Modern versus traditional medicine

Last Tuesday (just shy of a week ago) I had surgery on my knee to address a torn meniscus, an injury I got because I went on a run after having spent the previous 15 years getting older.  I write about it here because I mentioned that I was having surgery to a guy who works at my gym. This guy is a proponent of traditional Chinese medicine and told me that I was doing myself a disservice by using conventional medicine because traditional Chinese medicine is superior. This, he said, was because traditional medicine has been around for thousands of years, whereas modern medicine has only been around for a few hundred.

Meniscus 1

My poor presurgical knee with its torn meniscus.

The procedure I had is properly referred to as a partial meniscectomy with a joint debridement. Basically that means that they used a scope to go in to my knee capsule and remove the flap of torn meniscus tissue then clean the area up. 

As serious as it sounds, the whole procedure only lasted about 30 minutes. I arrived at the hospital at 7:30 am and was back at home walking around by 11:30.

My post-surgical knee looking almost as good as new.

My post-surgical knee looking almost as good as new.

Prior to surgery it felt as though there was a homunculus with a jackhammer dwelling inside my knee and doing his best to destroy it. Now, a week after surgery, the only pain I feel is from the swelling caused by the procedure itself and that has diminished consistently each day.

The little jackhammering fellow that I imagined causing all the pain.

The little jackhammering fellow that I imagined causing all the pain.

It would be very easy to take this procedure for granted as a minor one but if you stop and think about it, they went into my knee, an area that is usually closed to the outside world, removed bad tissue, and then cleaned the area up all while I felt no pain.  This did not ever happen during the heyday of ancient “traditional” medicine, it happened because in the 19th century practitioners began to use a more systematic and scientific analysis of patient symptoms in the diagnosis of disease and pathology.

It’s true that ancient chinese medicine has been around for at least 2500 years. Chinese medicine encompasses things like Massage and acupuncture, which have been shown to be quite effective in pain management, and other procedures that do nothing beyond the placebo effect. The evidence that massage is effective for pain management is robust enough to suggest that it is a worthwhile adjunct to scientific medicine. This is not controversial though, because massage is often a regular part of the post-operative physical therapy regimen. It was prescribed to me as part of mine.  What’s important to remember is that despite its efficacy for pain management, massage is not doing anything to treat disease or pathology; it helps control the pain. It is the all-natural version of ibuprofen. Certainly worthy of taking seriously but not the end-all-be-all of medicine.

Had I opted to forego surgery and use “traditional” medicine I would still have excruciating pain in my knee and would need to manage it using massage or acupuncture. The pain relief would only last until the effects wore off then I would need to go back and do it again. A 45-minute massage at my local wellness center is $49 and that is not covered by my insurance if I just go on my own without real medical advice. You can see that this would be great for the person charging me for the massage but not really for me. I’d have to keep going back to get the benefit. The surgery I had means that they fixed the problem. I don’t need to go have surgery every week to keep the pain down.

I guess I see the appeal of the ancient therapy argument however I can’t escape the observation that up until very recent times people died of things like influenza by the hundreds of thousands and, with regard to surgery, even very minor surgical procedures would have been torturous.  Ancient therapies aren’t better simply because they are older, they have to work if we want to call them better. I don’t have anything against traditional practices or Chinese medicine if they work but, for my money, I am going to bet on the side that uses science.

Morality and Fat?

Last week NYU psychology professor, Geoffrey Miller got himself into hot water for posting a tweet that read: “Dear obese PhD applicants: if you didn’t have the willpower to stop eating carbs, you won’t have the willpower to do a dissertation. #truth.”

geoffrey-miller

Aside from Professor Miller’s clear lack of understanding of nutrition (it’s not just about carbs) his tweet brings up an important point regarding obesity. We here in the US don’t often treat obesity solely as a potential health problem, rather we treat it is a moral issue. This is the result of prejudice rather than reason and is not helpful at all to anyone who is trying to lose weight. So to address the question of whether we should be viewing body weight as a moral issue we really need to step away from our cultural perceptions and look at our biology.

Body fat is just stored energy, if you consume more energy than you expend, you store it as fat. Our bodies have evolved over several hundred thousand years to survive in our environment; one of the ways that we did so was to adapt a way to store food energy, which allowed us to eat enough to fuel both our present need and to store energy for later when the food supply may be scarce, like during periods of famine. Our DNA doesn’t know that those of us in the affluent middle classes of the developed world have regular access to far more Calories than we need (1). By influencing us to eat more than we need, our genes allow us to store energy for the future, which enables proper development and guards against starvation (2). One of the things that happen when we diet and lose weight is that our resting metabolism slows down. In other words our bodies get more efficient and use less energy, which is certainly a good adaptation to prevent starvation, but a major pain for those of us who want to lose weight (3). Our bodies don’t only slow down our metabolism when we cut back on calories and lose weight, they also signal us to be hungrier (4). Furthermore, there have been over 600 genes identified that play a role in weight gain and obesity (5).

Now, while it is true that our bodies have evolved to hold onto the food that we eat and drive us to eat more than we need, I am not suggesting that biology justifies us in abandoning our efforts to improve our health by eating well and making positive lifestyle choices; we are thinking animals and it is now, as it always will be our own responsibility to take care of ourselves.  I am, however, suggesting that if you are a person who struggles with your weight, you have not morally faltered. There will always be those who disagree with me on this point but I am curious as to what their goals actually are with weight loss. It is probably not health.

According to historian and author Peter Stearns (6) the attitudes in the United States about fat result from our cultural need to morally compensate for excessive and wasteful consumerism. The problem with this line of moral reasoning is that it creates an unfortunate paradox, because our biological drive to eat is motivated by the need to store energy for later, which, contrary to being wasteful, is, from the physiologic perspective, actually a very thrifty thing to do. In the case of body fat, our cultural and biological perceptions of thrifty behavior are in dynamic conflict with each other.

Attaching morality to this problem can cause us to believe that unsuccessful attempts at weight loss are an indication of our own moral shortcomings, which can lead us to search for implausible or even harmful alternative solutions.  If, however, we keep in mind that weight loss is a physical and mental challenge that has nothing to do with our moral value it is possible to see that it is completely unwarranted to deem our lives unworthy simply because we have to struggle with something.

So to Professor Miller I say this: Get your biases and prejudices under control, Sir before you post foolish comments for the world to see. You are free to be a sanctimonious pedant in your private life but as an academic and a potential thought leader you have a responsibility to demonstrate better critical thinking.

References

  1. Statistics from the Food and Agriculture Organization of the United States. Data spreadsheet available at: http://www.fao.org/fileadmin/templates/…/FoodConsumptionNutrients_en.xls
  2. Tooby, J., Cosmides, L. 1990. “The Past Explains the Present: Emotional Adaptations and the Structure of Ancestral Environments.” Ethology & Sociobiology, 11: 375-424.
  3. Leibel, R. Rosenbaum, M., Hirsch, J. 1995. “Changes in Energy Expenditure Resulting from Altered Body Weight.” New England Journal of Medicine, March 9 332(10): 621-628.
  4.  Jhanwar-Uniyal, M., Beck, B., Jhanwar, Y.S., Burlet, C., Leibowitz, S.F. 1993. Neuropeptide Y projection from arcuate nucleus to parvocellular division of paraventricular nucleus: specific relation to the ingestion of carbohydrate. Brain Research 631:97-106. This study shows one of the mechanisms by which our bodies make us hungrier when calories are low an increase in a neurotransmitter called neuropeptide Y, which causes cravings for carbohydrate, a quick energy source, to increase. This stuff gets released in really high amounts during calorie reduction, which is, of course, interpreted by the body as starvation.
  5. Pérusse L, Rankinen T, Zuberi A, Chagnon YC, Weisnagel SJ, Argyropoulos G, Walts B, Snyder EE, Bouchard C. The human obesity gene map: the 2004 update. Obes Res. 2005 Mar;13(3):381-490.
  6. Stearns, P. Fat History: bodies and beauty in the modern west. 1997. New York, NY :New York University Press.

Operational Definitions and Health

Operational definitions are clear, detailed, and yet concise definitions of given measures. Their intended purpose is to minimize confusion that can result from more variable or nebulous definitions.  Operational definitions have an important place in the health sciences but can be very difficult to delineate. Think about this: what does it mean to be healthy?

According to the World Health Organization (WHO), Health encompasses three dimensions: It is a complete state of physical, mental, and social well-being and not merely the absence of disease or infirmity. This is a useful definition if we look at health from a high-level, epidemiologic perspective, but it can be difficult to apply to ourselves as individuals. We all have days when we don’t feel like we are complete on all of these dimensions. Does that mean we aren’t healthy on those days? The answer is maybe but not necessarily.

Most of us have an operational definition of health the not only encompasses being free from disease or disorder but also some degree of overall wellness, which echoes the WHO’s definition. But what does wellness mean, then? Wellness generally includes both physical and mental health. But what does it mean to be mentally healthy…? I could do this all day but I won’t. I hope, though, that it illustrates the difficulty involved in coming up with a meaningful operational definition of good health.

Charlatan trudeauI started thinking about operational definitions in this context because I recently read that Kevin Trudeau, the sociopathic swindler behind the whole series of “They” don’t want you to know about conspiracy books, recently declared bankruptcy to avoid paying $37 million in fines to the federal government and now faces potential incarceration. These fines were originally levied because he defied a 2004 settlement with the FTC in which he was banned from peddling any products other than his books because of fraudulent  claims that he and his infomercial costar, “Dr.” Robert Barefoot (another self-aggrandizing quack), made about coral calcium being a cure for cancer. Trudeau had been off of my radar for a while but hearing about him again reminded me of something he wrote in his  digest of misinformation Natural Cures “They” Don’t Want You To Know About, that always stuck with me as a perfect example of why it is important to think about operational definitions when it comes to making decisions about our health. In his book, Trudeau offers what is perhaps the most unattainable definition of good health that I have ever seen. According to Trudeau:

An ideal scenario would be waking up in the morning full of energy and vitality, content, and feeling absolutely great. You go throughout your day with energy, a bounce in your step, a smile on your face. You don’t feel stressed, anxious, or depressed’ you don’t feel tired, you have no headaches or pain in your body’ you are not overweight and you don’t get colds or flus or sickness. You don’t get diseases, you have no pain, you’re not ravenous with your appetite, you eat what you want and you are never that hungry. You don’t deprive yourself of the foods you enjoy. You go to sleep at night and you sleep soundly and peacefully and get a wonderful whole night’s rest. Your sexual desires are healthy and strong, and you are capable of both giving and receiving sexual pleasure. Your skin, your hair, and your nails look healthy and radiant. You have strength and tone in your muscles, your body is fluid, graceful, and flexible. You are firm, strong, vibrant, and feel great! (pg 11)

Sure this would be ideal, however it is pretty clear that Trudeau is either profoundly unaware of the human experience—nobody feels that good all of the time—or that he is creating a market for himself. If we believe his definition of what it means to be healthy then we will inevitably feel unhealthy most of the time. Trudeau, who despite his general sleaziness is very good at the game that he plays, then has the opportunity to assuage the concern that he contrived for us by making unsubstantiated claims then selling us books about them. Trudeau is a highly visible hack but there are many others who use the same tactics.

Mental-HealthIn fact, it is entirely normal to have some mood variation throughout the day. A 2007 study by Katerndhal and colleagues, showed that healthy patients without an underlying mood disorder such as depression or panic disorder, experience maximum and minimum mood levels throughout the day that reflect their circadian rhythm. Further these same healthy people also have additional mood fluctuations in response to sporadic stressors. The point is that variable moods, and stress levels are a normal part of good mental and physical health.

Furthermore, with regard to stress levels, if we are never exposed to both physical and mental stresses, we can become very unhealthy.  On the physical side, think about exercise:  the reason we need to do it is because we need to stress our bodies by overloading them in order to stay in good condition. On the mental side, there is a great deal of emerging evidence that we can maximize our cognitive function by keeping our brains and bodies active.

So despite the fact that it is tough to define health, a good place to start is first with the absence of disease, then with the WHO’s definition of physical, mental, and social activity. However it is important that we also account for the fact that we aren’t going to be in top form all of the time; further someone who is free from disease and able to recover from bouts, even prolonged bouts, of poor physical, mental, or social acuity likely has a good prognosis with regard to his overall health and wellness.

Health science is an objective physical science so I do not mean to imply that we should choose a subjective and unfalsifiable definition of health that fits any situation; this would be as ridiculous as any claim made by Trudeau and his ilk. There are, in fact, a variety of risk factors that can rob us of our physical and mental health and shorten our time on earth. I merely mean to imply that we should all remember that un-scientific charlatans like Kevin Trudeau, Robert Barefoot, and the plethora of other self-serving nostrum peddlers out there have only their own interests in mind and are using operational definitions that meet their own needs at the expense of ours.

For more scientific info about health risk factors see the WHO’s report on global health risks at: http://www.who.int/healthinfo/global_burden_disease/GlobalHealthRisks_report_full.pdf

Healthy Skepticism: Fruit Flies and Organic Food

As a self-styled scientific skeptic I often need to remind myself about confirmation bias. This is the very human tendency to seek out the evidence that confirms what we already believe and ignore evidence that disagrees with our existing opinions and beliefs. I had to remind myself of this earlier this week when I read about a well-conducted study that provides evidence that organically grown food may have some benefits over conventional foods. The evidence is not absolutely conclusive but it is compelling nonetheless.

Truthfully, I am not sold on the idea that the benefits of organically raised food extend anywhere beyond marketing. However, this has always been a tough topic for me to discuss because there are a lot of people whom I like and respect that swear by the “Organic” lifestyle. Furthermore a diet that is rich in vegetables and lean meats, whether organic or not, and low on foods that don’t have a lot of nutritional value other than calories, is likely to be a healthy diet.

Should_I_Choose_Organic_Foods

The reason I think it is worth evaluating is that organically grown food is much more expensive the conventional food, making it inaccessible to many, which has public health implications. The elevated cost, at least in the U.S., is a result of the increased cost and labor involved in adhering to the USDAs guidelines for organic certification. In reality the criteria for displaying the Organic label differ worldwide, but typically for foods to be considered organic they need to be grown without synthetic pesticides, fertilizers, and without the routine use of antibiotics or growth hormones. Organic livestock needs to be fed organically grown feed (that meets the aforementioned standards) and be provided with access to the outdoors and the freedom to move about.

Whether there is an actual health benefit or not is, at this point, somewhat irrelevant from an industry perspective because clearly we believe it in the U.S.   According to the USDA , the Organic Food Industry has grown immensely over the last 15 years.  In 1997 the sales of Organic foodstuffs was $3.6 billion but by 2008 the market had boomed and sales increased to $21.1 billion.  It didn’t stop there, 2011 data from the Organic Trade Association placed the value of the organic food industry at $29 billion. I have no problem with an industry making money, that’s how the economy works; however when I see that much money involved I do tend to be very skeptical of that industry’s claims, particularly where health is concerned.

Organic trade association logo

So back to the article that tested my skepticism.  It was published by Chhabra and Colleagues and was an experiment that evaluated the benefits of an Organic diet on Drosophila Melanogaster fruit flies. Okay, so fruit flies are not human but they do have short lifespans and so make it easy to study the effects of various things on longevity among other things. Further, much of what we have learned about genetics and human physiology over the years began with research on Drosophila Melanogaster so they have been repeatedly validated as a good preliminary model for research on animal physiology. What the authors did was raise separate groups of fruit flies on either diets of conventionally grown bananas or bananas that were grown organically.

Drosophila melanogaster

They found  that  the flies on the organic diet lived for a longer period of time and had improved fertility. This is a significant finding. What is even more interesting about it is the study’s lead author Ria Chhabra was a high school student when this paper was published. According to Tara Parker-Pope who edits the Well Blog for the New York Times, Chhabra came up with the idea for this study after she heard her parents arguing about the worth of organic foods. Now while it’s true that one study such as this certainly can’t completely answer the question about the value of organic foods, Chhabra deserves many accolades for her scientific approach to the problem!

While Chhabra’s study is compelling,  the results can’t be directly translated to humans. In fact, there have been numerous studies done on the value of the organic food for humans and the results have been mixed. However, in a 2012 Meta-Analysis published by Smith-Spangler and colleagues that looked at health outcomes, nutrient levels, and contaminant levels, the authors concluded that the available published literature does not contain significant evidence that organic food is healthier than conventional food.

So despite some interesting evidence demonstrating the benefits of Organic Food on Drosophila Melanogaster (and despite my worries about confirmation bias) there still is, to my mind, not enough evidence to support the claims we often hear about Organic food. However,  there really is no harm to be done in consuming an organic diet if you can afford it, it is generally a healthy diet. Further, if you do eat organically raised livestock you can rest in the knowledge that these animals are likely to have lived a better life than their factory-farmed counterparts, which is, by itself, a worthwhile aim.

There is one vital caveat, however, and that is that for some very important crops, organic methods provide a smaller yield than conventional methods. Therefore if we mandate that businesses use organic processing methods, then we will likely drive up costs and potentially reduce access to food for a large number of people. As a consequence, our well-intentioned attempts at improving public health could end up having exactly the opposite affect.

Healthy Skepticism: Why is the Scientific Method Important?

All of the advances made in public health, medicine, and nutrition within the past century have been achieved through scientific experimentation and observation: all of them. Therefore familiarity with the scientific method has particular bearing with regard to health-related topics because these are areas that have immediate application to our daily lives. Furthermore, the fact that a lot of us are interested in these topics results in a huge number of heavily marketed hypotheses, some of which have some plausibility, many of which do not.

The scientific method is an elegantly simple process that is also the best way yet discovered to separate the truth from wishful thinking. The practice involves a series of steps:  first you observe something and develop a hypothesis, which is a conditional explanation of what you have observed, then use it to make predictions. Next—and this is the most important part—you gather evidence to test those predictions by using either experiments or further observations. Finally, you amend the hypothesis then repeat the testing process; you keep doing this until you minimize the differences between your predictions and the actual observations. Lastly you have your conclusions reviewed and replicated by your peers in order to make sure that your interpretations of the observations are sound. If you are fortunate enough to gain consistency between your experiments and your predictions the hypothesis becomes a theory, which is often used in the vernacular to mean an incomplete or untested idea but in scientific terms is actually a well-supported structural framework that can be used to explain observations and to make predictions. That’s it! While it is certainly true that science gets more convoluted as you dive deeper into it, at its core it always follows these simple rules.

Many popular claims actually follow the scientific method nicely until they get to the point where it becomes necessary to test the purported hypothesis, after which point they rely on argument rather than evidence, which is not scientific.  Even the cleverest arguments can be trumped by meager experimental or empirical evidence.

plaque-aristotle-c3d5Aristotle, it is said, argued that women don’t have as many teeth as men. As the story goes however, he never bothered to check and verify his assertion… men and women do indeed have the same number of teeth (at least on average). The point is that, while reason is important, arguments, no matter how authoritative, eloquent, or how much we want to believe them, are not enough to determine whether a testable hypothesis is correct. Sound reasons or strong intuitions that something ought to be true don’t guarantee that it will be.

An understanding of how to think about what constitutes science is the most important thing you can have to help you sift through the bad health and nutrition information (and all other information for that matter). However, I am not implying that in order to be a sound decision-maker you need to go out and become a lab-coat-wearing scientist, nor am I suggesting that those who are vocational scientists are somehow superior to anybody who is not. I am merely suggesting that we can all benefit in our daily lives if we adopt a scientific frame of mind when we evaluate information.

It is interesting to note that, though we may not initially realize it, we actually encounter practical scientists in many places in our daily lives. Consider, if you will, your auto mechanic. Although most mechanics I have known do not identify themselves as scientists, in fact they are. If I take my car into the shop with no more than a basic description of what is wrong (“it’s making a kerchunking sound every time I shift gears”) it is the mechanic’s job to hypothesize, based on his or her experience, what the problem may be. S/he will then test to see if the hypothesis was correct by fixing this part or that (I can’t really use any good terminology here because I really know nothing about cars). If S/he was right, great, the problem is solved. If not, it’s time to try something different. Mechanics do this until they fix the problem. It could even be argued that they have an advantage over more obvious scientists because they have nothing to gain by clinging to their original hypotheses and so don’t bother justifying why they should have been right; they simply go with the evidence. Now most of us would not take our car to a mechanic who, instead of amending his or her initial hypothesis until the problem was fixed, gave us rationalizations, but many of us have followed the advice of people who do this with our health.

Honourable_Bertrand_RussellBertrand Russell, who was critical of many of the scientific advances of his time (the atomic bomb for example),  nonetheless argued that “the scientific temper is capable of regenerating mankind and providing an issue for all our troubles.” Due to the simple fact that, in my day, I have been taken in by many a health charlatan, it is my goal to spotlight some of the techniques used by these impostors to separate us from our money, and very often, our health and well-being.