Do We Know What Really Makes Us Healthy?

[Bob]

http://www.nytimes.com/2007/09/16/magaz ... ted=1&_r=1

Do We Really Know What Makes Us Healthy?
New York Times
By GARY TAUBES

Published: September 16, 2007

Once upon a time, women took estrogen only to relieve the hot flashes, sweating, vaginal dryness and the other discomforting symptoms of menopause. In the late 1960s, thanks in part to the efforts of Robert Wilson, a Brooklyn gynecologist, and his 1966 best seller, “Feminine Forever,” this began to change, and estrogen therapy evolved into a long-term remedy for the chronic ills of aging. Menopause, Wilson argued, was not a natural age-related condition; it was an illness, akin to diabetes or kidney failure, and one that could be treated by taking estrogen to replace the hormones that a woman’s ovaries secreted in ever diminishing amounts. With this argument estrogen evolved into hormone-replacement therapy, or H.R.T., as it came to be called, and became one of the most popular prescription drug treatments in America.

By the mid-1990s, the American Heart Association, the American College of Physicians and the American College of Obstetricians and Gynecologists had all concluded that the beneficial effects of H.R.T. were sufficiently well established that it could be recommended to older women as a means of warding off heart disease and osteoporosis. By 2001, 15 million women were filling H.R.T. prescriptions annually; perhaps 5 million were older women, taking the drug solely with the expectation that it would allow them to lead a longer and healthier life. A year later, the tide would turn. In the summer of 2002, estrogen therapy was exposed as a hazard to health rather than a benefit, and its story became what Jerry Avorn, a Harvard epidemiologist, has called the “estrogen debacle” and a “case study waiting to be written” on the elusive search for truth in medicine.

Many explanations have been offered to make sense of the here-today-gone-tomorrow nature of medical wisdom — what we are advised with confidence one year is reversed the next — but the simplest one is that it is the natural rhythm of science. An observation leads to a hypothesis. The hypothesis (last year’s advice) is tested, and it fails this year’s test, which is always the most likely outcome in any scientific endeavor. There are, after all, an infinite number of wrong hypotheses for every right one, and so the odds are always against any particular hypothesis being true, no matter how obvious or vitally important it might seem.

In the case of H.R.T., as with most issues of diet, lifestyle and disease, the hypotheses begin their transformation into public-health recommendations only after they’ve received the requisite support from a field of research known as epidemiology. This science evolved over the last 250 years to make sense of epidemics — hence the name — and infectious diseases. Since the 1950s, it has been used to identify, or at least to try to identify, the causes of the common chronic diseases that befall us, particularly heart disease and cancer. In the process, the perception of what epidemiologic research can legitimately accomplish — by the public, the press and perhaps by many epidemiologists themselves — may have run far ahead of the reality. The case of hormone-replacement therapy for post-menopausal women is just one of the cautionary tales in the annals of epidemiology. It’s a particularly glaring example of the difficulties of trying to establish reliable knowledge in any scientific field with research tools that themselves may be unreliable. . .

The Flip-Flop Rhythm of Science

At the center of the H.R.T. story is the science of epidemiology itself and, in particular, a kind of study known as a prospective or cohort study, of which the Nurses’ Health Study is among the most renowned. In these studies, the investigators monitor disease rates and lifestyle factors (diet, physical activity, prescription drug use, exposure to pollutants, etc.) in or between large populations (the 122,000 nurses of the Nurses’ study, for example). They then try to infer conclusions — i.e., hypotheses — about what caused the disease variations observed. Because these studies can generate an enormous number of speculations about the causes or prevention of chronic diseases, they provide the fodder for much of the health news that appears in the media — from the potential benefits of fish oil, fruits and vegetables to the supposed dangers of sedentary lives, trans fats and electromagnetic fields. Because these studies often provide the only available evidence outside the laboratory on critical issues of our well-being, they have come to play a significant role in generating public-health recommendations as well. . . .

Science vs. the Public Health

Understanding how we got into this situation is the simple part of the story. The randomized-controlled trials needed to ascertain reliable knowledge about long-term risks and benefits of a drug, lifestyle factor or aspect of our diet are inordinately expensive and time consuming. By randomly assigning research subjects into an intervention group (who take a particular pill or eat a particular diet) or a placebo group, these trials “control” for all other possible variables, both known and unknown, that might effect the outcome: the relative health or wealth of the subjects, for instance. This is why randomized trials, particularly those known as placebo-controlled, double-blind trials, are typically considered the gold standard for establishing reliable knowledge about whether a drug, surgical intervention or diet is really safe and effective.

But clinical trials also have limitations beyond their exorbitant costs and the years or decades it takes them to provide meaningful results. They can rarely be used, for instance, to study suspected harmful effects. Randomly subjecting thousands of individuals to secondhand tobacco smoke, pollutants or potentially noxious trans fats presents obvious ethical dilemmas. And even when these trials are done to study the benefits of a particular intervention, it’s rarely clear how the results apply to the public at large or to any specific patient. Clinical trials invariably enroll subjects who are relatively healthy, who are motivated to volunteer and will show up regularly for treatments and checkups. As a result, randomized trials “are very good for showing that a drug does what the pharmaceutical company says it does,” David Atkins, a preventive-medicine specialist at the Agency for Healthcare Research and Quality, says, “but not very good for telling you how big the benefit really is and what are the harms in typical people. Because they don’t enroll typical people.”

These limitations mean that the job of establishing the long-term and relatively rare risks of drug therapies has fallen to observational studies, as has the job of determining the risks and benefits of virtually all factors of diet and lifestyle that might be related to chronic diseases. The former has been a fruitful field of research; many side effects of drugs have been discovered by these observational studies. The latter is the primary point of contention. . . .

What to Believe?

So how should we respond the next time we’re asked to believe that an association implies a cause and effect, that some medication or some facet of our diet or lifestyle is either killing us or making us healthier? We can fall back on several guiding principles, these skeptical epidemiologists say. One is to assume that the first report of an association is incorrect or meaningless, no matter how big that association might be. After all, it’s the first claim in any scientific endeavor that is most likely to be wrong. Only after that report is made public will the authors have the opportunity to be informed by their peers of all the many ways that they might have simply misinterpreted what they saw. The regrettable reality, of course, is that it’s this first report that is most newsworthy. So be skeptical.

If the association appears consistently in study after study, population after population, but is small — in the range of tens of percent — then doubt it. For the individual, such small associations, even if real, will have only minor effects or no effect on overall health or risk of disease. They can have enormous public-health implications, but they’re also small enough to be treated with suspicion until a clinical trial demonstrates their validity.

If the association involves some aspect of human behavior, which is, of course, the case with the great majority of the epidemiology that attracts our attention, then question its validity. If taking a pill, eating a diet or living in proximity to some potentially noxious aspect of the environment is associated with a particular risk of disease, then other factors of socioeconomic status, education, medical care and the whole gamut of healthy-user effects are as well. These will make the association, for all practical purposes, impossible to interpret reliably.

The exception to this rule is unexpected harm, what Avorn calls “bolt from the blue events,” that no one, not the epidemiologists, the subjects or their physicians, could possibly have seen coming — higher rates of vaginal cancer, for example, among the children of women taking the drug DES to prevent miscarriage, or mesothelioma among workers exposed to asbestos. If the subjects are exposing themselves to a particular pill or a vitamin or eating a diet with the goal of promoting health, and, lo and behold, it has no effect or a negative effect — it’s associated with an increased risk of some disorder, rather than a decreased risk — then that’s a bad sign and worthy of our consideration, if not some anxiety. Since healthy-user effects in these cases work toward reducing the association with disease, their failure to do so implies something unexpected is at work.

All of this suggests that the best advice is to keep in mind the law of unintended consequences. The reason clinicians test drugs with randomized trials is to establish whether the hoped-for benefits are real and, if so, whether there are unforeseen side effects that may outweigh the benefits. If the implication of an epidemiologist’s study is that some drug or diet will bring us improved prosperity and health, then wonder about the unforeseen consequences. In these cases, it’s never a bad idea to remain skeptical until somebody spends the time and the money to do a randomized trial and, contrary to much of the history of the endeavor to date, fails to refute it.

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Gary Taubes is the author of the forthcoming book “Good Calories, Bad Calories: Challenging the Conventional Wisdom on Diet, Weight Control and Disease.”

[Interloper]

It happens when humans believe they can do something better than the way "Nature" works. Like back in the '50s and '60s when (male) pediatricians and obstetrician-gynocologists insisted that infant formula was superior to mothers' milk, even among well-nourished women. And, that childbirth was best done with the woman lying immobilized on her back, rather than being able to lie on her side or to squat -- which is how female humans have given birth since they became bipedal.

Of course, it's really about 1. profits for infant formula manufacturers and all the secondary industries that contribut to it (baby bottle makers, dairy industry, etc.) and 2. to make things easier and more convenient for modernday hospital maternity wards.

[Chris Fleming]

^^Saw this video about infant formula--the majority of the formula was sugar--something like 42% sugar and 10% high fructose corn syrup, bringing it to be over 50% sugar. The rest was mainly soy (said to cause estrogen hormone). Can't believe people give their kids that poison and then wonder why so many kids end up having disorders and juvenile diabetes.

Look at the aspartame in so called "diet" soda. Not to mention the high fructose corn syrup in damn near everything (went to buy bread the other day and HFCS was in it!). These are the kinds of things people will look back on 50 years from now and shake their heads saying, "what the hell were they thinking?". Kind of like the old adverts talking about how "more doctors smoke Camels".

Have to laugh at those drug commercials where the majority of the commercial is telling you all of the bad shit that will probably happen to you if you take the drug!

The question might be more accurately asked, "Do we know what is really making us sick".

Pisses me off--I'm not an old dude but I'm the oldest with 3 other siblings. All three of them have internal problems of various kinds, (my youngest brother is a football player, very big and strong, and yet has diabetes) and all three of them guzzle diet soda like there's no tomorrow.

[Interloper]

Chris,
When infant formula first was introduced back in, I think, the late '40s, it had more powdered cow's milk in it, plus the natural milk sugars (lactose, galactose). I don't think they were using corn syrup or soy in those days. But contemporary infant formula is just like you said. Scary crap they're feeding children. No wonder childhood obesity and diabetes are on the rise; the poor kids get started on that road in infancy.

[Marilyn]

Funny thing breast milk is incredibly sweet. It is no wonder sweets are so addictive.

[I-mon]

Bob (and others) where do you get your medical/science news?

[meeks]

Funny thing breast milk is incredibly sweet. It is no wonder sweets are so addictive.

Breast milk is nectar of the gods. why anyone would deny their infant/toddler/kid/boyfriend/spouse such goodness is beyond me - if I could buy that instead of cow's milk there'd be no need for chocolate syrup.

on a serious note, chinese medicine considers it 1 of the 3 elixirs of longevity. I truly believe that a lot of health issues could be avoided if mothers that were capable of producing milk fed their infant breast milk exclusively, and if mothers unable to produce milk would use a wet nurse (another woman capable of producing milk on behalf of the mother) instead of formula. It's unfortunate that big business (as usual) gets inside of people's heads and convinces them that their powdered crap is more beneficial than natural breast milk.

did you guys know that aspartame is BANNED IN EUROPE and (I think) Japan? Here's a neat blurb:

The FDA Commissioner made that decision even though FDA Investigators and Toxicologists were warning him about the dangers of aspartame. The Public Board of Inquiry made up of scientists, including the President of the American Association of Neuropathologists, voted unanimously against approval of aspartame. The FDA Commissioner's original team of scientific experts was against approval of aspartame because the brain tumor data was so "worrisome." Of course, soon after the FDA Commissioner approved aspartame for carbonated beverages, he took a consulting position with the PR firm for G.D. Searle (maker of aspartame at the time) at $1,000/day.

[cdobe]

Bob,
all your articles point in a certain direction. That however is not because the modern medicine is so evil or harmful as a whole. It is because of your selection of information. There are a lot of people on this planet, whose lifes have been saved or made bearable due to modern medicine. Please look at the complete picture.

CD

[Bob]

cdobe:

That is an interesting and yet unwarranted inference: "evil or harmful as a whole?" The articles are posted for discussion. I seldom, if ever, post my own commentary regarding the articles. Without going into my background in detail, I have been a recipient of a cornea transplant--I am quite aware of the pluses of modern medicines.

Perhaps it is you who should give more consideration to the limits of modern medicine?

This is not a smart-ass suggestion but if you really find the pattern of my posts regarding medicine so "biased" that it draws you away from the content of the article and leads you to inferring the motives of the poster, i.e. me, then maybe you should simply avoid the postings. The postings obviously are not to your liking.

Basically, if you don't like the food at this restaurant, there are plenty more to choose from or better yet, you can start your own restaurant.

I'll stop over and take a look at your menu. LOL

[cdobe]

cdobe:

That is an interesting and yet unwarranted inference: "evil or harmful as a whole?" The articles are posted for discussion. I seldom, if ever, post my own commentary regarding the articles. Without going into my background in detail, I have been a recipient of a cornea transplant--I am quite aware of the pluses of modern medicines.

Perhaps it is you who should give more consideration to the limits of modern medicine?

Bob,
I'm glad to hear, that you appreciate the positive aspects of modern medicine as well. My impression doesn't come out of nowhere though. Your uncommented articles have always been very critical about science-based medicine and the scientific method itself and very favourable of alternative or traditional healing methods.
I myself am not a believer type of person (not saying that you or anyone else here is). I do not believe in everything that has the label "science" on it. I'm also not emotionally attached to any form of ideology, when it comes to these issues. I do not stand on either side of the fence, nor somewhere in between. There is good science and bad science plus the possibilities of misinterpretations and mistakes.

I hope I didn't offend you with my remark. That was not my intention.

cd

[Steve James]

Re: breast feeding. "Baby formulas" like Similac are really recent developments. Before them, mothers heated up bottles with cow's milk. The reasons for both were primarily conveniences for mothers. Before bottles, mothers with resources would often hire wet-nurses to breast feed their babies ... because breast-feeding was inconvenient, messy and sometimes frowned on in western societies. I live in a very big city, and I rarely see a woman breast-feeding in public.

I also think that 1) breast-feeding was considered something that poor women did and 2) that "formula" was first advertised as being "modern" and better for the baby. The "back to nature" movements (i.e., Mother Earth, hippies, New Age) and communes with different standards of "decency" and ideas about childbirth and child nurturing were the first to advocate going back to breast-feeding. However, that's where I think you're right that "big farm" and "big Pharm" got into the business of convincing women in the west to prefer formula feeding over breast feeding. I had a girlfriend who said she wouldn't breast feed because her breasts would get too big .

I feel more for the women in the developing world who are being sold the "bottle is better" bill of goods by western companies. To many tragedies to mention: from women given contaminated or expired formula, to inadequate explanation of how to correctly mix dry formula --of course, without providing or insuring clean water to begin with. Those women, imo, are being abused for profit, too. But, I think the situation with American (western) women (people) is as much their creation as it is that of the companies. Advertising is like a con game. It only works because it convinces people to want/buy something that they don't need (whether they can afford it or not). That's why cow's milk has advertisers and human milk doesn't Whenever there's an ad for something that most people really need, it's called a "public service announcement" --as in "sorry to bother you with this unpleasant information that asks you to eat vegetables and stop smoking." Then the tobacco and alcohol companies hire lobbyists to protest how much the gov't wastes on public service messages.

[Bob]

cdobe:

We are "brothers of the night" meaning we are probably a lot closer in thought than you might think. However, I have posted blog sites and articles quite critical of TCM and alternative medicine--I hate charlatans, especially with regard to alternative medicine. On the other hand, at least here in the US, aside from the technology, allopathic preventative medicine must be looked at much more critically than we currently do and I think integrative medicine is a good path for preventative medicine. The Taube's article is out of the NY Times as are many of the articles I post. The Wall Street Journal often has pretty good articles regarding many of these issues. Pharmaceutical companies and their relationship to doctors must be far more scrutinized than they currently are--

Science and rationality are only one small part of living a meaningful and robust life and sometimes they tend to predominate and constrain the subjective, qualitative living of life--a forgotten art for many--took me many years to recover it.

Enough of my personal views--I also like to read, both negative and positive, comments regarding these articles. Insight is everything and I learn a lot from those who comment on the articles--even negative comments.

The door is always open for a good beer, tasty meal, and lively conversation. Thanks for your clarification.

[Darth Rock&Roll]

clean water
clean air
clean food
regular exercise
emotional balance
purpose through work


these are things taht make us healthy or that we use to keep us healthy.
If you are locked into an unhealthy environment such as a large city, stressful job and time constraints that force you to not be able to observe
good dietary conditions or exercise opportunities, tehn quite simply, you are going to bag at according to the strengths of your personal construct genetically/physically and mentally.

don't abuse yourself is the best way. abuse is many formed.

[marqs]

About artificial-sweeteners, I recently read a short article (was in Finnish, partially based on this Southhampton university-study http://www.ncbi.nlm.nih.gov/pubmed/20619074) about how they accelerate the digestion of glucose, and are used to fatten pigs in some cases. Apparently humans have the same reaction, meaning that if some food is eaten with diet-soda, it digests glucose more efficiently (leading to faster & more digested calories) than normally, esp. if the food is carb-heavy. This hasn't been definitively proven yet, but the nutrition researcher who wrote about this was quite convinced that this is the effect in humans. The linked study doesn't yet indicate the effect on humans, but there were other studies that pointed to that direction. I think this was esp. about saccarine

[Interloper]

Funny thing breast milk is incredibly sweet. It is no wonder sweets are so addictive.

Milk sugars have a sweeter taste than sucrose does; IOW, it takes lower quantities of lactose and galactose to sweeten milk than would sucrose (you'd need more sucrose -- which comes from sugar cane and other plants to get as sweet a taste). So, babies aren't really taking in all that much sugar when they drink breast milk, compared to a similar liquid volume of, say Coke.