Medical Science

Assault on Science

I recently read a very interesting book called Science Under Siege. The authors are Peter Hotez, pediatrician and vaccine researcher at Texas Children’s Hospital in Houston, Texas and Michael Mann, the prominent climate researcher who found strong evidence for manmade global warming. It is an excellent book and I highly recommend reading it. Public confidence in science has significantly declined since the pandemic, but the majority of polls continue to show strong support for science (see this link to the Pew Research Center). On the other hand, there is a well funded, sophisticated effort to discredit science and scientists. Many people do not understand how science is done, how it is funded, and its contributions to society. In this post I will write about all of those things, as well as the people and groups who are funding the assault on science and scientists.

What is the Scientific Method?

The scientific method is a systematic way to advance knowledge. Here are the steps of the scientific method: This excellent formulation is copied from a webpage from American Journal Experts.

  1. Define a question: Constructing a clear and precise problem statement that identifies the main question or goal of the investigation is the first step. The wording must lend itself to experimentation by posing a question that is both testable and measurable.
  2. Gather information and resources: Researching the topic in question to find out what is already known and what types of related questions others are asking is the next step in this process. This background information is vital to gaining a full understanding of the subject and in determining the best design for experiments. 
  3. Form a hypothesis: Composing a concise statement that identifies specific variables and potential results, which can then be tested, is a crucial step that must be completed before any experimentation. An imperfection in the composition of a hypothesis can result in weaknesses to the entire design of an experiment.
  4. Perform the experiments: Testing the hypothesis by performing replicable experiments and collecting resultant data is another fundamental step of the scientific method. By controlling some elements of an experiment while purposely manipulating others, cause and effect relationships are established.
  5. Analyze the data: Interpreting the experimental process and results by recognizing trends in the data is a necessary step for comprehending its meaning and supporting the conclusions. Drawing inferences through this systematic process lends substantive evidence for either supporting or rejecting the hypothesis.
  6. Report the results: Sharing the outcomes of an experiment, through an essay, presentation, graphic, or journal article, is often regarded as a final step in this process. Detailing the project’s design, methods, and results not only promotes transparency and replicability but also adds to the body of knowledge for future research.
  7. Retest the hypothesis: Repeating experiments to see if a hypothesis holds up in all cases is a step that is manifested through varying scenarios. Sometimes a researcher immediately checks their own work or replicates it at a future time, or another researcher will repeat the experiments to further test the hypothesis.

This is clearly not an easy process. There must be transparency at every step so that other researchers can evaluate the methods and repeat the experiments to be sure they get the same results.

How are scientific findings published?

Once results are obtained from a scientific study, a paper describing the results is prepared by the authors. There are usually several authors for any scientific paper. The principal investigator prepares the initial draft and sends it to his/her colleagues. There are usually many drafts and modifications before a final paper is ready to submit. The final paper as agreed upon by the authors is submitted to a peer reviewed scientific journal. The paper is first reviewed by the editor of the journal. If the editor feels there is significant problem with the paper or if he/she thinks it is not appropriate for readers of the journal then the editor can reject the paper. If the paper passes editorial review, then it is sent to at least 3 scientists in the same field for evaluation. These are called peer reviewers. Each reviewer writes a review of the paper, which are sent to the editors of the journal and to the authors of the paper. The reviewers often suggest modifications to the paper. The journal editor may reject the paper based on the reviewers comments, may suggest that modifications be made and the paper be resubmitted, or much more rarely may accept the paper for publication based on positive reviews from the peer reviewers.

As I can attest from my own numerous scientific publications, the acceptance of a paper by a peer reviewed journal is a long and rigorous process. I have also had papers rejected by the editor and after review by peer reviewers.

Very rarely, investigators publish papers based on fraudulent data. This is usually discovered eventually and the editors then publicly retract the paper. This happened to Andrew Wakefield with his publications about a connection between MMR vaccine and autism in the medical journal the Lancet. All of these papers were found to be based on fraudulent data and were retracted. He actually lost his medical license in the UK because of this. Subsequent large very well designed studies showed no connection between vaccines and autism. This is an example of how the scientific method advances knowledge.

Double blind randomized controlled trials

This kind of trial is the gold standard of scientific research. Subjects for the research are recruited and are randomly assigned to either the experimental group or the control group. Great care is taken to be sure that the selection for either group is completely random. The size of the two groups has to be large enough to ensure that any factors that might bias the results should be balanced out in the two groups by the random selection. The intervention being tested (usually a medicine or other treatment) is given to the experimental group and an identical placebo (inactive) pill or intervention is given to the control group. The investigators administering the treatment don’t know whether they are administering the experimental treatment or the placebo, and they also don’t know which people are in the experimental or the control group. That’s why this kind of trial is called “double blind.” The code for which patients got the experimental treatment and which got the placebo treatment is not broken until the end of the trial. Double blind randomized controlled trials give the most reliable bias free results, but they are very expensive to conduct. There are other kinds of trials as well, because not every research question lends itself to a randomized controlled trial. Almost all well designed research is expensive to conduct. In the next section I will write about how research is funded.

How research is funded

Most research is conducted at academic institutions. Funding for research has to cover the salaries of the researchers and their staff, and the research infrastructure of the institution. All of that is very expensive. Almost all research is funded by grants, either federal (National Institutes of Health (NIH) or National Science Foundation (NSF) or private foundations. Most large grants are federal.

Grant application process

Some grants are designed for application by institutions themselves but most grants are applied for by research scientists. Application for a scientific grant is a major involved process. There is a 12 page limit for the main application for an NIH grant, but supplementary documents required like budgets and investigator bio sketches can run to 150 pages. Each federal grant application is evaluated by a study section composed of eminent scientists in the field. Funding is only available for a small number of grants so most grant applications are rejected. If the study section gives the grant a good score the grant may be awarded to the institution or the investigator. Even if the grant is awarded to the investigator, the grant money is administered by the institution. It never goes directly to the investigator. A percentage of each grant is used by the institution to pay for its research infrastructure. The rest is used by the institution to pay the investigator’s salary and to pay for the costs of the research. Private foundations each have their own rules for grant applications, but they are also difficult to get. Grants from private foundations are usually, but not always smaller than federal grants.

Are scientific results truth?

Science is a systematic way to search for truth about how the world works and how we can successfully manipulate it to get desired results. It is a mistake to put too much emphasis on the results of one study. When many studies find the same or similar results, we have increasing confidence that the results represent truth, but never absolute. Scientific results are always to some degree provisional. That does not mean they are not useful.

Benefits of science to society

Rather than enumerate the benefits, here is a link to a University of California website that explains the benefits much better than I can. As the webpage points out, the benefits of science to society are substantial.

Attacks on science and scientists

Because science is a systematic search for knowledge, the findings of some scientific studies are often inconvenient for certain groups or individuals with ideological beliefs. Some scientific findings also threaten some wealthy people whose wealth comes from industries that scientific results threaten. The fossil fuel industry, for example, has created huge wealth for companies and individuals. Climate science has clearly shown that CO2 emissions from fossil fuels is causing rapid global warming that will be catastrophic if CO2 emissions are not drastically reduced. Scientific research has also been instrumental in developing alternative energy sources such as solar, wind, and others that have become economically viable. The fossil fuel industry has invested tremendous amounts of money to attack these findings. They work at creating the idea that these well validated scientific results are controversial. They hire people with academic credentials who question that CO2 emissions are causing climate change. This kind of opposition research is rarely published in peer reviewed journals. Front groups are created as well as PACs to lobby legislators that are funded without revealing the source of those funds. This is so-called dark money, but it has been shown to come primarily from people who get their wealth from fossil fuels. Koch industries is a good example. There also is a large industry that promotes supplements, vitamins, and alternative medicines that have no basis in science. This industry attacks legitimate health research as well as proven preventive treatments, particularly vaccines for children and adults.

These attacks on science are sophisticated, coordinated, and so far unfortunately very effective. In addition prominent scientists have been subpoenaed to appear before hostile congressional committees, harassed and threatened with arrest and/or bodily harm. These things are well documented in the book by Hotez and Mann.

Bottom Line

Science is a systematic way to advance knowledge. As results are validated by multiple well designed studies we find out more about the world and how to manipulate it to our benefit. Publication of scientific results in peer reviewed journals is a difficult and rigorous process. Almost all science is done in academic institutions and is almost entirely funded by federal grants and grants from private foundations. Obtaining grant funding is also a very rigorous process. Grants are administered by institutions and grant money is never given directly to investigators.

Wealthy people who stand to lose money because of scientific findings are conducting a sophisticated, well funded campaign to attack scientific results they don’t like and to discredit, harass, and threaten legitimate scientists.

Autism: Is There An Epidemic?

HHS Secretary Robert F. Kennedy Jr has declared that there is an epidemic of autism and that there must be some environmental toxin that is causing it. The evidence says otherwise. I will review the evidence in this post.

Increased diagnosis of autism

There is no question that autism is being diagnosed more frequently than in the past. According to the CDC, in 2000 the prevalence of autism was 7 per thousand 8 year old’s and by 2024 was 32 per thousand, a 4.5 times increase.

Evolution of diagnostic criteria for autism

Up until 1980, autism was considered a form of schizophrenia in children. It was thought to be rare, probably because many of these children were institutionalized. Over the various versions of the DSM (Diagnostic and Statistical Manual) criteria over the years, the criteria to diagnose autism have been constantly expanded, resulting in a progressive increase in the frequency of the diagnosis of autism. In the most recent version of the DSM all the subcategories of autism including Asperger’s disease were combined into one diagnosis – autism spectrum disorder. This resulted in a marked increase in the diagnosis of autism, because it included all the less severe forms of autism. There is an excellent description of this evolution on the Arizona Autism United blog: How the Autism Diagnosis Has Evolved Over Time.

Has the frequency of severe autism increased?

Severe or profound autism includes children who have no or little speech, are intellectually disabled, and some have challenging behavior that interferes with safety and well being. According to the CDC, people with severe autism make up about 26% of people with autism. Kennedy says that severe autism has markedly increased. According to Christine Ladd-Acosta, who is the vice director of the Wendy Klag Center for Autism and Developmental Disabilities, the data show that severe or profound autism has increased little or none in the last 10 years. Maureen Durkin, another well known autism researcher, divided autism cases up into different buckets. She found that severe autism has not increased at all, and in fact has decreased a little.

Screening for autism spectrum disorder

The American Academy of Pediatrics began recommending screening children for autism spectrum disorder in 2006. Screening is recommended at well child visits. There is some controversy about the benefits of screening children with no symptoms, but it is clear that screening has increased the diagnosis of autism spectrum disorder, especially milder forms of autism. Screening has also resulted in earlier diagnosis of children with more severe autism. Earlier intervention improves the outcomes in these children.

Causes of Autism Spectrum Disorder

Genetic Causes

Multiple studies including identical twin studies have shown the cause of 80% of autism spectrum disorder cases are genetic. Here is a link to an NIH article that summarizes these studies. Genetic causes are both hereditary and caused by genetic mutations.

Environmental causes

There are certain environmental factors associated with slightly increased risk of autism spectrum disorder. All of these factors account for a very small increase in the incidence of autism spectrum disorder, each less than 1%.

  • Advanced parental age
  • Prenatal exposure to air pollution or certain pesticides
  • Maternal obesity, diabetes or immune system disorders
  • Extreme prematurity or very low birth weight
  • Birth complications leading to periods of oxygen deprivation to the baby’s brain

Do childhood vaccines cause autism spectrum disorder?

The answer to this is a definite no. Multiple large well designed studies have shown no association of vaccines, or any component of vaccines including thimersal and aluminum that have any association with autism spectrum disorder. Here is a link to an article from the CDC summarizing these studies.

Does taking Tylenol (acetaminophen) during pregnancy cause autism?

Once again the answer is no. There were a few small studies that showed an association of acetaminophen during pregnancy and development of autism spectrum disorder. Larger, better designed studies have shown no association of acetaminophen use during pregnancy and subsequent development of autism spectrum disorder in children born from those pregnancies.

Autism spectrum as neurodiversity

Many people with milder forms of autism spectrum are fully functional and live independently. They view themselves as on a spectrum of neurodiversity rather than having a disorder. Here is a link to an article from Autism Speaks describing the idea of neurodiversity.

Bottom Line

The increase in the incidence of autism spectrum disorder is almost entirely due to increased diagnosis and increased awareness. The cause of 80% of autism spectrum disorder is genetic. There are a few environmental causes that have increased over time, but these account for only a tiny portion of the increase. There are many well designed studies that show that vaccines do not cause autism spectrum disorder. There are also similar large well designed studies that show that taking acetaminophen during pregnancy does not cause autism spectrum disorder in the babies born from those pregnancies.

Many people on the autism spectrum are fully functional and live independently. They view themselves as people with neurodiversity rather than people with a medical disorder.

There is a very good podcast called Science Versus that reviews all of the evidence that I have outlined above. It is worth listening to. Here is a link to the transcript of the podcast. You can listen to the episode on your normal podcast app. The show notes for the episode has all the references that are used in the episode.

Empathy vs Compassion

I recently read a fascinating book by psychologist Paul Bloom called Against Empathy: The Case for Rational Compassion. In this post I will discuss this book in more detail as well as review other evidence about the difference between empathy, theory of mind, and compassion. I will also discuss how Bloom’s book has been misused by some right wing Christians.

Empathy

Definition of Empathy

Most definitions of empathy include vicariously feeling the same emotions as another person and understanding another person’s perspective. Psychologists separate these two things. Vicariously feeling another person’s emotions or pain is called emotional empathy. It is neurologically distinct from understanding another person’s perspective, which is called cognitive empathy or theory of mind. Bloom focuses his critique on emotional empathy, not theory of mind.

Emotional Empathy

Emotional empathy is hard wired into us. It is a mostly unconscious response to another person’s distress. It can motivate us to be kind and helpful to the person or people who elicit this response. It can also lead to harm and even violence. Much more about that later in this post. Emotional empathy is a system 1 response. I’ll explain what that means below.

System 1 and System 2 modes of thinking

System 1 and system two are descriptions of of two ways that our minds operate. It is a somewhat simplified model, but it is consistent with current neuroscientific research. The best accessible description of system 1 and system 2 is a book by Daniel Kahneman called Thinking, Fast and Slow. I highly recommend reading it.

System 1 is what we use for most routine tasks in our lives. It is our fast, automatic, intuitive and emotional mode of thinking. It operates without conscious awareness and relies on mental shortcuts to make quick judgments and decisions. System 1 is essentially our brain’s “autopilot” mode, constantly monitoring our surroundings and making rapid assessments. It is essential to our lives, but , it’s also important to be aware of its limitations. It can sometimes lead to errors in judgment, particularly when dealing with complex or unfamiliar situations. 

System 2 thinking is a deliberate, conscious, and effortful process used for complex tasks and decisions. It is characterized by logical reasoning, careful analysis, and consideration of multiple factors. Unlike System 1 (fast, intuitive thinking), System 2 requires focused attention and effort.

Emotional empathy as a system 1 mode of thinking

Emotional empathy happens without our conscious awareness. It is contextual. Bloom cites research that emotional empathy is influenced by what we think about the person we are empathizing with and how we judge the situation that person is in. In one study subjects were shown videos of people in pain said to be suffering from AIDS. Some of the people in the videos were described as having gotten AIDS from intravenous drug use and some were described as having gotten AIDS from a blood transfusion. Subjects showed much more empathy for the people who were described as having gotten AIDS from a blood transfusion than those described as having gotten AIDS from intravenous drug use.

Emotional empathy is also influenced by the group to which the other person belongs. Is it one of Us or one of Them? There was a study of a painful shock to the hand in European soccer fans. One person was shocked while others witnessed the person who was shocked. Subjects showed more empathy if the person was a fan of the subject’s team and much less empathy if the person was a fan of the opposing team. All of these responses were shown to be below the level of consciousness. When subjects were asked about the reason for the difference in their empathy scores, they denied that there was any bias.

Does high emotional empathy correlate with good behavior?

People do vary in how empathic they are. On one end of the spectrum are people who have a high emotional empathy response, and on the other end of the spectrum are people who have very little emotional empathy. We would expect that people with a high emotional empathy response would be more likely to take action to help. People with high emotional empathy feel peoples’ distress more strongly and this should motivate them to help if for no other reason than to reduce their own distress. Another way that they could reduce their distress, however, is to escape rather than help. We would also expect that people with very low emotional empathy would have more cruel or violent behavior.

It turns out that there is almost no correlation with empathy and good or bad behavior. A meta-analysis of all the studies showed that low empathy has no association with aggression, and high empathy has minimal to no effect on good behavior. To quote Bloom, “Being high in empathy doesn’t make one a good person and being low in empathy doesn’t make one a bad person.”

Emotional empathy as a spotlight

Emotional empathy acts like a spotlight. To quote Bloom again, “making visible the suffering of others making their troubles real, salient and concrete.” The spotlight effect is a weakness as well as a strength. When you point a spotlight at something, everything else is in darkness. What you see depends on where you point the spotlight. This focus effect makes you more vulnerable to bias. It also leads to something called “the identifiable victim effect.” This sets up a situation where one identifiable victim elicits more emotional empathy than than a thousand victims. Stalin once said “One death is a tragedy; one million deaths is a statistic.” We also see this effect in deaths from the COVID pandemic. Eighty percent of Americans do not know anyone who died from COVID, though over a million Americans died from the COVID pandemic. The people who died were disproportionately elderly, black or poor. For people outside of those groups there was no emotional empathy spotlight effect. That is likely why so many people were not convinced that COVID was a serious disease.

The dark side of emotional empathy

Emotional empathy where there is conflict between groups can exacerbate conflict, even wars. People on one side feel empathy for members of their group who feel they have been harmed by the other side. Empathy with your side leads to the desire to punish the perpetrators. Of course people in the group on the other side of the conflict feel emotional empathy for the people on their side and therefore want to punish the other group. In these kind of situations emotional empathy exacerbates rather than mediates conflict between groups.

Burnout

People in the helping professions (doctors, nurses, therapists) do not do well when they experience high emotional empathy with all their clients. Experiencing the pain and suffering of patients, even though empathic suffering is not as severe as the suffering of the patient, is not pleasant. Over time, symptoms of burnout can develop. These include fatigue, poor concentration, lack of energy and effectiveness, cynicism and detachment.

Manipulating emotional empathy

The emotional empathy response can be manipulated for good causes, but also for things that are morally suspect or wrong.

Charities

Charities understand that eliciting emotional empathy will increase donations. They do this by showing images of individual people or animals who are obviously in distress. Stories go with the images about the suffering of this individual person or animal. Since we have an increased emotional empathy response to children in distress, the charity ads often use images of children. The emotional empathy response is not a good way to decide which charities should get your donations. Some charities do much more good for a lot more people than others. All charities, both good and not so good use the same techniques to manipulate emotional empathy. There is a better way to decide which charities should get your donations. More about that later in this post.

Politicians

Politicians often highlight individual people to manipulate the emotional empathy response to recruit people to vote for them or to take one side or the other in political and policy battles. Once again, this is not a good way to choose which politician or which policies you want to support.

The Christian right

There have been several recent books by right wing Christian authors who have cherry picked Paul Bloom’s critique of emotional empathy. Essentially anything or anyone that elicits empathy that contradicts their view of Christianity is termed “toxic empathy.” This is just another manipulation of empathy in a negative sense that promotes a particular religious viewpoint.

Compassion

Definition of compassion

Psychologist Paul Gilbert defines compassion as basic kindness with a deep awareness of the suffering of oneself and of other living things coupled with the wish and the effort to relieve that suffering.

Compassion as system 2 thinking

Understanding (rather than feeling) the suffering of a person or group of people uses system 2 thinking. That understanding facilitates the desire to help in the most effective way possible. Determining the most effective way to help requires logical reasoning, analysis, and consideration of multiple factors. These are characteristics of system 2 thinking.

Awareness of the vast amount of suffering in the world does not mean that an individual person can help relieve the suffering of all sentient beings. Compassion involves choosing both how and whom one can help the most.

Compassion in the helping professions

As noted above, emotional empathy alone can lead to burnout. It can also lead to less than ideal doctor-patient relationships. Patients are not interested in doctors or nurses feeling their pain. They want compassionate competent care. Doctors, nurses and therapists must of necessity maintain a certain emotional distance from their patients in order to provide that compassionate care. Compassionate care clearly involves mostly system 2 thinking. Unlike emotional empathy, understanding and compassion lead to the opposite of burnout. Multiple studies have shown that compassionate care is good for both patients and their clinicians. Here is a link to a review of a book by Dr. Anthony Mazzarelli and Dr. Stephen Trzeciak: Wonder Drug: Scientific evidence that serving others is best medicine.

Compassion training

It is possible to enhance compassion through training. For over a thousand years buddhists have practiced a form of meditation on compassion called “loving kindness” meditation. It involves both compassion for self and then expanding to family, friends, and eventually all sentient beings. Here is a link to a website that describes this kind of meditation: Metta Meditation: A Complete Guide to Loving-Kindness. There are many other ways to enhance one’s ability to be compassionate including cognitively based compassion training, Stanford multidisciplinary research based training, as well as many others. They have all been shown to increase compassion, which in turn leads to helping others. Once again compassion for self and others is as good for the helper as it is for the one who is helped

Bottom Line

You cannot turn off emotional empathy, nor should you even try. It is an automatic system 1 response. When combined with understanding and compassion it is always a good thing. It makes suffering visible and salient. The important thing is to learn to recognize your emotional empathy system 1 response and then engage your system 2 understanding and compassion. Emotional empathy by itself is not good or bad, but can be either. Your capacity for understanding and compassion (which is essentially kindness) can be enhanced by training. We definitely need more kindness in our world today.

Water Fluoridation

This is another post responding to misinformation promulgated by HHS Secretary Robert Kennedy Jr. Misinformation seems to proliferate faster that true science-based information. Perhaps one way to combat this is for readers of these blog posts to share them as widely as possible to people they know.

Secretary Kennedy is opposed to adding fluoride to public water supplies. He maintains that adding fluoride to public water supplies causes lower IQ’s in children. Two states, Utah and now Florida have already banned fluoridation of public water supplies, mostly in response to his claims about the evils of water fluoridation. I will examine the evidence for these claims in this post

Positive effects of water fluoridation

The US Public Health Service recommends public water fluoridation at a level of 0.7 mg per liter. This level of fluoride in water reduces tooth decay in children by 25% even in children who do not brush or floss regularly. This therefore most benefits poor and marginalized populations for whom dental hygiene can be difficult. Public water fluoridation at this level is one of the most effective public health interventions. Tooth decay can lead to chronic inflammation, which can lead to many other diseases including heart disease.

Sources of natural fluoride

Fluoride occurs naturally in almost all water supplies through the erosion of rocks and soil containing fluoride. The levels of natural fluoride are usually too low to prevent tooth decay, but some water supplies have much higher levels of natural fluoride up to as much as 50 mg per liter in some mountainous and volcanic regions.

Adverse effects of high natural fluoride

Fluorosis

Fluorosis has two components. At fluoride levels greater than 1.5 mg/L children who have growing teeth can develop brown discoloration of teeth. This is called dental fluorosis and is mostly a cosmetic problem. Long term exposure to fluoride levels greater than 10 mg/L can lead to skeletal fluorosis, which is a much more serious condition.  In skeletal fluorosis the bones are generally weaker than normal with stiffness and pain in the joints as the early symptoms. In severe cases, muscles are impaired and bones in the central skeleton are irregularly thickened.

Lower IQ in children

In January of 2025 JAMA (Journal of the American Medical Association) published an analysis of combined data from many international studies that showed lower IQ scores in children exposed to higher levels of fluoride from all sources: Fluoride Exposure and Children’s IQ Scores. The study found that the higher the exposure to fluoride, the lower were the children’s IQ scores. This finding was statistically significant for levels above 1.5 mg/L but not at or below this level. None of these studies were done in the United States. The US Public Health recommendation of 0.7 mg/L is well below the threshold for association of lower IQ in children.

Other sources of fluoride

The most significant other sources of fluoride are supplements, toothpaste and oral rinses. For children who have fluoride at 0.7 mg\l in drinking water, fluoride containing supplements should not be given. Most toothpastes contain fluoride, so children with fluoride in the water supply should use only a pea sized amount of toothpaste per brushing and should be encouraged to spit out the toothpaste after brushing. If the water supply has not been fluoridated and contains only trace amounts of natural fluoride, then supplements should be given to children.

Bottom Line

Fluoridation of public water systems at the recommended concentration of 0.7 mg/L is safe and effective at markedly reducing tooth decay in children. There is no evidence that fluoride in water at this level has any adverse effects. There is some evidence that concentrations of higher than 1.5 mg/L are associated with modest decreased IQ in children. Elimination of fluoride from public water systems will increase tooth decay in the most vulnerable populations and will not have any benefit. Children who live in communities with fluoridated water should not take fluoride supplements, should use only small amounts of fluoridated toothpaste, and should be encouraged to spit out toothpaste after brushing and not swallow it. Communities who have high natural levels of fluoride in drinking water can reduce fluoride to safe levels by reverse osmosis or charcoal filter systems.

Autism: Is There Really An Epidemic?

Robert F. Kennedy Jr has reported that there is an epidemic of autism. It is clear that autism is being diagnosed more frequently in the last 10 years, but does that represent an increase in the incidence of autism or better diagnosis? In this post I will review the literature about autism in order to give an evidence-based answer to that question.

Diagnostic Criteria Changes Over Time

There is an excellent paper describing how the criteria for diagnosing autism has changed over time: Update on diagnostic classification in autism. The following information is taken from that paper.

The diagnosis of autism was first described in 1943 by Kanner. Prior to that children with severe autism symptoms were diagnosed as “schizophrenia of childhood.” In 1944 Ausberger reported on a group of children who had similar symptoms to the children Kanner described, but they had no intellectual deficits.

It was not until 1980 that the diagnostic criteria for autistic disorder were included in the Diagnostic and Statistical Manual (DSM)-III). Core features were onset prior to 30 months of age, pervasive lack of responsiveness to others, gross deficiencies in language development, peculiar speech patterns, and bizarre responses to the environment, including resistance to change and fascination with objects. This led to a marked increase in the diagnosis of more severe autism. In 1987, DSM-III-R expanded the menu of symptoms supporting the diagnosis of autism, and formally separated core features into three domains of impairment in social interaction, communication, and restricted or repetitive behaviors.

The next significant change occurred in the DSM -IV in 1994 with the introduction of the diagnosis of Asperger’s disorder. Aspergers’s disorder included what used to be called high functioning autism (autism without intellectual disability). The addition of diagnostic criteria for less severe forms of autism led to another increase in the diagnosis of autism.

In the years since the introduction of the DSM-IV criteria, advances in genetics found that all of the autism disorders had a strong genetic component and that the different forms of autism-like illnesses probably were manifestations of the same condition. In 2013 in DSM V, all of the the autism like illnesses including Asperger’s syndrome were combined into something called autism spectrum disorder.

Subsequent research showed that autism could be diagnosed as early as 18 months of age. This led to the recommendation by the American Academy of Pediatrics that all children should be screened for autism at 18 and 24 months of age. This universal screening has resulted in finding many more cases of autism at an early age that would have been missed previously, or the diagnosis delayed.

Causes of Autism

Genetics is a causal factor in 60%-90% of Autism. Autism is also is associated with prematurity, older parents, low birth weight, air pollution, and perhaps other environmental factors. Autism is not associated with any vaccines or with thimersol. Multiple large well designed studies have found no association between any vaccine, multiple vaccines, and thimersol with autism.

Neurodiversity

An alternate way to view the autism spectrum is not as a disorder, but as an example of neurodiversity. In the neurodiversity perspective, there is natural variation in human brains and minds and there is no single “normal” way to think, learn or behave. Neurodiversity encompasses the wide range of neurological differences, including those often associated with conditions like autism, ADHD, and dyslexia. The neurodiversity paradigm views these differences as strengths and not deficits, promoting acceptance and inclusion of all individuals. Organizations of persons with autism like the Autism Self-Advocacy network promote autism as neurodiversity rather than the medical model of a disorder.

Bottom Line

It is clear that the increased sensitivity to diagnosing autism as well as the universal screening of children at 18 and 24 months has led to the increase in the diagnosis of autism from one in 150 in 2000 to one in 36 in 2020. There is no evidence that there is an epidemic of autism, but rather that diagnosis has improved tremendously. Children on the autism spectrum, even the ones with the severe form of the condition do much better when diagnosed early. There is no cure for autism (and the autism advocacy movement would say that no cure is needed), but the earlier it is diagnosed and interventions begun, the better the long term outcomes.

Inflammation: Pathway to Chronic Diseases

Inflammation is activation of the immune system in response to threat or injury to the body. Acute inflammation mobilizes the immune system to repair an injury or fight an infection. Once healing takes place the immune system goes back to baseline. Chronic inflammation, however, involves long term activation of the immune system caused by some ongoing stress to the body. More and more, researchers are beginning to show that chronic inflammation is the common pathway to many diseases. There are multiple causes of chronic inflammation. In this post I will write about the causes of chronic inflammation. I will also do a series of posts about the many diseases that chronic inflammation causes. These posts will be based on the structure of an excellent book: Inflamed – Deep Medicine and the Anatomy of Injustice. It is not easy to read because it is disturbing but I highly recommend it. I will also write about a test to measure chronic inflammation. I will write about things you can do to decrease chronic inflammation if you have it and how to prevent it if you don’t. There are many causes of chronic inflammation that have to do with the structure of our society. These are things an individual cannot control. These societal causes will take ongoing efforts by all of us to change some of the toxic structures of society.

The Process of Inflammation

The inflammatory process starts with damage or threat of damage to the body. That can be an infection, a wound, or perceived threat of such. The immune system mobilizes white blood cells called macrophages to the injured area or site of infection. The cells of the immune system also release a cascade of messenger molecules called cytokines that amplify inflammation. These include interleukin 1ß, interleukin- 6 and tumor necrosis factor -α. The liver also releases a protein called c-reactive protein. When the threat is neutralized the immune system helps the body start to heal by releasing anti-inflammatory cytokines including interleukin (IL)-1 receptor antagonist, IL-4, IL-10, IL-11, and IL-13.

In chronic inflammation the pro-inflammatory cytokines continue to predominate and the c-reactive protein continues to be elevated.

Causes of Chronic Inflammation

Causes an individual can do something about

  • Low levels of physical activity.
  • Having a BMI at or above 30 , especially when excess weight is deep within your belly (visceral fat). The best way to measure belly fat is to use a tape measure to measure your waist at the widest point. Increased belly fat is greater than 35 inches for women or greater than 40 inches for men
  • An imbalance of healthy and unhealthy bacteria in your intestine (dysbiosis). Dysbiosis can be caused by antibiotics and by eating foods low in soluble fiber.
  • Regularly eating foods that cause inflammation, especially highly processed foods, or foods high in sugar or salt
  • Inadequate sleep
  • Using tobacco products.
  • Regularly drinking too much alcohol
  • Periodontal disease (gum infection) and tooth decay
  • Perceived stress

Societal Causes

  • Experience of racism (structural or personal)
  • Poverty
  • Homelessness
  • Worry about debt
  • Work stress
  • Exposure to air pollution
  • Exposure to chemicals (pesticides and herbicides for farm workers, glyphosphate (RoundUp) for everyone, microplastics in our bloodstreams for everyone. Every day, we are surrounded by thousands of synthetic chemicals. They are in our food, clothes, tools, furniture, toys, cosmetics and medicines. We know the health effects of only a few of these).

Diseases caused by chronic inflammation

  • Cardiovascular Disease (coronary artery disease, heart attacks, congestive heart failure)
  • Strokes
  • Type 2 diabetes
  • Cancer (multiple types)
  • Inflammatory bowel disease (crohns disease, ulcerative colitis)
  • Rheumatoid Arthritis
  • Lupus and similar autoimmune diseases
  • Asthma
  • COPD
  • Pulmonary fibrosis
  • Depression

Tests to measure chronic inflammation

All of the inflammatory cytokines can be measured but those are expensive tests. A simple inexpensive test that measures inflammation, both acute and chronic is high sensitivity CRP. It will also be high with an acute infection or injury, but will return to normal after the infection or injury have resolved. If it remains elevated when you are not sick or injured it is a sign of chronic inflammation. It may be worth asking your doctor to order this test if you have any of the individual or societal risk factors for chronic inflammation. A normal hs-CRP is less than 0.55 mg/dl in men and less than 1.0 mg/dl in women. If your hs-CRP is high in the absence of acute infection or injury, that can serve as motivation to make lifestyle changes to decrease your chronic inflammation and put you in a population that has less risk of developing any of the diseases associated with chronic inflammation.

Anti-inflammatory lifestyle

  • Exercise regularly. The CDC recommends 30 minutes of moderate exercise (walking briskly) for 30 minutes at least 5 days a week.
  • Eat mostly unprocessed or minimally processed foods and avoid sugary drinks or foods with added sugar or high fructose corn syrup. Also include foods with high soluble fiber such as beans, carrots, sweet potatoes, nuts, berries and most fruits (not fruit juice). Organic foods, while more expensive, have no residual pesticides or herbicides. If you eat meat buy grass fed beef, and pasture raised chicken and pork. Eat more plant-based foods than meat.
  • Avoid taking antibiotics as much as possible
  • Sleep. Average at least 8 hours a night
  • Floss your teeth daily, brush twice a day and see your dentist every 6 months
  • If you don’t smoke, don’t start and if you do smoke quit.
  • It is better not to drink alcohol at all, but if you do limit it to 1 drink a day or less.
  • Learn meditation or self hypnosis to manage stress. There are good books and videos, but an in person course is best if it is available.
  • Drink only filtered water and not bottled water in plastic bottles
  • Gas stoves cause significant indoor air pollution. If possible switch to an electric stove. Induction type burners actually heat more quickly than gas. If you have to use a gas stove, be sure to turn the ventilator fan on and open a window if possible.

Bottom Line

Chronic inflammation is the common pathway for many chronic diseases. There are many individual strategies that reduce or prevent chronic inflammation. Many of these strategies are not possible for people with socioeconomic problems. The stress black people experience from structural and individual racism, homelessness or inadequate housing, anxiety over debt, exposure to environmental synthetic chemicals, and exposure to air pollution are societal problems that we all have a responsibility to address.

My next post will deal with chronic inflammation and cardiovascular disease.

Natural and Alternative Cancer Treatments – Do They Work?

People who are faced with a new diagnosis of cancer frequently turn to the internet to learn about treatment. Although there is good and reliable information about cancer and cancer treatment on the internet, it is much more common for people to find websites promoting various natural and alternative treatments for cancer as opposed to medically proven treatments such as surgery, radiation, chemotherapy and immunotherapy. Is there evidence that any of these alternative treatments work as well as or better than traditional cancer treatment?

This post will explore the most commonly recommended natural and alternative cancer treatments and present the evidence, if any, that any of them work.

CBD and THC

There is some evidence in tissue culture studies that cannabinoids like CBD and THC inhibit cancer cells. There have been some limited clinical trials in humans using cannabinoids as treatment. None of these trials has shown any beneficial effect on any cancers in humans.

Chinese Herbal Medicines

Traditional Chinese medicine uses a completely different framework than western medicine for health and disease. It has been used and developed for thousands of years. It focuses on restoring natural balance of the opposing forces of yin and yang. Treatment is individualized based on the imbalance diagnosed by the practitioner. In China, traditional Chinese medicine is frequently used as an adjunct to cancer treatment with surgery, chemotherapy and immunotherapy. Combinations of herbs are used as well as things like acupuncture and qigong. There is some evidence that the some of the herbs used in traditional Chinese medicine have some anticancer properties, but because of the individual nature of treatment it is almost impossible to do randomized trials. There is no good evidence that traditional Chinese herbal medicines alone successfully treat any cancers. There is evidence that people in China who use traditional Chinese medicine as an adjunct to other cancer treatments have fewer side effects from anticancer drugs and have better quality of life during treatment.

Ayurvedic Medicine

Another old (5000 year old) system from India that also teaches that disease is due to imbalance that can be corrected with traditional Indian herbal medicines. There are no clinical trials that show the Ayurvedic medicine cures or treats any cancers.

Special Diets

Many types of diets have been proposed to treat cancer. There is no evidence that any dietary changes treat any cancer. Plant based diets have been shown to decrease the risk of getting certain cancers, but there is no evidence plant based diets successfully treat any cancer.

Other unproven and disproven cancer treatments

There are numerous other alternative or natural cancer treatments that have been proposed by many different groups. They are in fact too numerous to mention separately in this post. There is an excellent Wikipedia article that has a comprehensive list of unproven and disproven cancer treatments. Here is a link to that web page: List of unproven and disproven cancer treatments.

Bottom Line

People who use natural and alternative cancer treatments tend to substitute those for proven medical treatments like surgery, chemotherapy and immunotherapy. As a result, people who use these therapies as an alternative to proven treatments have quicker progressions of cancer and die sooner than people who use proven therapies. Some alternative therapies used as an adjunct to proven therapies may improve quality of life during treatment. Because some herbal medicines can interact with chemotherapy drugs, it is important that your cancer treatment doctor knows that you are using one of these alternative therapies as an adjunct to the treatment he/she is giving you for your cancer.

Longevity – Health Span vs Life Span

Longevity is the newest health buzzword. There are an increasing number of so-called longevity experts. They say, just read my book and follow my instructions and you can live past 100 years. Some of these “experts” focus on health span. They say follow my instructions and you will stay healthy and die suddenly at an advanced age. As of 4/21/2024 there are 34 books on longevity listed on Amazon.

In this post I will do my best to distinguish the hype from the science with regard to living a long and healthy life.

Hype

  1. Calorie restricted diets – Some people have extrapolated mouse and rat experiments that show that animals fed restricted calorie diets live a lot longer than animals fed a normal diet. There is not one shred of evidence that this works with humans, and is more likely to lead to diseases of malnourishment.
  2. Nutrtional supplements – Recommendations range from vitamins, to protein powder, to collagen powder, to herbal preparations, to encapsulated fruits and vegetables. There is absolutely no evidence that any of these things or any other supplements including multivitamins work to extend your life. Anecdotal reports of feeling better on these supplements are almost certainly a placebo effect
  3. Anti-aging medicines – reservetrol, metformin, rapamycin have all been shown to prolong life in some experimental animals. In humans Metformin and reservetrol decrease the ability to exercise and rapamycin suppresses the immune system. There is no evidence whatever that these compounds increase life or health span in humans.
  4. Extensive lab tests – Other than lipid (cholesterol) tests, there is no evidence that otherwise healthy non-obese people benefit from any blood tests. More about screening tests later.
  5. Imaging tests – One of the most popular longevity “experts” ,Dr. Peter Attia, recommends full body MRI scans for his patients. Imaging tests in people who have no symptoms are much more likely to lead to over diagnosis and unnecessary treatment than to find things that really need to be treated,
  6. Very intense exercise regimens – The only thing very intense exercise regimens accomplish that moderate exercise regimens do not is that the intense regimens are more likely to cause injury.

Science

Genetics

Up until into the 80’s, lifestyle is the major contributor to healthy aging. There are some people, however who remain healthy well into their 90’s and a few to past 100. Genetics is the main contributor to these “super centenarians.” There is not a single or even a few aging genes. Super aging is caused by hundreds of genetic variants called SNP’s (single nucleotide polymorphisms). We cannot alter our genes (yet), so there are no lifestyle changes you can make in order to live to 100 if you don’t have the rare combination of all these genetic variants.

That is not to say that lifestyle is not important to healthy aging. In the US, the average person’s last birthday in good health is age 65! Lifestyle changes will almost certainly help you do better than that.

Exercise

Regular exercise decreases your risk of chronic disease and therefore increases your chance of living healthier longer. To accomplish the maximum health benefit the CDC recommends 150 minutes of moderate exercise per week. Brisk walking or cycling at a moderate pace on level ground would qualify. If you choose high intensity exercise like jogging or running or high intensity cycling, you only need to do 75 minutes a week according to the CDC. The CDC also recommends activity to strengthen your muscles two days a week. For a population of adults doing this exercise regimen the risk of death is decreased by 17%. This regimen decreases the risk of heart disease, diabetes, certain cancers and decreases the risk of hospitalization or death from infectious diseases like COVID, flu and pneumonia. This regimen also increases bone and muscle strength and thus decreases the risk of falls and fractures. This exercise regimen also helps maintain a healthy weight.

Any amount of walking or activity decreases risk somewhat. The CDC recommended regimen decreases risk the most.

Nutrition

Eat mostly unprocessed foods and avoid ultra-processed foods. The best way to identify ultra-processed foods is to look at the ingredients label. If there are more than four ingredients, and/or if there are some you don’t recognize, then put that food back on the shelf. It is best to keep nutrition advice simple. The most concise recommendation I know comes from author Michael Pollan. “Eat food (food is anything your grandmother would have recognized as food), not too much, mostly plants.” I can’t do much better than that. Most of the evidence about the beneficial effects of good nutrition come from studies of the Mediterranean style diet. The Mediterranean diet adheres to Michal Pollan’s advice. It has lots of fruits, vegetables, fish, olive oil and very little meat. Adherence to this type of diet showed a 46% increase in living healthfully until 70 or greater.

Social Connectedness

The CDC defines social connectedness as the degree to which people have and perceive a desired number, quality, and diversity of relationships that create a sense of belonging, and being cared for, valued, and supported. An analysis of multiple studies showed that high social connectedness as defined above decreases the risk of premature death by 50%! High social connectedness also decreases the risk of heart disease, stroke and dementia.

Social Determinants of Health

The main reason that the US average health span is 65 years is the tremendous inequity of resources in the US. People who live in substandard housing (or no housing at all) do not have the opportunity or resources to do all of the things above that tend to extend life. That is why life expectancy at birth is related to zip code more than any other factor. My feeling is that we should expend our resources working on improving health equity, which will increase both life and health span for everyone rather than focusing on helping wealthy people live to 100.

Screening Tests

There are a few screening tests recommended by the US Preventive Care Task Force for healthy people. These tests are meant to find disease, especially cancer early so it can be more successfully treated and thus prolong healthy life. The absolute risk reduction of death for these tests is small, most around 1%, but that ends up saving a lot of people when you apply it to the whole US population. The recommended screening tests are listed below.

  1. Mammograms for women beginning at age 50. Recommended every two years. Absolute risk reduction about 1%.
  2. Pap Smears beginning at age 21 every 3 years through age 29 and then every 5 years from age 30 to 65. The absolute death risk reduction is .0009%, which means your would need to do pap smears on 11140 women to prevent one death from cervical cancer.
  3. Colorectal cancer screening. There are three different tests: colonoscopy, the most invasive (recommended every 10 years), Cologuard (a stool sent to a lab in a box recommended every 3 years) and fecal immunochemical test (done on a stool sample and either tested at home or sent to lab recommended every year). All three tests reduce deaths from colon cancer with an absolute risk reduction of around 0.6%. Only colonoscopy can prevent some cancers by removing precancerous polyps.

Vaccines

There is no question that vaccines save lives by preventing some serious life threatening diseases, or making them less severe. Vaccines are especially important for infants and children, who are most at risk from the infectious diseases prevented by vaccines. Childhood vaccines prevent diptheria, whooping cough, tetanus, measles, mumps, rubella, polio, rotavirus (which causes severe diarrhea and dehydration in infants), hemophilus influenza (which caused joint infections and meningitis), hepatitis b, RSV (which causes severe respiratory illness), pneumonia caused by strep (the most common kind of bacterial pnuemonia), COVID (also for adults), meningitis, chicken pox, and HPV (the virus that causes cervical cancer in women).

Adults can get any of these vaccines, but also a vaccine to prevent shingles.

Bottom Line

Living in good health to past 100 depends on genetics, not lifestyle. Many things recommended by so called longevity experts do nothing to prolong life and may increase risk. There are a number of lifestyle changes including exercise, good nutrition, social connectedness, certain screening tests and vaccines that increase you chances of remaining healthy well into your eighties. The main cause of early death in the US is poverty, homelessness and systemic racism. Addressing these inequities is a lot more important than helping wealthy people try to live to 100.

Drug Company Direct to Consumer Advertising – Costly and Dangerous

Television viewers in the United States watch an average of nine drug advertisements per day, or about 16 hours per year, far in excess of the time spent with their physician. That is because pharmaceutical companies spend huge amounts of money on direct to consumer advertising. In 2022 pharmaceutical companies spent 6.88 billion U.S. dollars on direct to consumer advertising! Pharmaceutical companies claim that these ads educate patients about treatment options they might not know about and foster conversations with their physicians. Pharmaceutical companies, however, are in the business of making money and these ads do a great deal to increase their revenue or they would not spend billions of dollars on them. This post will examine the claim that the ads are helpful to patients and doctors and will document the substantial harm that these ads do to both the health system and to individuals.

Almost all other countries besides the United States ban direct to consumer advertising of prescription medicines. The only other country that allows them is New Zealand.

History of Direct to Consumer Advertising

In the 1960’s congress granted the FDA the authority to regulate prescription drug labeling and advertising. The FDA was to ensure that prescription drug ads were: not false or misleading; presented a fair balance of drug risks and benefits; included facts that are material to a drug’s advertised use; included a brief summary that notes every risk described in the drug’s labeling. Because of these requirements, almost all drug advertising was directly to physicians.

In the late 90’s, the FDA changed the required risk information by stating that only major risks must be disclosed in ads and that they must provide resources that consumers can be directed to for full risk information. Because of this change, direct to consumer advertising has exploded since the late 90’s.

Compliance with FDA Requirements

Pharmaceutical companies are not required to submit ads to the FDA before they are used. They are required to submit ads to the FDA for review after they are in use, but the FDA lacks resources to review these ads in a timely manner. Many times the ad has already stopped running by the time the FDA gets around to reviewing it. A 2018 study published in the Journal of General Internal Medicine evaluated all broadcast direct to consumer pharmaceutical ads for 6 months for compliance with FDA regulations. The study found that only 26% of the ads were fully compliant with FDA regulations.

Online Direct to Consumer Advertising

Pharmaceutical companies have markedly increased online advertising through social media including FaceBook, Twitter (now X), YouTube and blog posts. This advertising reaches consumers in English speaking countries who ban direct to consumer prescription drug advertising. The FDA can only review a small portion of these. Here is a link to an article from an international policy journal about online direct to consumer ads by pharmaceutical companies: The Tip of the Iceberg of Misleading Online Advertising.

What the FDA does not require in direct to consumer advertising

Here is a list of important things that pharmaceutical companies are not required by the FDA to include in direct to consumer advertising.

  • Cost – Many of the medicines advertised are very expensive, especially cancer drugs. Pharmaceutical companies are not required to tell you anything about cost in their ads
  • If there is a generic version of the drug (a drug with the same active ingredient that might be cheaper) -Many times there is a generic version of the brand name drug that will do exactly the same thing as the drug advertised
  • If there is a similar drug with fewer or different risks that can treat the condition – There may also be a similar drug with fewer risks that could treat the condition advertised. The pharmaceutical companies are not required to tell you that in their ads
  • If changes in your behavior could help your condition (such as diet and exercise) – Eighty percent of chronic disease could be treated with life style changes. Ads are not required to tell you that
  • How many people have the condition the drug treats – The percentage of people who have the condition the drug treats may be very small. They don’t have to tell you that either
  • How the drug works (its “mechanism of action”)
  • How quickly the drug works
  • How many people who take the drug will be helped by it – It could be that only a small percentage of people who take the advertised drug will improve. Ads are not required to tell you that.

Evidence that direct to consumer drug advertising is helpful

There is evidence that direct to consumer drug advertising is beneficial for patients and their doctors. Here are the claims that have at least some evidence. This list come from a paper in the journal Pharmacy and Therapeutics: Direct-to-Consumer Pharmaceutical Advertising – Therapeutic or Toxic? The paper also summarizes the evidence for each of these claims

  • Informs, educates, and empowers patients. 
  • Encourages patients to contact a clinician. 
  • Strengthens a patient’s relationship with a clinician
  • Encourages patient compliance. 
  • Reduces underdiagnosis and undertreatment of conditions. 

I don’t find the evidence for any of these particularly convincing. None of the papers cited in the article disclose whether any of the authors have financial relationships with pharmaceutical companies.

Evidence that direct to consumer drug advertising is harmful

Despite pharmaceutical companies touting the educational benefits of direct to consumer advertising, remember that the main purpose of these ads is to sell a product, not to educate consumers. Here is a list of well documented harms of direct to consumer drug advertising:

  • Present incomplete or biased information – Most ads either leave out risk of the disease the advertised drug treats or use vague terms (like millions) Ads for drugs for which lifestyle modification is a viable alternative did not mention lifestyle changes. Over half of ads presented the advertised drug as a scientific breakthrough. See this paper from the Annals of Family Medicine: Creating Demand for Prescription Drugs: A Content Analysis of Television Direct-to-Consumer Advertising
  • Spur people to ask for medications they don’t need - A study published in the Journal of the American Medical Association found that “Fewer than one-third of the most common drugs featured in direct-to-consumer television advertising were rated as having high therapeutic value, defined as providing at least moderate improvement in clinical outcomes compared with existing therapies” (Therapeutic Value of Drugs Frequently Marketed Using Direct-to-Consumer Television Advertising, 2015 to 2021)
  • Promote medications before long-term safety is known. In the case of Vioxx, a new pain relief drug, it was pulled from the market due to an unexpected rise in heart attacks and strokes — but not before millions of people saw the ad and began taking it. (Merck to pay $950 million for illegal marketing of Vioxx)
  • Create conflicts between patients asking for a drug and doctors who don’t recommend it – An article in Consumer reports reported that 78% of doctors report that patients at least occasionally ask them for medicines they saw in drug ads. 54% of those doctors said they often decline these requests (Consumer Reports Survey: Patients and Doctors Disagree on Some Essential Issues)
  • Drive up healthcare costs without adding health benefits – New drugs are much more expensive than generic drugs that may do the same job. Also, unfortunately doctors are much more likely to prescribe the medicines that patient’s ask for rather than an alternative less expensive and/or more effective treatment. This is the biggest societal harm of direct to consumer prescription drug advertising. See this paper: Effects of Patient Medication Requests on Physician Prescribing Behavior.

Bottom Line

The FDA simply does not have the resources to adequately regulate pharmaceutical company direct to consumer advertising. Even if they did, it is unlikely that the FDA could even partially mitigate the well documented harms of the tremendous spending by pharmaceutical companies on these ads. I agree with my friend and mentor Dr. Kurt Stange that the only viable recourse is to ban direct to consumer drug advertising as almost every other country in the world has done. Here is his editorial in the Annals of Family Medicine: Time to Ban Direct-to-Consumer Prescription Drug Marketing.

Diet and Heart Disease – Not as Simple as We Thought

We have all been told for years that the main dietary risk factor for heart disease and stroke is how much saturated fat we eat. We have also been told that eating foods high in cholesterol also increases risk of heart disease and stroke. Evidence is accumulating that consumption of saturated fat increases risk of heart disease and stroke little if at all. Since your body makes cholesterol itself, eating cholesterol rich foods has almost no effect on serum cholesterol. Other aspects of diet have a much greater effect on increasing the risk of heart disease and stroke. In this post I will summarize the evidence and spend some time discussing things we eat and drink that do substantially increase the risk of heart disease, stroke and other chronic diseases.

The Seven Country Study

The most famous study that led to the saturated fat hypothesis was carried out by Ancel Keys. The study started in 1956 and was published in 1978. He looked at the dietary patterns of 7 different countries. The countries included Finland, Greece, US, Italy, Yugoslavia, Netherlands and Japan. He found that saturated fat intake was correlated with increased risk of heart attack and stroke. The country with the lowest saturated fat intake was Crete in Italy, which also had the lowest incidence of heart disease and stroke of the 7 countries. The diet of Crete is the basis for the famous Mediterranean Diet.

Diets of free living humans are notoriously difficult to measure. Keys did his best to accurately determine diet. He had a subset of his subjects in each country weigh their food for a number of days, which is considered the gold standard for dietary studies. The problem with any population study like this is that populations in different countries differ in lots of other ways besides diet. Also diets are complex, so some other factor or factors in diet could account for the low heart disease incidence in Crete. Another problem was that diet was measured in Crete during Lent, when most people did not eat meat. All Keys could really say was that saturated fat intake was associated with heart disease, but he could not say that saturated fat caused heart disease.

People who adhered to the Mediterranean Diet did reduce their population risk of heart disease, but there is a lot more to the Mediterranean Diet than reduced saturated fats. It also includes little added sugar, lots of vegetables and fruit and mostly unprocessed foods. It is not clear that reduction in saturated fat is responsible for the health benefits of the Mediterranean Diet.

The Framingham Study

The next big population study was the Framingham Study. A large group of people in Framingham Massachusetts was followed over many years with surveys about diet, activity, smoking and laboratory measurements of total cholesterol, LDL, HDL and triglyerides among other measurements. Heart attacks, strokes, death from either of these things and death from any cause were recorded in the study group. This was the first large study that implicated cigarette smoking as a cause of cardiovascular disease and cancer. It was also found that the higher the total cholesterol and especially the higher the LDL (low density lipoprotein) the higher the risk of cardiovascular disease. It was also one of the first studies that showed that the higher the blood pressure, the greater the risk of cardiovascular disease. This was a tremendously important and well done study.

The Diet-Heart Hypothesis

The diet-heart hypothesis is that saturated fat is the main dietary cause of cardiovascular disease. It has been very influential over 60 years and is still promoted by the American Heart Association and many cardiologists. Here is the train of thought. The 7 country study implicated saturated fat as associated with cardiovascular disease. It has been found through multiple studies that saturated fat intake raises LDL (so called bad cholesterol). The Framingham study showed that increased LDL was a major risk factor for cardiovascular disease. Since saturated fat raises LDL, therefore saturated fat must cause cardiovascular disease.

That makes perfect sense, so many randomized trials were carried out to nail down the diet-heart hypothesis. Unfortunately, as is often the case with beautiful theories, further randomized trials did not consistently show the expected increase in heart disease from eating saturated fat. The other part of the hypothesis was that eating polyunsaturated fats would decrease the population risk of heart disease. That was based on the observation that consuming polyunsaturated fats decreased LDL levels. Randomized trials have generally failed to consistently show that eating polyunsaturated fats reduces the risk of cardiovascular disease.

Reduced Risk of Cardiovascular Disease in US

Heart disease was epidemic in the US, peaking in the 60’s. Since then, the incidence of heart disease in the US and most other developed countries has decreased by 60%! Scientists debate the cause for this decline. Although saturated fat consumption decreased some, Americans still eat much more saturated fat than the 5% of fat recommended by the American Heart Association. So the fact that we eat somewhat less saturated fat does not explain the remarkable decline in heart disease over the last 60 years. What else changed?

Cigarette Smoking

In the 1940’s half of all Americans said they smoked cigarettes. Smoking began to decline in the US in the 60’s and today only 11.5% of Americans smoke tobacco! This has to be a major factor in the decline of cardiovascular disease (and lung cancer).

High Blood Pressure

High blood pressure is a major risk factor for heart disease. The number of people with high blood pressure successfully controlled on medicine has more than doubled since 1960. This is clearly another major factor in the decline of cardiovascular disease

Trans Fats

The rise of trans fat consumption was an unintended consequence of the heart-diet hypothesis. Because animal fat (mostly saturated fat) was postulated to cause heart disease, the food industry started figuring out how to use vegetable oil to replace lard and butter, which were high in saturated fats. They needed something that would be solid, not liquid at room temperature. They discovered that if they partially hydrogenated vegetable oil, then it would be solid at room temperature and could substitute for lard and butter. They marketed these products as healthier because they were only partially saturated fats, not saturated fats. The medical establishment bought this story and recommended margarine as a substitute for butter and Crisco (the most successfully marketed shortening substitute) as healthier alternatives. I have been unable to find statistics on trans fat consumption in the US, but it was very large.

It turns out that consumption of trans fats markedly increased the risk of cardiovascular disease. For every 2% increase in the consumption of trans fats, heart disease increased by 23%. This is a shocking number! The consumption of trans fats certainly contributed to the epidemic of heart disease in the 50’s and 60’s. The FDA essentially banned the addition of trans fats to food in June of 1978. The elimination of trans fats is almost certainly another major factor in the decline of heart disease.

Interesterification

Since trans fats have been banned, food companies have come up with a new way to make vegetable oil solid and spreadable. It is called interesterification. It is complicated, but the simplest explanation is that it involves changing the arrangement of fatty acids on a glycerol backbone. These are fully hydrogenated fats, so are not trans fats. We know very little about how these new industrial fats affect human health, but the information we do have suggests that these new products may be just as bad for you as trans fats. You would do best to avoid them until we know more. More about how to do this later in this post.

Do we need to limit red meat consumption?

The main risk of consumption of any food is eating too much of it. It is total calorie intake that makes us fat, and being fat increases the risk of cardiovascular disease, diabetes and some cancers. Eating red meat by itself is very unlikely to increase your risk of heart disease as long as your total calorie intake is equal to the calories you burn up. So there is very little health risk to you in eating red meat, but there is a big risk to the environment. Cattle raising worldwide contributes about 16% of greenhouse gas emissions. Here is a link to a balanced discussion of greenhouse gas emissions from cattle raising: Livestock Don’t Contribute 14.5% of Global Greenhouse Gas Emissions.

The other thing to think about when consuming any meat product, including chicken is that almost all the meat you buy in the grocery store comes from giant factory farms, where animals are treated very inhumanely. That in itself is bad enough, but raising all those animals together increases risk of spreading disease to the people who eat them. Antibiotics are used in many factory farms to keep animals from getting sick. This contributes to the evolution of bacteria that are resistant to most antibiotics.

If you are not willing to give up eating meat entirely, try to find locally raised beef, pork and poultry. Farmer’s Markets are a good place to find meat from locally raised animals. It may be a little more expensive, but likely a lot safer.

What about eating fish?

If you are at high risk of cardiovascular disease or have cardiovascular disease then eating oily fish (salmon, sardines, anchovies, herring, mackerel, tuna, swordfish) twice a week reduces your risk of a heart attack by 50%. If you are at average risk, these fish don’t have unusual health benefits but if you like them, it’s fine to eat them. Because most of these fish contain some mercury they should probably be avoided by pregnant women and children. If you get canned tuna, get Pacific Island Tuna at Walmart. It is sustainably caught. Here is a link to an article from the Nature Conservancy about it: The Nature Conservancy. By the way taking fish oil is not nearly as good for you as eating fish.

Highly Processed Foods

There are convincing data that consumption of lots of highly processed foods leads to health concerns ranging from increased risk of obesity, high blood pressure, breast and colorectal cancer, to dying prematurely from all causes.These foods all also contain additives whose health effects have never been adequately tested. How do you recognize them? Just look at the label where the ingredients are listed. If there are more than two things you don’t recognize, put it back on the shelf. Here is an example of an ingredients list from a loaf of bread!

This is not bread you would want to eat! If you mostly stay out of the central aisles of the grocery store you will avoid most highly processed foods. Just be sure to look at the ingredients label before you buy anything.

It is all well and good for me to make these recommendations, but highly processed foods and factory farmed meat are cheap. People who are poor cannot afford to buy anything else. This is only one of the things that have led to the major health inequities that are present in this richest country in the world.

Foods that decrease risk of cardiovascular disease

Fiber

Increased dietary fiber has been shown to decrease risk of cardiovascular disease. This may well have to do with promoting a healthy microbiome in the intestine. Sources of fiber that promote growth of healthy gut bacteria are ones that contain inulin. The highest sources of inulin are leeks, asparagus, onions, wheat, garlic, chicory, oats, soybeans, and Jerusalem artichoke. Sourdough bread (no added sugar, honey, or high fructose corn syrup) is also a good source of fiber. Whole grains, fruits, nuts and vegetables are also good sources of fiber.

Fresh Fruits

Fresh fruits are a good source of fiber and also contain many beneficial nutrients including vitamins and antioxidants. Data from multiple studies show that eating fresh fruit daily reduces risk of cardiovascular disease.

Nuts

Eating a handful of nuts per day reduces your risk of heart disease by 20%. Peanuts are technically of legume, not a nut, but legumes reduce the risk of cardiovascular disease as well. Unsalted nuts are better for you than salted.

Whole grains

Whole grains are also a good source of fiber and other beneficial nutrients. Eating whole grains most days is associated with decreased obesity, diabetes and heart disease. Examples of whole grains are

  • Barley.
  • Bulgur, also called cracked wheat.
  • Farro.
  • Millet.
  • Quinoa.
  • Black rice.
  • Brown rice.
  • Red rice.
  • Wild rice.
  • Oatmeal.
  • Popcorn.
  • Whole-wheat flour.
  • Whole-grain breakfast cereals.
  • Whole-wheat bread, pasta or crackers.

Make sure to read the ingredients label for cereals and crackers. Don’t buy anything that has more than two ingredients you don’t recognize.

Fresh Vegetables

Fresh vegetables are also a good source of fiber. Sorry folks, but potato chips and french fries do not count as fresh vegetables! Once again eating fresh vegetables daily significantly lowers your risk of cardiovascular disease.

Bottom Line

Eating red meat and saturated fats does very little to increase your risk of heart disease, but it also does not reduce your risk. Raising livestock on factory farms causes significant harm to the environment and puts people at risk of infectious disease. Eating meat from locally raised animals is safer.

Eating high fiber foods, whole grains, nuts, fruits and vegetable does substantially reduce your risk of cardiovascular disease as well as cancer.

Eating highly processed foods, and this includes the new industrial fats made by interesterfication increases your risk of cardiovascular disease and cancer. The biggest risk of these is probably because they encourage people to eat more calories than they need and have almost certainly led to the epidemic of obesity.

The most concise recommendation for a healthy diet comes from author Michael Poulin: “Eat food (food is anything your grandmother would have recognized as food), mostly plants, not too much.”