Month: October 2012

New Product: Cascal Fermented Soda

Seth Roberts3 Comments

This low-calorie soda (60 to 80 calories in a 12-ounce can) falls somewhere between kombucha and less-sweet sodas such as the aptly named GUS (Grown Up Soda). Its hook is the use of fermented juices as its base, resulting in a more complex flavor than sodas and sparkling waters based on plain juice.

$1.25 at Whole Foods. I’m in.

My interest in fermented foods partly derives from learning about a similar product. At a Fancy Food Show a few years ago, I learned about someone who wanted to develop a high-end non-alcoholic alternative to wine. He found he couldn’t get enough complexity without fermentation. That emphasized to me how our food preferences — in this case, a desire for complexity — push us to eat fermented foods.

JAMA Jumps to Conclusions About Vitamin D

Seth Roberts10 Comments

A recent experiment published in JAMA, one of the most prestigious medical journals in the world, found that giving people a very large dose of Vitamin D (100,000 IU) once/month did not prevent colds, even though it greatly increased blood levels of Vitamin D. This finding supports my view that it is important to take Vitamin D in the morning. (Because a study in which this wasn’t done found no effect.) My view implies that blood levels may not matter — you can get high levels of Vitamin D by taking it at what I consider the wrong times of day. The usual thinking about Vitamin D has been that blood level is all that matters.

The editors of JAMA considered the Vitamin D study so important that they asked someone (Dr. Jeffrey Linder, associated with Harvard Medical School) to write a commentary — an associated editorial that puts the new finding in context.

Linder’s commentary (might be gated) is important because (a) it is a kind of random sample of how top research doctors think (he was selected to write it) and (b) he completely fails to grasp that the time of day Vitamin D is taken might matter. Colds, the immune system, sleep, time of day — it’s not far-fetched. When you do an experiment to see if X causes Y, and find no effect, I believe that there are usually many possible reasons other than X never causes Y. Something was wrong with the equipment, something was wrong with your X (e.g., it was stale), something was wrong with your measurements (e.g., ceiling effect), and on and on. Linder did not see it this way.

The 2011 IOM report called for additional research to determine whether vitamin D therapy reduces the incidence of respiratory tract infections. The VIDARIS trial [= the new study] has rigorously addressed this question. Results suggest that vitamin D should join the therapies listed in the Cochrane reviewsas being ineffective for preventing or treating upper respiratory tract infections in healthy adults.

He seriously thinks one null result proves something. Sure, the new study is “rigorous” in certain ways. But it was far from exhaustive. It did not explore the many ways Vitamin D may be given, for example. It did not consider the possibility that blood levels don’t matter. Linder’s combination of (a) interest in rigor and (b) failure to understand the importance of exhaustive reminds me of a friend. When she was in 1st grade she had a pile of pennies. She knew how many she had — she had counted them. However, she did not know how to subtract. When she spent some of her pennies, to find out how many she had left she had to count them all over again.

My friend had half the skills an accountant needs. Linder’s commentary reflects only half the skills a scientist needs. To the extent that he is representative of top research doctors, this is shocking. It is as if most accountants at Arthur Andersen didn’t know how to subtract.

I have asked Dr. Linder if he has any response. If he does, I will post it.

Vitamin D3 Eliminated Colds and Improved Sleep When Taken in the Morning (Stories 24 and 25)

Seth Roberts12 Comments

A year and a half ago, the father of a friend of mine started taking Vitamin D3, 5000 IU/day at around 7 am — soon after getting up. That his regimen is exactly what I’d recommend (good dose, good time of day) is a coincidence — he doesn’t read this blog. He used to get 3 or 4 terrible colds every year, year after year. Since he started the Vitamin D3, he hasn’t gotten any. “A huge lifestyle improvement,” said my friend. His dad studied engineering at Caltech and is a considerable skeptic about new this and that.

Much more recently his mother changed the time of day she took her usual dose of Vitamin D3. For years she had been taking half in the morning (with a calcium supplement) and half at night. Two weeks ago she started taking the whole dose in the morning. Immediately — the first night — her sleep improved. She used to wake up every 2 hours. Since taking the Vitamin D3 in the morning, she has been waking up only every 3-6 hours. A few days ago, my friend reports she had “her best sleep in years”.

Sleep and immune function are linked in many ways beyond the fact that we sleep more when we’re sick. A molecule that promotes sleep turned out to be very close to a molecule that produces fever, for example. I found that when I did two things to improve my sleep (more standing, more morning light) I stopped getting colds. So it makes sense that a treatment that improves one (sleep or immune function) would also improve the other (immune function or sleep).

A few days ago I posted a link about a recent Vitamin D study that found no effect of Vitamin D on colds. The study completely neglected importance of time of day by giving one large injection of Vitamin D (100,000 IU) per month at unspecified time. I commented: “One more Vitamin D experiment that failed to have subjects take the Vitamin D early in the morning — the time it appears most likely to have a good effect.” These two stories, which I learned about after that post, support my comment. What’s interesting is that the researchers who do Vitamin D studies keep failing to take time of day into account and keep failing to find an effect and keep failing to figure out why. I have gathered 23 anecdotes that suggest that their studies are failing because they are failing to make sure their subjects take their Vitamin D early in the morning. Yet these researchers, if they resemble most medical researchers, disparage anecdotes. (Disparagement of anecdotes reaches its apotheosis in “evidence-based medicine”.) The same anecdotes that, I believe, contain the information they need to do a successful Vitamin D clinical trial. Could there be a serious problem with how Vitamin D researchers are trained to do research? A better approach would be to study anecdotes to get ideas about causation and then test those ideas. This isn’t complicated or hard to understand, but I haven’t heard of it being taught. If you understand this method, you treasure anecdotes rather than dismiss them (“anecdotal evidence”).

 

Hidden Side Effects of Statins and How Easily You Can Uncover Them

Seth Roberts6 Comments

In 2009, a British rheumatologist named Andrew Banji wrote about the hidden side effects of statins in the Daily Mail:

I discovered the link between statins and rheumatic side-effects quite by chance. My attack of tendon inflammation occurred at the front of my shin – a highly unusual place for tenosynovitis – so I decided to do some research into what could have triggered this. I was amazed to discover the only other related case was linked to a patient on statins.

Following a high cholesterol-reading of 9.2 a couple of months before, I’d been put on the drug. Intrigued by the connection, I decided to stop taking my statin to see what happened. Within a couple of weeks, the pain had gone.

I went back to my GP and, over successive months, tried various statins, including rosuvastatin which is one that is often prescribed.

Each form of the drug caused terrible problems, including night cramp, muscle pain, severe muscle disorders known as myopathy and general fatigue. In fact, I became so tired I couldn’t lift anything when I was gardening or even walk the half-mile from my home to the center of town.

Yet whenever I halted the medication, my symptoms disappeared within a few weeks. . . .

I began to realize many of my patients with musculoskeletal conditions such as polymyalgia – pain, stiffness, and tenderness in the muscles – were on statins. When I advised them to stop taking their medication, their problems went away.\

By 2009, statins were perhaps the most heavily prescribed drugs ever, making tens of billions of dollars for drug companies. Yet this story shows that at that point a doctor who was taking statins was not yet aware of major common side effects. How convenient for drug companies. The story also shows that patients with a variety of muscular problems had to be told by a doctor to stop taking their statins to find out if the statins were causing the problem. That should have been common sense. On a more positive note, this story shows how easily some health problems can be fixed (“when I advised them to stop taking their medicaiton, their problems went away”).

Kahneman Criticizes Social Psychologists For Replication Difficulties

Seth Roberts7 Comments

In a letter linked to by Nature, Daniel Kahneman told social psychologists that they should worry about the repeatability of what are called “social priming effects”. For example, after you see words associated with old age you walk more slowly. John Bargh of New York University is the most prominent researcher in the study of these effects. Many people first heard about them in Malcolm Gladwell’s Blink.

Kahneman wrote:

Questions have been raised about the robustness of priming results. The storm of doubts is fed by several sources, including the recent exposure of fraudulent researchers [who studied priming], general concerns with replicability that affect many disciplines, multiple reported failures to replicate salient results in the priming literature, and the growing belief in the existence of a pervasive file drawer problem [= studies with inconvenient results are not published] that undermines two methodological pillars of your field: the preference for conceptual over literal replication and the use of meta-analysis.

He went on to propose a complicated scheme by which Lab B will see if a result from Lab A can be repeated, then Lab C will see if the result from Lab B can be repeated. And so on. A non-starter, too complex and too costly. What Kahneman proposes requires substantial graduate student labor and will not help the grad students involved get a job — in fact, “wasting” their time (how they will see it) makes it harder for them to get a job. I don’t think anyone believes grad students should pay for the sins of established researchers.

I completely agree there is a problem. It isn’t just social priming research. You’ve heard the saying: “1. Fast. 2. Cheap. 3. Good. Choose 2.” When it comes to psychology research, “1.True. 2. Career. 3. Simple. Choose 2.” Overwhelmingly researchers choose 2 and 3. There isn’t anything wrong with choosing to have a career (= publish papers) so I put a lot of blame for the current state of affairs on journal policies, which put enormous pressure on researchers to choose “3. Simple”. Hardly any journals in psychology publish (a) negative results, (b) exact replications, and (c) complex sets of results (e.g., where Study 1 finds X and apparently identical Study 2 does not find X). The percentage of psychology papers with even one of these characteristics is about 0.0%. You could look at several thousand and not find a single instance. My proposed solution to the problem pointed out by Kahneman is new journal policies: 1. Publish negative results. 2. Publish (and encourage) exact replications. 3. Publish (and encourage) complexity.

Such papers exist. I previously blogged about a paper that emphasized the complexity of findings in “choice overload” research — the finding that too many choices can have bad effects. Basically it concluded the original result was wrong (“mean effect size of virtually zero”), except perhaps in special circumstances. Unless you read this blog — and have a good memory — you are unlikely to have heard of the revisionist paper. Yet I suspect almost everyone reading this has heard of the original result. A friend of mine, who has a Ph.D. in psychology from Stanford, told me he considered Sheena Iyengar, the researcher most associated with the original result, the greatest psychologist of his generation. Iyengar wrote a book (“The Art of Choosing”) about the result. I found nothing in it about the complexities and lack of repeatability.

Why is personal science important? Because personal scientists — people doing science to help themselves, e.g., sleep better — ignore 2. Career and 3. Simple.

Assorted Links

Seth Roberts4 Comments

Thanks to Bryan Castañeda.

When You’re a Lawyer, Everything Looks Like an Opportunity to Argue

Seth Roberts5 Comments

I recently posted about Unaccountable by Mart Makary, a book about the bad behavior of doctors. One of his points is “The when-you’re-a-hammer problem plagues modern medicine at every level.” He illustrated this with a case where transplant surgeons said an otherwise-healthy person with a small liver tumor should get a liver transplant. Which struck Makary as ridiculous.

A lawyer who reads this blog sees the same thing in lawyers. He told me the following story:

One of the sixteen defendants we sued moved to transfer the venue of our case from [Southern California city] to [Northern California city]. Both plaintiffs, all of his doctors (over a dozen), all of the witnesses (again, about a dozen), and all of locations where the incident took place are in or near [N. California city]. When we got the motion I took it to my boss who said, “Huh. We should’ve filed it in [N. California city] to begin with. I don’t know why we didn’t.” It would’ve been inconvenient for us, b/c we’re in [S. California city], but we’ve filed cases up there before, so we could handle it.
So, did we stipulate with the defendant and just transfer the case up north? No. We filed a pathetic, perfunctory opposition. We had an argument, but it was very weak: one of the defendants was located in [S. California city]. That’s basically all we had to hang our hat on.
We filed our opposition, defendant filed their reply. We all trekked down to court to argue our positions in front of the judge. The hearing should’ve taken 30 seconds – “Defendant’s motion granted.” — but the judge actually entertained oral argument. Finally, he granted the motion.
When I got back to the office, I noted to my secretary what a huge waste of time all of this was. The law was clear, virtually all of the facts were on opposing counsel’s side, we should’ve filed up north to begin with, so why fight it? Why not save everyone — us, opposing counsel, the judge and his staff — time and just agree? “Well, you gotta take a shot,” was her reply. Which is what I hear from attorneys all the time. “You gotta try, you gotta make the argument.” In other words, we have hammers so the hammers must be used no matter what.

No, it isn’t quite like a transplant surgeon who says a new liver is needed b/c of a small tumor – no one’s life or health is at risk — but how much time and resources are wasted in the legal system on bullshit like this?

Five Most Important Rules of Nature Photography

Seth Roberts2 Comments

A friend sent me some photos taken on a mountain hike. They seemed to derive from the following rules:

1. Carry a small camera in a big bag.

2. Always take a picture of a flower.

3. Change clothes from one picture to the next. (For example, wear pants in one picture and shorts in another picture, or a blue shirt in one picture and a white shirt in another picture.)

4. Make a funny face (for example, press finger into cheek).

5. Wear a funny shirt.

Assorted Links

Seth Roberts2 Comments

Thanks to Rashad Mahmood.

Extremely Disappointing Facts About Doctors

Seth Roberts11 Comments

The gist of Unaccountable: What Hospitals Won’t Tell You — and How Transparency Can Revolutionize Health Care (copy sent me by publisher) by Mart Makary, a med school professor at Johns Hopkins, is that doctors have failed to regulate themselves. Nobody else regulates them, so they are unaccountable. In many ways, Makary shows, bad behavior (e.g., unnecessary treatment, understating the risks of treatment) is common. Hospitals hide how bad things are. Makary mostly discusses surgeons — he’s a surgeon — but gives plenty of reasons to think other specialties are no better.

The book is one horror story after another. At one point, Makary quit medical school. He was disgusted and appalled by seeing doctors — his teachers — push an old woman to consent to an operation she didn’t want and didn’t need. She refused, again and again, but the doctors kept pushing. Makary objected. He was ignored. Finally she agreed. The operation killed her.

I know Peter Attia as a co-founder, with Gary Taubes, of the recently formed Nutritional Science Initiative. Makary met him when Attia did a surgery residency at John Hopkins Hospital. Attia had seen a doctor about back pain and had been told he needed surgery. They operated on the wrong side, causing damage that prevents Attia, an excellent athlete, from playing most sports. Eventually Attia left medicine. He felt “modern medicine was too frequently dishonest with patients, at times understating risks and overtreating patients as a matter of reflex” — “as a matter of reflex” meaning “as a matter of course”, i.e., usually. And Johns Hopkins Hospital is one of the better hospitals in America. “Almost everyone I talk to has a story about a friend or a family member who was hurt, disfigured, or killed by a medical mistake,” writes Makary. He has six such stories, including his grandfather and his brother. His grandfather died from unnecessary surgery.

The “when-you’re-a-hammer problem” says Makary, “plagues modern medicine at every level.” He witnessed a case conference where a young otherwise-healthy patient had a small liver tumor. “The transplant surgeons [more than one] in the audience recommended a liver transplant. I was flabbergasted. Why on earth would any doctor recommend a transplant?” Makary asked around. He discovered there was nothing unusual about the transplant surgeons in the audience. He called a friend who was one of the few surgeons trained in both cancer treatment and transplants. His friend said “there was a battle for turf taking place nationwide between transplant surgeons and cancer surgeons. Both claim to be liver experts.”

Makary tells about trying to obtain informed consent for a surgery when he was an intern. He didn’t know much about the surgery. The patient didn’t agree. “It was well-known among interns that if an attending senior surgeon found out that a patient refused surgery close to surgery date, duck for cover. Mine would surely be livid.” Makary spoke to an upper resident. He couldn’t get approval. They went to the chief resident. He got approval. Congratulations all around amongst the doctors, “glad that the wrath of the attending surgeon would be averted.”

Supposedly state medical boards oversee doctors. Makary devotes part of a chapter to describing how they don’t. He asked state medical boards why they don’t search a national database before issuing a medical license. “My favorite excuse was that they could not afford the four-dollar-per-doctor fee.”

In 1978, the Shah of Iran needed an operation. The United States government set him up with a Texan named Michael DeBakey, “considered by many to be the best surgeon in the world.” During the surgery, DeBakey failed to take “a simple standard safety measure.” Due to this failure, the Shah developed a serious complication, became very sick, and died. The Shah and the United States government had failed to realize — and, more important, none of the experts they consulted had told them (I assume) — is that DeBakey was a famous heart surgeon. The Shah’s operation involved his spleen. DeBakey knew little about such operations and had done almost none — but (I assume) didn’t point this out.

A survey done at many hospitals asks employees if they “feel comfortable speaking up when [they] sense a patient safety concern.” At the median hospital, the percentage is about 70%. In the Milgram experiment (where subjects are ordered to give painful shocks), when audiences were asked by Milgram to predict what they would do in that situation almost all said they wouldn’t give the shocks. In fact, most people did give the shocks — indicating that people vastly overestimated their likelihood of resistance and speaking up. So 70% is likely an overestimate. (A study of nurses found that about 95% of them broke safety rules when ordered to do so. Roughly all of them had said they would never do such a thing.) Since talk is cheap, why is the median percentage as low as 70%? No doubt many respondents had seen themselves fail to speak up.

These aren’t the worst stories, these are average, I just opened the book here and there. There are dozens more. No previous book has spelled out so clearly the depth and width of doctor misbehavior, especially how common it is, and the failure of those supposedly responsible, such as hospital administrators and state boards, to do anything about it.

Title from 12 extremely disappointing facts about popular music.