for forcing the retraction. But they don't quite say that.

Here's what they are trying to say: "we screwed up and did a shoddy job in the peer review process, and now we realize that we never should have published this piece of dreck. Now we want to retract it so that no one will associate our journal with this bad science."

I know some very good scientists who have retracted papers merely because they couldn't replicate the results, and they grew worried that something was wrong. That's how science should work: rather than publish something erroneous, most scientists will admit their errors and retract their findings, or at least issue a correction. Obviously, Seralini has no plans to do this. His intent on publishing this paper was to make a political point, not a scientific one, and he distorted his findings in the paper itself, overstating his results with insufficient statistical evidence, and more so in statements to the press.

Retractions are indeed interesting. I'm still not sure the journal did the right thing to retract this paper, but I know they never should have published it in the first place.

(And for those who don't have time to look at the controversy after the original study: no, genetically modified corn does not cause cancer. Not even a little bit.)

Deepak Chopra's pseudoscience is called out by Jerry Coyne

Deepak Chopra is upset.

Why? Well, it all goes back to statements like this one, from Chopra himself:

“Consciousness may exist in photons, which seem to be the carrier of all information in the universe.”

Chopra is upset that evolutionary biologist Jerry Coyne pointed out how absurd this statement is. More specifically, Coyne wrote that:

“[Chopra's] lucrative brand of woo is finally exposed as a lot of scientifically-sounding psychobabble.”

Prof. Coyne’s main topic was another pseudoscientist, Rupert Sheldrake, but he also criticized Chopra, whom he called “Sheldrake’s American counterpart.” As a result, Deepak Chopra is very unhappy, as he makes clear in his very touchy response published last week in the New Republic. I didn’t know Deepak Chopra had such thin skin.

So how did he respond? Well, his entire indignant riposte is essentially a list of his credentials:

“I regularly write articles and books co-authored by full professors … at Harvard,” Chopra protests. 

And he tells us that he is regularly invited to give talks by conferences sponsored by Harvard Medical School, and he’s an Adjunct Professor in the business schools at both Northwestern and Columbia. And more!

With such impressive credentials, how can anything Chopra says can be wrong? But hang on a minute: Jerry Coyne is a Professor at the University of Chicago, and he got his Ph.D. in evolutionary biology at Harvard, under renowned biologist Richard Lewontin. So he must be right too!

What’s wrong with Chopra’s defense is that it’s a classic argument from authority, a logical fallacy that amounts to little more than saying “I have impressive credentials, so I must be right.” As Coyne explains in his rebuttal at the New Republic,

“Science doesn’t work that way. Scientists don’t defer to authority and credentials. We defer to the quality of one’s arguments and the evidence that backs them up.”

Chopra's claim that photons have consciousness, I have to say, is the purest nonsense. Does Chopra even know what a photon is? (Doubtful: he’s been throwing around the term “quantum” for decades with apparently no understanding of what it means.)  Chopra says this sort of stuff all the time; Coyne also gives us this example:

“The gaia hypothesis says nature does have a mind, that the globe is conscious.”

So both photons and the entire planet are conscious. I can see why Coyne called this psychobabble. If Chopra doesn’t want to be ridiculed, he shouldn’t make ridiculous claims. (He also claims that telepathy is a serious research topic. Right.)

Chopra has become very wealthy spouting this kind of nonsense. His website heavily promotes his line of nutritional supplements, books, videos, and seminars (which he calls “meditation experiences”). He's particularly fond of Ayurvedic supplements, which he claims provide a wide range of vague health benefits. One example: $35 for a 25-ounce bottle of fruit juice called Zrii (or 2 ounces for $4.75). This is little more than modern snake oil.

Visiting Chopra's website is a deep dive into the world of pseudoscience. Jerry Coyne got this one exactly right - which is not surprising, because he went to Harvard.

Guys: no more invasive prostate cancer exams!

Good news for all the over-40 men out there: we don't need routine screening for prostate cancer. More to the point, we don't need to subject ourselves to the dreaded "digital rectal exam" that has been a standard procedure for decades.  (Sorry for the ick factor, but that's what it's called, and yes, "digital" does mean "finger", not "computer.")   Most guys don't need any encouragement to avoid this particular invasive procedure, but now there's good scientific evidence saying we don't need it.

One of the most widely used screens for prostate cancer is the PSA test. I wrote about this last year, after several studies and a thorough review concluded that

“there is moderate certainty that the benefits of PSA-based screening for prostate cancer do not outweigh the harms.” (USPSTF, Annals of Internal Medicine, 22 May 2012)

Now, the Choosing Wisely campaign and the American Academy of Family Physicians (AAFP) have included not only PSA testing, but also digital rectal exams as procedures that are usually unnecessary. Their advice to physicians is very clear:

Don’t routinely screen for prostate cancer using a prostate-specific antigen (PSA) test or digital rectal exam.

So guys, the next time you go to the doctor, don't let him (or her) give you the PSA test (it's expensive too! even if insurance pays for it) or the dreaded "digital rectal exam." If your physician hesitates (though I imagine most doctors will be glad to skip these tests), print this list and hand it to him. If you or your doctor want to know more, the list includes references to long, detailed summaries of the evidence.

It's not just prostate cancer screening that is wasteful and unncessary. After a review of the latest evidence, the AAFP, as part of the Choosing Wisely campaign, has identified 15 tests and procedures that most of us should just say "no" to.

Choosing Wisely, which was created by the American Board of Internal Medicine Foundation, is a great idea: a campaign to educate patients and physicians about what practices are:

• Supported by evidence
• Not duplicative of other tests or procedures already received
• Free from harm
• Truly necessary

The AAFP has identified their first set of 15 unnecessary procedures. Widespread attention to this list may save a huge amount of time and expense, and it should improve public health. Choosing Wisely and the American College of Medical Toxicology have also looked at homeopathy and other quack-y "complementary" or "integrative" treatments. Not surprisingly, their advice is simple: don't use them. (See Respectful Insolence for much more on that topic.)

Brevia: Critical thinking prize for this blog

Last week at CSICON 2013 in Seattle, this blog was the recipient of the

2012 Robert P. Balles Prize in Critical Thinking

which was awarded jointly to Joe Nickell and myself, by the Committee for Skeptical Inquiry.  The announcement reads, in part:

In his column for Forbes, "Fighting Pseudoscience," Steven Salzberg regularly shines the light of reason on the false or dubious claims made by those hawking homeopathy, demonizing vaccines, deifying celebrity gurus, or generally denying science and reality, often at the expense of public health. He has done so with a clear and accessible voice, and with a healthy dose of humor.

Recipients in past years include Richard Wiseman, Steven Novella, Michael Specter, Leonard Mlodinow, and Ben Goldacre. I feel privileged to join this select group of writers and skeptics.

[Note: this blog and my Forbes column contain identical content, with a few exceptions.]

GMOs versus antibiotic overuse: which is the greater evil?

People who worry about eating healthy food (and who doesn't?) have recently been very worried about genetically modified organisms, or GMOs.  Meanwhile, industrial livestock producers feed enormous quantities of antibiotics to cows, chickens, and bigs, as a way to make them grow faster.  Which of these practices poses the greater risk?

This one isn't even close. The threat of GMOs pales in comparison to the overuse of antibiotics, which are creating dangerous superbugs that already kill tens of thousands of people each year.

The anti-GMO forces have been making a big push recently to add "GMO" labels to foods. This particularly campaign is based on the hard-to-disagree-with notion that more information is always good. People have a right to know what they're eating, right?

Well, sure. But how many people out there understand what genetic engineering means? How many understand that virtually all the food we eat is genetically modified - including the most wholesome organic foods? Unless you live out in the wilderness eating wild nuts and berries, you're eating plants and animals that have been genetically modified over the centuries by humans, by selecting which ones to plant and breed.  The term GMO is meant to refer to something else:  precise genetic engineering, designed to alter just one or two genes. This creates genetic changes that are far less dramatic than the ones that turned ancient maize into today's modern corn, for example.  Thus the problem with "GMO" label is that it won't inform people unless they have a solid grounding in molecular genetics.

Teosinte is un-modified corn. Not so yummy, is it?

GMO opponents claim that GMOs are bad for you.  So far at least, there's no scientific evidence for this claim.  If GMOs were so bad, people would be dropping like flies every night after dinner.

But in the world of infectious disease, a different, far more deadly scenario is unfolding. Drug-resistant bacteria are spreading fast. Scientists have been warning for years that we are blindly marching towards an era when people start to die of previously treatable bacterial infections. Antibiotics, one of the greatest technological advances in the history of civilization, are losing their effectiveness.

Last week, the Washington Post reported that "nightmare bacteria" are real and on the rise.  In the U.S. alone, over 23,000 people died last year as a result of drug-resistant bacterial infections, according to the CDC. The CDC report implicated the use of antibiotics in animals as one of the primary causes.

Also last week, the Center for a Livable Future at the Johns Hopkins School of Public Health issued a report looking at how we've responded to report 5 years ago that recommended ways "to curb the threats to human health posed by modern industrial agriculture practices." How have we done? According to Dr. Robert Lawrence, director of the Center:

"There has been an appalling lack of progress.  The failure to act by the USDA and FDA, the lack of action or concern by Congress, and continued intransigence of the animal agriculture industry have made all of our problems worse."

Can the FDA regulate antibiotics in livestock? Not really, thanks to intensive lobbying by industry. One of the authors of the Hopkins report commented that the FDA is “almost pleading with industry to make voluntary changes.”

But industry isn't going to do this on their own, and so far the government has been utterly ineffective.  The study points out that:

"Congress has killed every effort to restrict the feeding of farm animals the same antibiotics used in human medicine ...  even as antibiotics have grown less effective in treating infection."

So listen up, GMO alarmists: you're protesting the wrong thing. If you really want people to eat healthier food, start raising Cain over the use of antibiotics in livestock.  If you want labels on our food, insist on labels showing whether our food animals were raised antibiotic-free.  Stop worrying about a hypothetical fear of a few genetic changes in soybeans, and worry instead about the very real rise of superbugs.  You're right to worry about how we raise our food - you're just looking in the wrong place.

Why Can't We Find The Best Surgeons?

Someone finally figured out how to rate surgeons. Don't expect to see a ranking list any time soon, though, the ranking technique was only used for a very small group of specialized surgeons. But boy, does it work well.

The New England Journal of Medicine reported last week on a remarkable new study, by John Birkmeyer and colleagues.  As they wrote:

"Few studies have directly assessed the technical skill of practicing surgeons, and to our knowledge none have linked the level of surgical skill to clinical outcomes."

They then proceeded to do exactly this.  Here's how the study worked: a group of surgeons filmed themselves performing gastric bypass surgery, and submitted one video for review.  A team of other surgeons then viewed the tapes and ranked the skill of the surgeons.  A least 10 evaluators ranked each video.

After doing the rankings, they followed up by looking at actual surgery results of gastric bypass surgeryon 10,343 patients by these same 20 surgeons, between 2006 and 2012.

The differences between the most skilled and least skilled surgeons were remarkable.  Comparing the top 25% to the bottom 25%, Birkmeyer and colleagues found:

• The least-skilled surgeons had nearly triple the rate of complications, 14.5% versus 5.2%.
• The least-skilled surgeons required longer operations, 137 minutes versus 98 minutes.
• Although death is a very rare outcome for gastric bypass surgery, patients had a higher risk of dying if their operation was done by the least-skilled doctors, 0.26% versus 0.05%.

Across the board, the most skilled surgeons had better results.  This shouldn't be surprising, as Birkmeyer and colleagues wrote:

"Few surgeons would be surprised that technical skill is an important determinant of outcomes in patients who have undergone laparoscopic gastric bypass. The procedure is technically complex and performed in patients with morbid obesity, for whom surgical exposure is often challenging."

We know how to rate physical abilities in sports - the top teams and players compete directly against one another. We know that Rafael Nadal and Novak Djokovic are two of the world's best tennis players, even if some people argue about which one deserves to be number 1 (right now it's Nadal).  We can argue about the best soccer team, or American football team, or golfer, but eventually we can see for ourselves by watching them perform.

But in the world of medicine, finding out who is best - or even good - is nearly impossible.  You can find the best hospitals;  U.S. News has a ranking for hospitals, ranked on a published list of criteria (Johns Hopkins Hospital is No. 1).  But not the best doctors.

Not surprisingly, people and institutions have tried to create rankings of top doctors.  The only ones I'm able to find are based on surveys, such as Castle Connolly.  A survey, though, is more a popularity contest than a real measure of how good a doctor is. Many publications offer lists such as the "Top Doctors" lists in New York Magazine or Washingtonian magazine, but these too are just surveys.

One could use outcome measures: shouldn't the best surgeons (and other doctors) have the best results? Yes, of course they should - but we don't know how to measure this, because results depend on how sick the patient was to begin with, whether the patient follows his/her treatment program, etc.  Outcome measures tend to make doctors in educated, affluent areas look better, simply because the patients are healthier.

And just imagine: if we had accurate rankings, then the best surgeons could charge more. The worst surgeons (and someone has to be worst) would face pressure to improve their techniques or find another specialty, which would be good for patients.  I imagine that plenty of patients would be happy to pay more for a better surgeon. Hospitals do charge dramatically different rates, but not necessarily based on the skill of their doctors.

I don't know about you, but if I need surgery, I want one of those surgeons in the top 25% operating on me.  I just don't know how to figure out who they are.  Birkmeyer's study shows how we might change that.

Five vitamins you shouldn't take

I used to take vitamin supplements almost every day. Taking vitamins seems like a good idea: after all, we know that vitamins are essential for life, and vitamin deficiencies can definitely hurt you.  I always thought that vitamins were an inexpensive way to get a little bit healthier.

Millions of Americans apparently agree with me. Close to half of the population in the U.S. takes vitamins, with multi-vitamins being the most popular.*  Vitamins are sold in virtually every grocery store, ranging from mega-markets like Wegmans to the organic Whole Foods chain.

The vitamin and supplements industry, which is immensely profitable, relies on the intuition that if a little bit of something is good for you, a bit more can't hurt.  Right?

Wrong.  If you don't have a serious vitamin deficiency, taking supplemental vitamins doesn't provide any benefit, in almost all cases that have been studied.  What's even more surprising is this: routinely taking mega-doses of vitamins might actually harm you.

So here are the top 5 vitamins that you should not take (unless your doctor recommends it):

1. Vitamin C.  Perhaps the most popular single vitamin supplement, vitamin C occurs in plentiful amounts in many fresh fruits and vegetables.  In the early days of global exploration, sailors often died from scurvy, caused by the lack of vitamin C.  Way back in the 1700's, Scottish doctor James Lind famously conducted an experiment that proved that citrus fruit cured scurvy, although vitamin C itself wasn't discovered until the 1930s.

Vitamin C gained its current popularity through the woefully misguided efforts of Linus Pauling, who published a book in 1970 recommending mega-doses of C to prevent the common cold. Although Pauling was a brilliant chemist (and Nobel laureate), he was completely wrong about vitamin C, as Paul Offit explains in detail in his new book, "Do You Believe in Magic?"

Vitamin C doesn't prevent or cure colds.  This question has been studied exhaustively: a review in 2005 covering 50 years worth of research concluded that

"the lack of effect ... throws doubt on the utility of this wide practice."  

Although Vitamin C is generally safe, megadoses of 2000 mg or more can increase the risk of kidney stones, which can be excruciatingly painful.

2. Vitamin A and beta carotene. Vitamins A, C, and E are all anti-oxidants, which have been promoted for their supposed anti-cancer properties.  The evidence doesn't support this: for example, in a large study supported by the National Cancer Institute*, smokers who took vitamin A were more likely to get lung cancer than those who didn't.

Vitamin A plays an important role in vision, but too much vitamin A can be toxic, causing multiple serious side effects. Perhaps the most famous cases of vitamin A toxicity occurred in early polar explorers, who ate the livers of their sled dogs, not realizing that the livers had excessively high amounts of vitamin A.  Antarctic explorer Douglas Mawson barely survived, and his companions died, probably of vitamin A poisoning.

3. Vitamin E. Long touted as an anti-cancer agent, vitamin E is a very popular supplement.  A large study last year, of 35,533 men, looked at vitamin E and the risk of prostate cancer. The authors found that the risk of cancer increased for men taking vitamin E.  In an even larger review done at Johns Hopkins University, Edgar Miller and Lawrence Appel found that the overall risk of death was higher in people who took vitamin E.  The Mayo Clinic summarizes the evidence this way:

"Evidence suggests that regular use of high-dose vitamin E may increase the risk of death from all causes by a small amount." 

4. Vitamin B6.  The B vitamins, including B6 and B12, are present in many foods, and deficiencies are rare.  But taking B6 supplements for a long time can be harmful, as NIH's website explains*:

"People almost never get too much vitamin B6 from food. But taking high levels of vitamin B6 from supplements for a year or longer can cause severe nerve damage, leading people to lose control of their bodily movements."

5. Multi-vitamins. This is the big one. With nearly 40% of Americans taking a multi-vitamin, they must be good for you, right? But a huge study that I wrote about last year, looking at 38,772 women over 25 years, found that the overall risk of death increased with long-term use of multivitamins, vitamin B6, folic acid, iron, magnesium, zinc, and copper.  Death, one must admit, is a pretty bad outcome.

On the evidence, supplementing your diet with any of these 5 vitamins carries little or no benefit, and may cause you harm.  This is why we do science, people. Our intuitions aren't always right: just because a little bit of something is good for you does not mean that a lot of it is even better.

Vitamins don't "boost your immune system," they don't promote joint health, they don't reduce stress, and they don't help prevent colds or other common ailments.

So what should one do?  Ignore the marketing, and treat supplements like you would any other medicine: take them with caution.  If you are taking regular vitamin supplements, or thinking about it, ask your doctor before doing so.

And by the way, 100 grams of spinach has healthy amounts of vitamins A, C, E, K, several B vitamins, and essential minerals including iron and calcium.

So ditch the vitamins and eat your spinach.  Or blueberries.  Blueberries are great.

[*The statistics and references used in this article were collected, in part, by the U.S. Centers for Disease Control, the U.S. Department of Agriculture, and the National Institutes of Health, all of which are currently shut down due to the stubborn actions of a minority of Representatives in the U.S. Congress.  Thanks, Congress!]

Cashing in on fears of autism

Autism has been the subject of much controversy in recent years.  Rates of diagnosis are rising, and many parents-to-be are understandably worried.  Despite the efforts of many good scientists, we still don't have an explanation for most cases, although we do know that vaccines have nothing to do with it. Many unscientific claims are out there, some of them designed to take advantage of vulnerable parents who are desperate for answers. In this climate, any new claim to have found "the" cause of autism ought to be stated very, very carefully, and backed up by solid evidence.

Just recently, scientists at the UC Davis Mind Institute published a study that described 6 antibodies found in the blood of some mothers of autistic children, and much less often found in mothers of normally developing children.  They suggested that these antibodies somehow got into the brains of developing fetuses, causing autism in the children.  They even gave a name to this form of autism: maternal autoantibody-related, or MAR autism.

If true, this study suggests that a test for these antibodies might predict whether or not a child will have autism.

The study seems plausible, and it was published in a respectable journal called Translational Psychiatry.  Unfortunately, though, the study and the way it has been promoted are plagued with problems.

Perhaps the biggest red flag is that the two lead authors, Daniel Braunschweig and Judy Van de Water already have a patent on the proteins described in their paper, and Van de Water is involved with a company, Pediatric Biosciences (PBI), that is already marketing a test to predict autism based on this study.  Van de Water is the Chief Scientific Advisor for the company, which has licensed her patent for this specific test.  The company website claims

"To date, the test has demonstrated 100% accuracy - meaning if a mother or prospective mother has developed the antibodies, then her child will later be diagnosed with AU [autism] or ASD [autism spectrum disorder]."

Wow. This sounds incredibly accurate. This test is apparently the sole product of PBI, and they trumpeted the new study with a press release claiming that

"PBI is developing a diagnostic test based on these findings that will provide physicians with a reliable set of biomarkers for pre-conception … diagnosis of this Maternal Autoantibody-Related (MAR) form of autism."  

PBI is marketing the test to all "women over 30 who are at least 2 times more likely to give birth to an autistic child" as well as other women.

So, with all this hype, and despite the major conflicts of interest of the lead authors, did the study show what they are claiming?  Is this a test that mothers should take?

In a word, no.

First, the study doesn't even answer the right question.  The study looked at antibodies found in the blood of mothers some years after their pregnancy, not during or before pregnancy. Therefore it doesn't tell us whether a test of a pregnant mother will predict anything at all.  Post hoc analyses like this are notoriously inaccurate: for example, it's easy to find factors that predict every presidential election for the past 50 years, but many of them will perform poorly at predicting future elections.  Similarly, finding 6 proteins that distinguish some mothers of autistic children from mothers of normal children, all measured after the fact, tells us nothing about whether we can predict autism in advance.

Second, their striking claim of 100% accuracy is false.  (Their press release only claimed 99%: "A positive result would mean that they have a 99 percent likelihood of having a child with autism if they proceed with a pregnancy.")  But the study provides no such evidence.  What it did show was that 56 mothers (out of 246) had antigens to one of 12 combinations of 3 antigens that they selected.  [Aside: there are many other combinations of antigens that they did not report, and no indication that they properly adjusted their statistics to account for this.] But the study failed to say whether these 56 mothers also had non-autistic children.  If they did, then even the mothers in their own study had a much lower chance than 99% of having an autistic child.  Given that many families with autistic children also have other, non-autistic children, touting an accuracy number like this, without proof, is outrageous.

The study isn't completely worthless: it points to a possible link between antibodies in the blood of the mother and autism in a child.  If Van de Water were truly interested in the welfare of autistic families, she would be focusing on the obvious next step: test a large, randomly sampled collection of pregnant women for the same antibodies.  Then follow them up, over the next few years, to see if the test can predict the likelihood of having an autistic child.  Meanwhile, no one should be selling a test before studies can show that it has some predictive value.

But Van de Water and her friends at Pediatric Biosciences seem far more interested in making money off the fears of prospective parents.  PBI is planning to charge about $800 for their test, which they'll begin selling next year. Stanford University biostatistician Steven Goodman says that they are "peddling false hope that giving birth to autistic kids can be avoided."

A news article in Science last week raised many serious questions about Van de Water's study and its claims.  Several scientists quoted in that article questioned the premise of the study: that antibodies from the mother somehow get into the brain of the developing fetus. Yale scientist George Anderson said the data are too preliminary and the statistics too weak to support a clinical test (essentially the same argument I'm making here).

And what about that 99% claim?  In their interview with Science, Van de Water and Jan D'Alvise (president of PBI) said it

"was not meant to convey likelihood in the statistical sense, but rather the 99% accuracy with which the study demonstrated specificity of the biomarkers for ASD."  

This is unadulterated poppycock. As of this writing, the company website still claims that the test has "100% accuracy--meaning if a mother or prospective mother has developed the antibodies, then her child will later be diagnosed with AU or ASD [autism]."  That claim couldn't be any more clear - or any more wrong.

With all the controversy over the causes of autism, and with the medical community still struggling to correct the tremendous damage caused by Andrew Wakefield's fraudulent study linking vaccines to autism, the last thing we need is an erroneous claim that someone has found the cause of autism.  And it's far too soon to start offering moms a test that tells them they're going to have an autistic child.

Dr. Oz tries to do science again, this time with green coffee bean extract

Dr. Mehmet Oz hosts a popular TV show in which he promotes all sorts of medical treatments, some good and some - well, not so good.  And once in a while, he tries to do a science experiment, as he did in 2011 with a badly flawed experiment on arsenic in apple juice.

Well, Dr. Oz has done it again.  This time he wanted to re-examine a claim that he himself had made on an earlier show about green coffee bean extract.

In April 2012, Oz aired a segment on his TV show called "Green Coffee Bean Extract: The Fat Burner That Works!"  On it he "this miracle pill can burn fat fast, for anyone who wants to lose weight." Not surprisingly, sales of green coffee bean extract skyrocketed in response.

"A marketing apocalypse was ignited!" Dr. Oz pointed out in his show in September of 2012.  "I was surprised by the firestorm," he said.

Dr. Oz loves this topic, by the way. He's run dozens of shows on weight-loss gimmicks, such as "The New Silver Bullet for Weight Loss" in which he promoted a new diet pill called Qnexa, and "Ancient Ayurvedic Secrets to Lose Weight".  But let's leave those for another day.

One problem with Oz's first green coffee bean show was that he based it on a study that has some serious problems.  That study claimed that a particular brand of green coffee bean extract called GCA led to significant weight loss.  Subjects lost a lot of weight, too: 8 kilograms (over 17 pounds) on average.    Dr. Oz called it "a staggering, newly released study."  Wow, must be good, right?

Let's look at that study, shall we?  First, it only involved 16 people, a tiny sample.  There were 3 treatments: high dose GCA, low dose GCA, and placebo.  The subjects were divided into 3 even smaller groups, but not by treatment: instead, each group took all 3 treatments, for 6 weeks at a time, with a 2-week rest period in between.  The only difference between groups was the order of the treatments (high-dose/low-dose/placebo).  Subjects in all 3 groups lost about the same amount of weight.  What was the difference?  Well, the authors claimed that the amount of weight loss during the periods when the subjects were taking GCA was greater than when they weren't, even though they lost weight even during placebo treatment.

One critique of the study is there was no proper placebo control.  Looking at the paper, it is impossible to tell how much weight loss is being attributed to the green coffee beans rather than the daily monitoring of diet, which is known to help with weight loss.  And it's a really, really small study.

Perhaps a larger problem is that the trial was carried out in India, and then written up by a U.S. researcher, Joe Vinson from the University of Scranton, as revealed by a story in The Globe and Mail (Canada) last December.  That's right: the subjects were recruited in India, all data was collected there, and the data was emailed to Vinson so he could write it up.

Even more troubling was that Vinson was paid by the makers of GCA to write the study.  Worse yet, the paper states that "The authors report no conflicts of interest in this work." When asked about this by The Globe and Mail:

"Vinson said that he doesn’t gain financially if the company sells a lot of product and that the journal didn’t require him to disclose the relationship."

This small, badly run study was anything but "staggering", as Dr. Oz called it.  I have little confidence that the data sent to Vinson from India was even correct.

Maybe Dr. Oz might was worried too, because a few months after his original show, he ran another show in which he looked at green coffee bean extract again.  He said he was responding to criticism of his earlier show, and he wanted to set the record straight.  For his second show, "Green Coffee Bean Extract: The Answer to Weight Loss?" he ran his own experiment:

"For the first time, we are doing an unprecedented experiment," he said. "We're doing our own study, right here on this show.... the first of its kind EVER on television!"  

Oz's experiment involved 100 women - all of them in the studio audience for his show - who took either green coffee bean extract or a placebo pill for two weeks.  And the result?  I won't make you watch the video; here is the entire statement of results, from Oz's website:

"In two weeks, the group of women who took the green coffee bean extract lost, on average, two pounds. However, the group of women who took the placebo lost an average of one pound – possibly because they were more aware of their diet for that two weeks because of the required food journal."

On the show, Oz stated proudly: "green coffee bean worked for us."

Maybe Dr. Oz's science experiment was better than the Vinson study.  But that doesn't mean it was any good.  First off, Oz seems to have ignored some critical rules on how to run a experiment involving humans.  As Scott Gavura pointed out at the Science-Based Medicine blog, Oz's study "makes a mockery of good research methodology."  Oz failed to explain how the women were recruited for the experiment, and Gavura points out that apparently did not obtain the ethics board approval that all experiments on human subjects require.

Oz also seems willfully ignorant of the notion that 2 weeks is far too short a time to assess the value of a weight-loss treatment.  Will he go back to those same women a few months later to see if the effect lasted? Somehow I doubt it.

But what about that result?  The women who took the coffee bean extract lost 2 pounds, versus just 1 pound for the other group.  (Actually, thanks to Scott Gavura, we know that the difference was even smaller, just 0.76 pounds.) Oz provides no statistical analysis to demonstrate that is even marginally significant. Nor does he provide the raw data that would allow others to replicate his analysis, as he might have to do if he were actually to try to publish his study. But for Oz, what he described on his show seems to be proof enough.  That's is a poor excuse for science.

Meanwhile, sales of green coffee bean extract continue to climb.  My advice: save your money.  And the next time Dr. Oz runs a science experiment, be skeptical.

Alternative medicine quacks show their greedy side

Congress is on holiday this month, but the lobbyists are baiting their hooks, planning their strategies for how to get more money for themselves.

A growing lobby is Complementary and Alternative Medicine (CAM) providers, who have discovered a new opportunity to extract even more money from patients than they do already. They want the government to force insurance providers to pay for quack treatments, regardless of whether or not the treatments work. Any attempt to require evidence, they argue, amounts to discrimination.

Discrimination? Yes! We must not allow the government to exclude health care providers just because those providers don't cure anything.  The CAMmers argument boils down to this: we have patients who want our services.  The patients like us. In some cases, thanks to lobbying at the state level, we even have state-approved licenses. Therefore insurance companies must pay for our services.

Neat.

To be specific, the CAMmers are lobbying furiously to try to protect a special clause in the Affordable Care Act (Obamacare) that promises them a fertile new ground for making money from vulnerable patients.

The strategy is simple: require the government to fund any treatment that a patient wants, and dress this up as "patient choice."  Then if insurance companies resist paying for ineffective treatments, accuse them of discriminating against the poor, hapless "integrative medicine" providers.

Thus through a diabolical twist of illogic, if Obamacare doesn't cover homeopathy, or naturopathy, or acupuncture, or magnetic energy healing, or any other so-called alternative therapy, it's discrimination.

The mind boggles.

Why is this an issue now?  Because, unbeknownst to most people outside the Washington beltway, two pro-CAM lobbying groups slipped a clause into the ACA, section 2706, that attempts to force insurance providers to cover a wide range of quack practices.  This section requires that insurers

"shall not discriminate with respect to participation under the plan or coverage against any health care provider who is acting within the scope of that provider's license or certification under applicable state law."

Sounds harmless, right?  Well, no.  This language was added to the ACA by Senator Tom Harkin, after heavy lobbying by the American Chiropractic Association and the Integrative Healthcare Policy Consortium.  In fact, it is virtually certain that lobbyists wrote the section, and Harkin simply inserted it into the law. The IHPC is a lobbying group dedicated to obtaining more government money for homeopathy, naturopathy, chiropractic, acupuncture, and a raft of other ineffective medical practices.

Section 2706 opens the door to anyone who provides what they claim is health care - no matter how ridiculous the claim - to file a lawsuit claiming discrimination if an insurance company won't pay for their services.  You could start offering dried bird poop for arthritis, call it "avian nature therapy," and if an insurer won't pay for it, you can sue.

Some in Congress have realized how truly bad an idea this is, and just a few weeks ago, a new bill was introduced to get rid of it, HR 2817.  The American Medical Association supports the new bill. This has some CAM proponents alarmed.

Over at the Huffington Post, John Weeks, an outspoken apologist for questionable medical practices, offers the predictable, whining claim that this is all about "discrimination" by legitimate health care providers (the big, bad AMA) against poor, defenseless integrative medicine providers.

Make no mistake: this is all about greed.  The CAM industry sees Obamacare as a chance to reap huge profits, by forcing insurance companies to pay for ineffective treatments, including many that are wildly implausible.

Homeopaths, naturopaths, acupuncturists, reiki practitioners, energy healers, and other CAM practitioners don't want to subject their methods to rigorous tests of effectiveness.  They know that their methods have failed scientific scrutiny, time and time again.  So now they want to force health care providers to pay for anything the patient wants. "Our patients believe us," they argue, "so pay us."

Forcing health care providers to pay for anything a patient wants, even if it doesn't work, is guaranteed to drive up costs, without any benefit to patients.  Let's ditch this bogus "discrimination" clause in the ACA, and insist that all medical care be held to the same high, scientifically rigorous standards.

Scientists are creating a dangerous flu strain, just to prove they can

In an outrageous display of chutzpah, a group of flu researchers led by Ron Fouchier of Erasmus Medical Center in the Netherlands announced today, in a letter to the journal Nature, that they were planning to engineer the new H7N9 avian flu strain to give it new, possibly much more deadly capabilities.  Fouchier is the same scientist who, two years ago, adapted the highly pathogenic H5N1 flu strain so that it could be passed from human to human, which it cannot do in its natural form.  The resulting outcry delayed publication of his paper, but it eventually did appear.

Now they want to do the same thing, and much more, with the new H7N9 influenza virus, which has killed 43 people in China to date, and which epidemiologists are tracking with great concern.

They should track Fouchier and his lab instead.

Wait a second, protests Fouchier.  He promises that

"All experiments proposed by influenza investigators are subject to review by institutional biosafety committees. The committees include experts in the fields of infectious disease, immunology, biosafety, molecular biology and public health; also, members of the public represent views from outside the research community."

Sorry, but I'm not reassured.  Fouchier's group wants to do this research because it's all they know how to do - and, I suspect, because they enjoy the publicity.  Despite their claims that the research is vital to our understanding of the flu, none of their past work, including their work on H5N1, has changed our ability to respond to a pandemic.  As flu expert Michael Osterholm said in a report by the Associated Press:

"H5N1 surveillance is as haphazard today as it was two years ago. Should we do the work if it's not actually going to make a difference?"

Precisely.  Fouchier and his colleagues can't do surveillance, nor do they work on vaccine development.  They have laboratories where they can engineer the flu virus to make new strains, so that's what they want to do. Two years after their controversial H5N1 experiments, they haven't contributed to any improvement in our ability to control a pandemic, nor have they shown how to develop a better flu vaccine.  The benefits of creating a deadly new H7N9 virus are marginal, at best.

What about the risk? As reported in the Daily Mail, Fouchier and his colleague Yoshihiro Kawaoka themselves said

"H7N9's pandemic risk would rise 'exponentially' if it gained the ability to spread more easily among people."

Really?  And from this they conclude that it's a good idea to engineer a virus that can do exactly that - spread more easily among people? Are we supposed to take this risk because of some theoretical benefit from a vague "better understanding" of how mutations in the virus change its pathogenicity?

Although Fouchier is in Rotterdam, the NIH funds part of his work through the National Institute of Allergies and Infectious Diseases (NIAID).  Dr. Anthony Fauci, the head of NIAID, offered the reassurance that a special panel will review this H7N9 project, and

"If the risk is felt to be too high by this outside review, they will recommend it won't be done and we won't fund it."

Despite this additional oversight, I remain skeptical. These special panels tend to include other scientists who are very sympathetic with the work they're reviewing, as was demonstrated two years ago when the H5N1 work was published despite the grave concerns expressed by many outside the field.  I predict they will approve Fouchier and Kawaoka's experiments.

Here's a thought: put me on the panel: I've published multiple research papers on the influenza virus (including this paper in Nature and this paper on H5N1 avian flu), so I think it's fair to say I'm qualified.  But somehow I doubt they will do that.

Did you scan and email a document recently? You might owe $1000 to a patent troll.

We've seen how badly the U.S. patent system is broken when it comes to gene patents.  The recent U.S. Supreme Court case overturning Myriad Genetics' patents on the human breast cancer genes, BRCA1 and BRCA2, was a step in the right direction.  But the problem goes much deeper than that.  The U.S. Patent and Trade Office (USPTO) simply can't keep up with technology, and as a result its lawyers keep granting patents that they just don't understand.  As a result, completely obvious ideas end up as patents, inhibiting innovation and keeping beneficial technology out of the hands of the public.  This is just the opposite of what the patent system is supposed to do.

It's not only gene patents that confuse the USPTO.  They also fail miserably when it comes to computer technology.  Some years ago, they issued a patent for scanning in a document and emailing it.  This idea is so obvious that it probably was "invented" by thousands of people back in the early days of scanners, and most of them probably didn't think to patent it.  But one guy did, and now his patent is owned by a patent troll: a company that doesn't make anything, but threatens to sue everyone in sight to extort money from them.

And now we have a law firm that is going around demanding $1000 in licensing fees from everyone who scans a document and then emails it.  ArsTechnica wrote about this back in April, and again in May when HP decided to fight back, pointing out that HP was selling printers that could scan and email documents before the patent in question was granted.

But that's kind of not the point, is it?  The USPTO should never have granted this patent, which was just for the idea of scanning and emailing - the inventor didn't build anything, nor did he create some novel technology.  Patenting ideas for computer programs as "business methods," which the patent office started allowing back in the 1990s, opened the floodgates to patent trolls, and we're suffering the consequences today.

And now, surprisingly, two U.S. states are fighting back.  In the past week, Vermont's and then Nebraska's attorneys generals have sent letters telling the patent troll (a company called MPHJ and its lawyers, a firm called Farley Daniels) to leave their citizens alone, as the Washington Post reported this week.  They might win, too, using a new law in Vermont that lets victims of patent trolls sue back.

The problem is that we have a large and powerful industry of patent lawyers who are deeply invested in the current system, and fight tooth and nail against any attempt to change it.  Perhaps the recent egregious over-reaching by some greedy folks, including those who hold patents on human genes, will finally make it clear that the patent system is broken and in desperate need of major reform.

Those fish oil supplements might cause cancer

Eating fish is good for you, especially fish that contain omega-3 fatty acids.  So I was surprised last week to read a new study in the Journal of the National Cancer Institute that found that omega-3 fatty acids increase the risk of prostate cancer.  The risk for both high-grade and low-grade cancer was increased with higher levels of omega-3 fatty acids.  This is a carefully done study, and the results should make anyone who is taking fish oil pills reconsider.

One reason this study caught many people off guard is that there has been much evidence showing that a diet rich in fish that contain omega-3 oils is good for you.  The Mayo Clinic says that  "eating fish helps your heart", especially fish like salmon that contain omega-3 fatty acids.  The American Heart Association (AHA) elaborates:

"Omega-3 fatty acids benefit the heart of healthy people, and those at high risk of — or who have — cardiovascular disease. Research has shown that omega-3 fatty acids decrease risk of arrhythmias (abnormal heartbeats), which can lead to sudden death. Omega-3 fatty acids also decrease triglyceride levels, slow growth rate of atherosclerotic plaque, and lower blood pressure (slightly)."

This all sounds great.  Because of the evidence about the benefits of fatty fish, supplement manufacturers have been marketing and selling fish oil pills for years, with great success.  As I described back in 2010, GlaxoSmithKline even created a high-dose omega-3 fatty acid pill called Lovaza that has FDA approval.

But the evidence for that you can get the same benefit from supplemental omega-3 fatty acids — taking a pill, that is — is much weaker.  In fact, a large review published last year in the Journal of the American Medical Association found no connection at all between supplemental omega-3 and a lower risk of heart attacks, strokes, or death in general.  Other studies have reported similarly negative results.  So it appears that fish oil pills may not have any heart benefits.

And now, with this new study, we learn that supplemental fish oil might increase the risk of prostate cancer.

The bottom line: the AHA recommendations about eating fish are probably still good ones.  The AHA website says:

"We recommend eating fish (particularly fatty fish) at least two times (two servings) a week. Each serving is 3.5 oz. cooked, or about ¾ cup of flaked fish.  Enjoy fish baked or grilled, not fried." 

But popping a fish oil pill is not going to cut it. As we've seen before, supplements often fail to show the benefits that a healthy diet offers.  So save your money and stop buying those fish oil pills — and fire up the grill and throw on a few salmon fillets for this weekend's barbecue.

Hopkins is #1 hospital in the U.S.

My institution had a bit of good news this week.  The latest U.S. News rankings of the nation's top hospitals just appeared, and Hopkins has regained the number 1 spot, which it temporarily lost last year.  We've been number 1 for 22 of the past 23 years.  See the story here.

I'd like to think this is, in part, because Hopkins Medicine has been one of the foremost institutions in the world at pursuing science-based and evidence-based medicine.

Another humanoid species walked the earth

[I'm on vacation, and this short post will appear while I'm away.]

One of the coolest scientific discoveries of the past few years was a small bone found in a remote region of Siberia.  The scientists who found it initially thought it was just an early human fossil, or else a Neanderthal fossil, but something about it looked a bit off.  It was just one small finger bone, not much to go on.

But DNA sequencing told a different tale.  The bone belonged to a female who was neither human nor Neanderthal, but something in between.  She and her kind appear to be closer to Neanderthals than to modern humans, but there is no doubt that she represents a new hominid species, one that died out only recently in evolutionary terms.  The evidence indicates that this previously unknown group, called the Denisovans after the cave in which the bone was found, actually interbred with humans.

The latest findings were published last fall in the journal Science, by a team led by Matthias Meyer and Svante Paabo.  With just one small, 75,000-year-old finger bone, they knew that extracting DNA would be a challenge.  Most of the DNA from ancient samples comes from bacteria and other creatures that have infiltrated the bone over the millenia.  But they were lucky in one respect: Siberia is cold, and has been for a very long time, which helps to preserve DNA.  Still they had to develop an entirely new method of extracting ancient DNA for this bone.

Meyer and colleagues extracted enough DNA to cover the entire genome of this ancient female.  They estimated that Denisovans and human diverged over 175,000 years ago.  They also discovered that modern Papuans contain vestiges of Denisovan DNA in their genomes, about 6%, suggesting that interbreeding occurred when humans were spreading across Asia.

Just this month, National Geographic's Jamie Shreeve published a feature article on the discovery, providing a fascinating look at how a single finger bone revealed a previously lost sister species.  (I highly recommend it, even for those who read the original Science article.) Now that we know what to look for, we might find more, and learn more, about these almost-humans from ancient Siberia.  And maybe we'll eventually figure out why they disappeared.

A final note: this discovery is yet another example of how evolution has shaped the history of life on this planet, but somehow I suspect the anti-evolution forces in the U.S. will find a way to deny it.

What Works for Knee Pain? Good Medicine, Bad Medicine, and Wasted Money

Knee pain is a very common problem, affecting young and old alike.  Among athletes, knees take a beating, particularly in sports that involve running and twisting.  Among older people, the cartilage that provides a cushion in our knees often just wears out, producing chronic stiffness and pain.

I've had knee problems myself, so I was interested to see an article posted on CNN, with content from Harvard Medical School called "Alternative Treatments for Knee Pain."  Would it describe "alternative" medicine, as in "complementary and alternative medicine," or would it present real medicine for knee pain?

A little of both, as it turns out.  But it does more: it inadvertently illustrates one of the major flaws with the U.S. health system.  We don't discriminate between effective and ineffective treatments, and some doctors seem content to let patients try anything, regardless of efficacy or cost.

The article describes several treatments for knee pain, and for each one it turns to Eric Berkson, M.D., for an opinion on how well the treatment works.  Berkson is an orthopaedic surgeon at Massachusetts General Hospital and an Instructor in Orthopaedic Surgery at Harvard Medical School.

Despite these excellent credentials, Dr. Berkson doesn't seem to have a firm command of science-based medicine. The article starts out strong, recommending the most effective therapies, but then wanders into unproven therapies, and concludes with Berkson making an unscientific recommendation for the most wildly ineffective treatment of all: acupuncture.  Let's look quickly at each "alternative."

The most effective treatments, according to Dr. Berkson, are physical therapy and weight loss.  Berkson is on solid scientific ground here: physical therapy strengthens the muscles around the knee, relieving some stress on the joint, and weight loss does the same thing by reducing the load directly.  If you stopped reading at this point, you'd be in great shape.

Next is a discussion of chondroitin and glucosamine, two very popular supplements that are often used to treat joint pain.  After many years of competing claims about these supplements, NIH conducted a large, $12.5 million study called GAIT to test whether these supplements worked for knee pain. The researchers looked at glucosamine and chondroitin separately and together, and compared them to a standard pain reliever (celecoxib, brand name Celebrex®, an NSAID) and to a placebo.

The conclusion: celecoxib worked, but the supplements did not.  In a small subset of patients with moderate to severe pain, there was a hint of a benefit for glucosamine-condroitin, but it wasn't significant.  For patients with mild pain, though, only celecoxib was better than a placebo.

Despite this large and compelling study, Berkson says

"there's a lot of evidence that they [glucosamine and chondroitin] work, but only in a certain percentage of patients." 

Perhaps he's referring to patients with moderate to severe pain from the GAIT study, but the article doesn't explain if that's what he means.  And then Berkson recommends them anyway, saying "there's little downside to trying the supplements."  Especially if it makes the patient think the doctor is helping.

The article then describes three different treatments that involve injections of various substances into the knee.  To keep this brief, I'll just consider the first: viscosupplementation, a fancy name which means that hyaluronic acid is injected into the knee. It's supposed to help lubricate the joint, which sounds plausible: after all, we lubricate machines to keep them running smoothly.  Shouldn't some "grease" help our knees?

For hyalonuric acid, the answer is simply no.  A large review just last year, involving over 12,000 patients (Rutjes et al. 2012) shows that hyaluronic acid has little or no benefit, and possibly causes harm.  Their conclusion:

"In patients with knee osteoarthritis, viscosupplementation is associated with a small and clinically irrelevant benefit and an increased risk for serious adverse events."

Berkson's own colleagues, the American Academy of Orthopaedic Surgeons, just issued a 1200-page report on treatments for knee osteoarthritis, and they found strong evidence against the use of hyalonuric acid.  To be specific, the AAOS says "We cannot recommend using hyaluronic acid for patients with osteoarthritis of the knee."  They label this a "strong" recommendation.

Despite the the advice of his own professional organization, Dr. Berkson says

"I have some patients who think [hyalonuric acid is] a miracle drug that keeps their symptoms at bay.  Given that the risks of injection are very low, it makes sense to try it if insurance will pay."

Oh my.  Here we have a medical expert recommending an expensive treatment - he estimates the cost is about $1500 - despite the evidence, apparently because he has patients who think it works.  Paying for expensive, ineffective procedures is a poor way to treat patients and a great way to run up costs.

(Aside: I might seem to be picking on Dr. Berkson here, but I think his responses are probably typical of many practicing doctors.  Not to excuse him, but it's easy to follow your instincts and to rely on anecdotes from patients.)

After briefly discussing two other injection therapies, the CNN/Harvard article addresses one last alternative: acupuncture.  It quotes Berkson again, this time saying:

"Acupuncture works in some patients, although I don't think science knows exactly why it works. It's worth trying if other things aren't working for you."

Despite Dr. Berkson's comment, the science doesn't support him.  Acupuncture for knee pain, and for other pain, simply doesn't work.  (See this article for a lengthy discussion, with citations.)  Just to pretend for a second: in order for acupuncture to work, there would have to be lines of force (called "meridians") through which a mystical, apparently unmeasurable life force ("qi") flows, and furthermore you'd have to be able to manipulate this life force by plunging needles into the skin.  There is no support whatsoever for these ideas in human biology and physiology.

The American Academy of Orthopaedic Surgeon's report addresses acupuncture too, stating that "We cannot recommend using acupuncture in patients with symptomatic osteoarthritis of the knee."

Dr. Berkson's recommendation is akin to a shrug: while admitting that he doesn't know why it might work, he just says to give it a try.  His own professional organization, after an extensive review of the scientific evidence, disagrees.

The CNN Health article, with "content provided by the faculty of the Harvard Medical School," demonstrates in a microcosm how health care dollars are wasted in the U.S.  First it recommends the most effective and least expensive treatments: weight loss and exercise.  Both of these involve lifestyle changes that are difficult for many people.  The article then suggests alternative treatments for knee pain that include:

1. Glucosamine and chondroitin supplements - ineffective but cheap. 
2. Knee injections of hyalonuric acid - ineffective and very expensive.
3. Acupuncture - ineffective, wildly implausible, and sort of cheap.

Despite the evidence against them, the doctor quoted throughout the article recommends trying all three, especially if (as is common) the patient doesn't have to pay the bills.

Science only supports three treatments for knee pain, as physician Harriet Hall summarized in her recent blog post: exercise, weight loss, and NSAIDs.  The "alternatives" described by CNN, no matter how appealing they sound, are a waste of time and money.