Month: January 2013

Best Introduction to the Shangri-La Diet?

Seth Roberts7 Comments

A long thread at Mark’s Daily Apple may be the best introduction to the Shangri-La Diet. It is dramatic (people object, people say the diet is crazy), varied (many voices, many sorts of data), responsive to feedback (questions and objections are answered) and no doubt more convincing than my book (because it isn’t by me). The helpful elements include:

1. An introductory success story (from a woman named heatseeker) that I have already blogged about.

2. Someone makes a common Paleo objection — it works because of macronutrient ratios. “You have stumbled on the perfect macro ratios for you!” Heatseeker says this is unlikely because she barely changed her macro ratios. She answers many other questions and objections (e.g., “how do you choke down the coconut oil?”).

3. Someone says it didn’t work for them (“neither did anything else”).

4. Link to a talk by me (“You Had Me at Bacon”) that puts the diet in the context of my other work, such as the effect of pork fat on sleep.

5. Link to Alex Chernavsky’s results, which are most impressive in context.

6. Emphasis that the flavorless calories can be anything so long as they are flavorless (i.e., have no smell, which can be achieved by eating them nose-clipped). As heatseeker says, she lost weight via flavorless fat, I lost weight via flavorless sugar, so the success cannot be due to the fat. It is more complicated than that.

7. A confident naysayer: “I started eating less and now I’m lean for life. It really is that simple.”

8. Link to a scientific paper by me about the underlying theory.

9. Heatseeker says: “I would say that after four years of eating according to TPB [The Primal Blueprint by Mark Sisson], and 2-3 years of really strict adherence, absolutely every promise made by Mark came true–EXCEPT the fat loss.” That Diet X works better than a credible alternative (in this case, TPB) is more interesting than the observation that it works better than nothing.

10. A link to me talking about “ what food makes my brain work best“. More context.

11. “Has been incredibly easy to follow, even while at work,” says someone who is not heatseeker.

12. Independent discovery: “38 years ago our gym teacher had one of the overweight girls (we had 2) in gym class doing this! By the time we hit our Christmas break she had lost most of her pudge!! This is a true story. I remember because the girl’s parents were not informed and the gym teacher almost got fired for ‘experimenting’ on the said pupil. What saved her was people finding out that the girl had been caught by the teacher barfing up her lunch in an effort to lose weight (bulimic) so to keep her from going down that path and to gain her trust as a confidant etc she helped her by showing her a method she herself had used to control hunger which was eating a fat source between meals. Fantastic eh??? I had never heard anything quite like this until I read this thread.”

13. Bonus side effect: “Last night I slept through the night! Completely! I did not even slightly stir for any reason. . . . I have not slept through the night in YEARS!!!!!!” More reason to think that lack of certain fats impairs sleep.

14. Psychological effect: “What is happening here with the SLD? I feel calm and neutral to food.” You may remember research that suggested self-control is like a muscle. One similarity is the more you use it the stronger it gets. Several people have said that as soon as they started SLD, they were able to overcome other addictions, such as smoking and coffee. Maybe this is because years of struggling with food, day after day, had left them with very strong self-control. Before SLD, their self-control was exhausted pushing away urges to eat. As soon as SLD got rid of those urges, their very strong self control made it easy to quit smoking or whatever.

15. Two reluctant yea-sayers: “I coincidentally started trying this as a gesture of support for a desperate friend of mine . . . The whole concept is ludicrous and it’s probably just placebo effect . . . I’m kind of embarrassed to admit that this has worked for me. 10 lbs down” (Person 1). “If there weren’t so many people saying this works for them, I’d think it was the stupidest thing in the world” (Person 2).

 

Fecal Transplant Roundup

Seth Roberts12 Comments

A new study has found that fecal transplants work better than antibiotics for clearing up a common and dangerous infection:

Such transplants cured 15 of 16 people who had recurring [= difficult-to-get-rid-of] infections with Clostridium difficile bacteria, whereas antibiotics cured only 3 of 13 and 4 of 13 patients in two comparison groups.

Clostridium difficile infections often result from antibiotic treatment. It is a big step forward for modern medicine to manage to grasp that the bacteria in our bodies protect us from infection. Here is a blog about the value of fecal transplants; here is another blog.

The comments contain many interesting details:

I spent Thanksgiving of 2012 in ICU and almost died from C-Diff. It was a harrowing experience for both me and my family. It required two months of care, recuperation and doses of vancomycin. My hospital bills are outrageous. [Fecal transplants are much cheaper — Seth] I am praying it doesn’t return, having just finished my last dose of vancomycin. I had a dental implant and was on clyndamycin for two weeks and that was the culprit. Dentists should be required to inform patients that C-Diff could be a reaction to that specific antibiotic. I was not warned about this being a possible side effect.

Our mother was hospitalized at a major university hospital and came down with C. diff. The antibiotics they gave her to fight the infection finally destroyed her kidneys and hearing and she decided that life was not worth living in that condition.

We have using this “treatment” for years and years in horses with difficult intestinal issues which didn’t respond to other medications. We pass a slurry of fecal material from a heathy horse ( often mixed with electrolytes and baking soda) directly into the stomach of the sick horse. It works in almost all cases.

After my gut microflora was destroyed by 9 months of antibiotics for Lyme disease, I got C. diff this past June. Was flabbergasted that NONE of my doctors, ALL of whom prescribe antibiotics, ( & hopefully read the NYT or the INTERNET) [knew] about fecal transplants! I ditched my Lyme doctor (who said along with my GI & GP): “Take Flagyll” (which didn’t work) and then Vancomycin. No thanks. Wasn’t going to wait around for the C. diff to corrode my guts or till I was almost dead, so I went right to Dr. Brandt for a transplant and in ONE day the symptoms were gone.

I had recurring c diff for 12 months.Tried a myriad of antibiotics and a colon cleanse.Nothing worked. I was getting sicker and weaker by the day, not to mention very depressed. I was “beyond” desperate. My husband (an internist) performed a fecal transplant (using my brothers stool–close DNA donor) at home (hanging the saline/stool bag from the ceiling fan!) 3+ years ago. I have been healthy ever since.

[A doctor:] This important study . . . is a big step in the right direction, however the study is quite small. [A doctor who doesn’t understand statistics even after it is explained in plain English. The evidence from this “small” study is very strong. In case you didn’t understand the numbers, the article says it in words: “the antibiotic groups were faring so poorly compared with the transplant patients that it was considered unethical to continue”. — Seth] A larger RCT is needed before this becomes standard of care [implying that his or her lack of understanding of statistics is the norm — Seth]. Since no one is currently in position to reap monopoly profits from this treatment, I predict the study will be a long time coming. [Which, if true, implies that doctors’ lack of understanding of statistics will kill a lot of people.–Seth]

The majority of cases of C. difficile infection occur in the hospital where they were usually brought on by use of broad-spectrum antibiotics destroying the natural balance of intestinal flora in the gut. A great many people outside the hospital setting walk around healthy colonized by C. difficile without becoming infected. Others become colonized while in the hospital, a virtual surety if you stay long enough. Broad-spectrum antibiotics wipe out bacteria that normally out-compete C. difficile at different niches within the intestinal ecosystem. [In other words, gross overuse of antibiotics has created a new ecosystem — modern hospitals — where C. difficile thrives. — Seth]

After a reaction to an antibiotic caused C Diff which lasted almost a year, was treated with multiple antibiotics of which Vancomycin was the only one that kept it at bay, having had a number of courses without success, meanwhile weight was down 25 lbs and health was deteriorating as in my opinion Vancomycin also presented some problems of its own, teeth browning, lethargy etc. C Diff ruins body and soul. After a lot of research was lucky to have found a doctor who checked out the fecal transplant history/procedure and performed the transplant. The feces donor was my brother having first had blood & feces testing. The transplant was a success, after suffering C Diff for almost a year my quality of life is great – normal.

The [squeamish] tone of this article is enraging. [It begins “The treatment may sound appalling”. The headline calls it “This, er, Option”. — Seth] I contracted ulcerative colitis when I was fifteen, and the squeamishness of my parents and doctors in my small town prevented me from accessing real care. More concerned with being grossed out than dealing with the problem at hand, I was allowed to go a year without receiving proper care. As a result, I ended up with such extreme internal bleeding that I was sent unconscious to the intensive care unit at Swedish Hospital in Seattle, three hours away from home, where a surgeon removed my entire colon. He chided my parents and local doctors for not seeking help from a specialist sooner; had they done so, I would not have been in such dire condition. I spent the next year of my childhood in the hospital. All this is to say: get over feeling grossed out by the human body and consider any possible treatments that might work. If this one does, great. Ditch the whole “ew” reaction because it stands in the way of saving lives.

I was plagued for decades with room-clearing gas and stomach cramps. Yogurt and probiotics didn’t stand a chance against the established bad bugs. Then I went for my first colonoscopy (which gave me a whistle-clean gut.) I was told I could have anything I wanted. First thing, I drank a full quart of organic kefir. I haven’t had a problem since. [Very interesting. Before a colonoscopy, you take something special to clean out your gut.–Seth]

Thanks to Alex Blackwood and Karen Goeders.

Assorted Links

Seth Roberts8 Comments

 

No Stagnation in My Kitchen

Seth Roberts12 Comments

Stagnation of innovation is often illustrated with kitchens. In 1996, Paul Krugman wrote, “I live in a house with a late-50s-vintage kitchen, never remodeled. The non-self-defrosting refrigerator, and the gas range with its open pilot lights . . . it is still a pretty functional kitchen.” (Illustrating, at least, his lack of change.) Tyler Cowen said “if he were to introduce his grandmother to a modern American kitchen, it wouldn’t be all that earth-shattering for her.” David Brooks mentioned lack of innovation in many things, including “appliances”. Last week, the Economist said:

Take kitchens. In 1900 kitchens in even the poshest of households were primitive things. . . . Fast forward to 1970 and middle-class kitchens in America and Europe feature gas and electric hobs [= burners] and ovens, fridges, food processors, microwaves and dishwashers. Move forward another 40 years, though, and things scarcely change.

For a long time I wanted to go to the giant kitchen and housewares trade show in Chicago every summer, until this article convinced it would be the same old stuff with tiny variations.

In contrast, my kitchen has changed greatly in the last ten years. Here’s how:

1. Tea-brewing equipment. Soon after I started practicing the Shangri-La Diet (calories without smell), I started drinking lots of tea (smell without calories).

2. Electric tea kettle (heats water for tea better than microwave).

3. Kitchen scale (for tea and flaxseed). I discovered that flaxseed oil and, later, ground flaxseed improved my brain function and gums.

4. Noseclips. For the Shangri-La Diet.

5. Yogurt maker. I believe that fermented foods are essential for health.

6. Kombucha brewing tools (e.g., glass jars).

7. Spice grinder (for flax seed).

8. Soup cooker (for pork belly and miso soup). Eating lots of pork belly improved my sleep.

I would like to make more fermented foods. I hear that in South Korea I can get a machine that makes both natto and yogurt.

My kitchen changed because my ideas about health changed. My ideas about health changed because of my research. I found a new way to lose weight. I had a new explanation of why we like foods with complex, sour, and unami flavors (so that we will eat more fermented food). Self-experimentation convinced me that I was seriously omega-3-deficient, thus the flaxseeds. I discovered that if I eat a lot of animal fat, I sleep better.

I believe kitchen stagnation reflects stagnation in our thinking about health. Every October, I point out that the Nobel Prize in Medicine has again been given to research that is so far useless. “Molecular medicine has come nowhere close to matching the effects of improved sanitation,” says the Economist. Could mainstream health researchers be trapped by their desires to show off (no cheap equipment), to be respected (no “crazy ideas”), and to produce a steady stream of publications (no time to test implausible ideas)? Could having goals other than the truth (such as respectability) make it harder to find the truth? People who have written about stagnation in innovation do not seem to have considered these possibilities.

“The Most Influential Tree in the World”

Seth Roberts2 Comments

The title comes from Andrew Montford’s new book Hiding the Decline (copy given me by author) about Climategate. From an introductory section:

When the figures were published the extraordinary lack of data underlying the blade of the Yamal hockey stick caused a minor sensation. In fact the high point at the end of the graph was shown to have been based on only four trees, and only one of these had the hockey stick shape. McIntyre dubbed it ‘the most influential tree in the world’.

Most of Hiding the Decline is about the inquiries that followed Climategate. I enjoyed reading about smug powerful people making fools of themselves and the fairy-tale-like consternation created by two unlikely events: 1. A non-scientist (Steve McIntyre) gets involved in the global warming debate. As in a fairy tale, McIntyre is free to speak the truth. In particular, he is free to question. Professional climate scientists cannot speak the truth for fear of career damage. 2. The release of the Climategate emails. As in a fairy tale, a sudden burst of truth about bad behavior previously hidden.

Hiding the Decline is as well-written as a book by a professional writer but this is a book no professional science writer could write due to its investment in an officially-wrong point of view. There are lots of badly-written books from tiny-minority points of view. The appearance of a well-written one, joining Montford’s earlier The Hockey Stick Illusion, is no small deal. How much free speech do we have? It depends on the medium. Maybe the sequence from less to more censored is: 1. Conversation. 2. Email and other private writing. 3. Blog post. 4. Poorly-written book. 5. Article in minor magazine. 6. Well-written book. 7. Article in prestigious magazine. 8. Textbook. From one step to the next (e.g., from conversation to email), views become less diverse. This book is disagreement with the official line high up the tree.

One reason we enjoy certain jokes is that they speak a forbidden truth. When you can’t usually say it, the truth is funny. The forbidden truth aspect of Hiding the Decline is another reason I enjoyed it so much.

Does the story have a happy ending? Montford thinks not:

As we look back over the ten years of this story, the impression we get is of a wave of dishonesty, a public sector that will spin and lie, and mislead and lie, and distort and lie, and lie again. . . . Despite the emails showing, apparently incontrovertibly, that FOI laws were flouted with the full knowledge of senior figures in university, there have been almost no discernible repercussions for anyone involved. . . . The response to [Climategate] was an extraordinary failure of the institutions and of the people who are paid to protect the public interest – a failure of honesty, a failure of diligence, a failure of integrity.

My view is different. The institutions (University of East Anglia, Penn State, and so on) and officials (e.g., Vice Chancellor of the University of East Anglia) “failed” only in their ostensible purpose. Their actual purpose centers on protecting the people who created or hired them (see The Dictator’s Handbook). At this they succeeded, but suffered a large loss of credibility. To me, Climategate is the story of how two people — Steve McIntyre and the hacker of the Climategate emails — both with zero official standing, had a huge effect on worldwide public discourse. (A Google search for Climategate returns about 2 million hits.) They exposed dishonesty in powerful and heretofore respected people (science professors) on a matter far more important than expense accounts. They pushed the rest of us a non-trivial distance toward seeing the truth. I didn’t know that was possible, and I’m glad it is.

Assorted Links

Seth Roberts3 Comments

Thanks to Patrick Vlaskovits.

What Should Your Cholesterol Be?

Seth Roberts9 Comments

According to the Mayo Clinic website, lower levels of cholesterol are better. For total cholesterol, says the Mayo Clinic, below 5.2 mmol/L (= 200 mg/dL) is “desirable”. A level from 5.2 to 6.2 mmol/L is “borderline high”, and above 6.2 mmol/L (= 240 mg/dL) is “high”.

A 2011 study from Norway, based on 500,000 person-years of observation, found drastically different results. For both men and women, the lowest levels of total cholesterol (below 5.0 mmol/L) were associated with the most death. For men, the best level was intermediate — what the Mayo Clinic calls “borderline high”. For women, the safest levels were the highest.

If high cholesterol causes heart disease, as we are so often told, the pattern for women makes no sense. For a long time, experts have told us to limit egg consumption because eggs are high in cholesterol. However, a new study shows that egg consumption has no association with heart disease risk.

Via Malcolm Kendrick. I also like his post about whether statins cause muscle pain.

The First John Maddox Prize

Seth Roberts5 Comments

The panel that chose the winners of the first John Maddox Prize — Colin Blakemore, a British psychologist, Tracey Brown (Sense About Science), Phil Campbell (Nature), and Brenda Maddox — deserve a prize for Most Contentious Award. The Maddox Prize is supposed to be awarded to people who have excelled at:

any kind of public activity, including all forms of writing, speaking and public engagement, in any of the following areas:

  • Addressing misleading information about scientific or medical issues in any forum.
  • Bringing sound evidence to bear in a public or policy debate.
  • Helping people to make sense of a complex scientific issue.

The first winners, announced in November, were Simon Wessely, a British psychiatrist, and Fang Shi-min, a Chinese journalist. Criticism of Fang is here. Criticism of Wessely is here (in the comments) and here. One of his papers is here. Wessely is best known for promoting the use of cognitive behavioral therapy (CBT) to treat people with chronic fatigue syndrome (CFS). In particular, “he and his colleagues demonstrated substantial overlap in symptoms between chronic fatigue syndrome and clinical depression. . . . He subsequently developed a treatment approach using cognitive-behavioural therapy techniques, which in many cases brought about substantial improvement.”

The puzzle is that this is considered significant. Maybe people with CFS are depressed because they have CFS? Maybe this is why CBT helps them? A statement explaining the reward does not answer this objection. As for Fang, I have no idea if he deserves the prize. I would be surprised if members of the prize committee could judge for themselves the accuracy and value of his work.

Hard to Say Whether Medicine Does More Good Than Harm

Seth Roberts6 Comments

A draft article by Spyros Makridakis about blood pressure and iatrogenics takes issue with the statement that “The treatment of hypertension has been one of medicine’s major successes of the past half-century.” Over the last half-century, the article says, the death rate for people with high blood pressure decreased by almost exactly the same amount as the death rate for people without high blood pressure. Apparently “one of medicine’s major successes” is a case where the health benefit no more than equaled the health cost — leaving aside what the treatment cost in time and money.

Because very high blood pressure (systolic > 180 mm Hg) is quite dangerous and blood pressure drugs really work, this is a surprising outcome. Makridakis points out that doctors start treating high blood pressure when it rises above systolic = 140 mm Hg, a point when there is little or no increase in death rate. This article tells doctors to immediately prescribe drugs when systolic blood pressure is above 160. Yet death rate clearly increases only when systolic blood pressure is above 180. Makridakis concludes (as do I) that blood pressure drugs have significant health costs as well as benefits. The drugs are so often prescribed when they do no good and the costs are so high that the overall health costs of blood pressure treatment have managed to be as high as the overall benefits. Even when handed a relatively easy-to-measure problem (high blood pressure) and a relatively simple solution (blood pressure drugs), our health care system managed to achieve no clear gain. If this is “one of medicine’s major successes”, medicine is in bad shape.

The last paragraph of Makridakis’s article makes a surprising statement: “We strongly believe that medicine is extremely useful.” It does not explain this belief, which is contradicted by the rest of the article. I was puzzled. I wrote to the author:

I recently read your paper on “High blood pressure and iatrogenics”. The main part makes good sense. Then it ends with something quite puzzling: “We strongly believe that medicine is extremely useful.” No doubt a few areas of medicine are extremely useful. For large chunks of medicine, it is hard to tell whether they do more good than harm, because so many drugs and other treatments have undisclosed or unnoticed bad effects.

For example, tonsillectomies — for a long time the most common operation — is associated with a 50% increase in mortality in one study. The notion that cutting off part of the immune system is a good idea makes as much sense as the idea that cutting out part of the brain is a good idea. Another example is sleeping pills. They are associated with a three-fold increase in death rate soon after they begin to be taken. I am not saying that medicine overall does more harm than good. I am saying that a strong belief about the outcome of such an assessment (does medicine overall do more good than harm?) doesn’t make sense.

Makridakis replied:

Thank you for your email. The paper you mention is a draft posted for comments. I agree with you that my statement is wrong. It should have read: : “We strongly believe that medicine can be extremely useful”. For instance, this could be the case in treating heart attacks, strokes, traumas from car accidents or bullet shots. But in most other cases the harm from treatment can be greater than the benefits. In addition, the harm from preventive medicine can exceed its value. Thank you for pointing out this mistake to me.

Puzzle resolved.

Sleeping Pills are Very Dangerous

Seth Roberts8 Comments

Do you know how dangerous prescription sleeping pills are? I didn’t, and I do sleep research.

I came across Dr. Daniel Kripke’s book Dark Side of Sleeping Pills while finishing yesterday’s post on undisclosed risks of medical treatments. I had written an almost-complete draft a year ago. One line in the draft said “undisclosed risks of sleeping pills” with no additional information. I couldn’t remember why I’d written that so I googled “dangers of sleeping pills” and found Dr. Kripke’s book. I was unaware the evidence was so strong. I asked Dr. Kripke to tell the story of how he came to write it. He replied:

It is almost a life-long story.

As a young psychiatrist, I learned that the American Cancer Society had done a questionnaire survey of a million people which showed mortality related to long and short sleep. [People who sleep less or more than average have higher death rates.] In 1975, I asked if they would collaborate with me on a more complete analysis of the data on sleep length and insomnia. As a control variable, we included analysis of their one question about sleeping pill use. To my surprise, it looked like sleeping pill use was a strong predictor of early death, while insomnia was not (if you controlled for sleeping pill use by insomniacs).

There were many reasons why these results needed further study, so I asked if I could refine the questions for the new Cancer Prevention Study II (CPSII) which the American Cancer Society commenced in 1982 with 1.1 million participants. Imagine my surprise when I observed that sleeping pill use was associated with a comparable mortality hazard ratio as cigarette smoking! These studies, and about 20 more done all over the world with similar results, had two important limitations: in general, the studies did not identify the sleeping pills used and did not measure whether those taking sleeping pills at the start of the study continued the drugs, or whether those who were not taking sleeping pills (the comparison group) started taking them. So another study was needed.

Meanwhile, sleeping pills were never my main scientific concern. I was mainly interested in bright light treatment of depression and trying to understand how light worked. When I saw that patients needed information about light treatment, I wrote a very short book called “Brighten Your Life”, but it wasn’t long enough to publish, so I added information about sleeping pills to make it longer. When we found no publisher for the book, I made the information available at two web sites: www.BrightenYourLife.info and www.DarkSideOfSleepingPills.com. I found that the web site about sleeping pills was more popular than the advice about light treatment–indeed, one of the most popular sources about sleeping pills at Google. Therefore, over the years, I have worked to revise and update both web sites to try to help patients. It costs some money to program and maintain the web sites, but people write me to tell me how they have benefited. I see so much misinformation coming from the drug companies that I want people to have an alternative source.

Five or six years ago, my friend Dr. Bob Langer was working at the Geisinger Health Research Center, which had access to electronic health records about sleeping pill use from a large number of people. It took us five years to plan a study, obtain approval from ethics committees, retrieve the complex data from computer files in anonymized form, and analyze the very complex results. When these were published by the medical journal BMJ Open, the new information became available at https://bmjopen.bmj.com/content/2/1/e000850.full. It is an interesting web site which includes more data in a supplement to the main article and some comments and debate about the article. The interest in the article was world-wide, with stories on the BBC, at Agence France Press, in major newspapers in Japan, India, and China, and even mentions in far-off places like Myanmar and Ruanda. The new data showed that people taking drugs such as zolpidem and temazepam had about 4.6 times the mortality rate of people of the same age and sex who took no sleeping pills. The new data confirm that sleeping pills might cause as much death as cigarettes, and also some cancer, so I feel a big responsibility to make the information available. There may be hundreds of thousands of lives at stake. People need to know that sleeping pills are too risky to use, and I wish I had more help in telling people.

Recently we updated the Dark Side Of Sleeping Pills and Brighten Your Life and made them available together in a Kindle book, which is easy to purchase at Amazon and read off-line. The books have some new information which we have not yet had a chance to put in the web sites.

Even with, now, more than 20 scientific papers showing that taking sleeping pills is associated with more death and more cancer, many people don’t believe it. They imagine there is some other explanation, though nobody has been able to demonstrate an alternative explanation. Of course, statistical association is not quite the same thing as proof of causality, but if it is good enough for the American Cancer Society to advise avoiding cigarettes, it is enough evidence of risk to stay away from sleeping pills, in my opinion. The problem is that the drug companies have never done a controlled trial study large enough to prove one way or another whether the sleeping pills cause death and cancer, and I think they never will. The cigarette companies have never tried to prove that cigarettes are safe, and they know better than to try. It is the same. Whereas the FDA requires the very large studies for heart and diabetes drugs and so forth, the FDA has dropped the ball with sleeping pills. For more information about that, please see the Kindle book. There is, however, a new alternative to large, expensive, and dangerous controlled trials called a Mendelian randomization study, which uses the new genetic methods to determine causality when a genetic variation causes a risk factor such as sleeping pill usage. Since the genetic data already exist to do the Mendelian randomization studies, it is a matter of doing the difficult statistical analyses. I hope scientific colleagues will join in this task, because I can’t do it by myself. It is crucial to determine for sure the risks of sleeping pills. Too many lives are at stake.

Sleeping pills are astonishingly dangerous for something that is treated as more or less safe. In some cases, they are associated with a five-fold increase in death rate after only a few years of use. Cigarette smoking is associated with only a two- or three-fold increase in death rate after long use. And doctors don’t prescribe cigarettes. Is there anything else treated as safe that is associated with such a large increase in death rate? I can’t think of anything.