- Super-old Ashkenazi Jews. Did they live to be more than a hundred “in spite of” their “bad habits” (eating steak & pork chops, smoking, refusal of Lipitor) or because of those habits? Small amounts of smoking could easily be beneficial due to (or illustrating) hormesis.
- Does Hollywood have a sense of humor? In the new movie about noted anti-Communist J. Edgar Hoover, Hoover’s love interest is played by Armie Hammer, grandson of Armand Hammer, who worked for the Soviet Union as a money launderer. Edward Jay Epstein writes about Hammer and the Soviet Union in this excellent Kindle book.
- An advantage of ebooks, not yet realized, is easy updates. When the book is improved — for example, mistakes fixed — you get a new copy. In an even better Kindle book, Epstein writes about the diamond industry. The vast difference between the purchase price of a diamond and its resale value may be the advertising industry’s greatest achievement. Recent events caused Epstein to add a new chapter. The book was easy for Epstein to update but unfortunately earlier purchasers did not get the new version.
- Michel Cabanac, who did some of the research behind the Shangri-La Diet, has written a book about his life’s work: how we self-regulate via pleasure. During a meal, for example, exactly the same food becomes less pleasant. When it becomes unpleasant, we stop eating. When we are hot, cold water is more pleasant than when we are cold. The secret to weight loss, Cabanac realized, is making exactly the same food less pleasant — an insight few weight-loss writers understand.
The Willat Effect: More Consequences
A month ago I bought three identical tea pots to compare tea side by side. I hoped to take advantage of the Willat Effect (side-by-side comparisons create connoisseurs) to become a tea connoisseur.
It worked. Side-by-side tea comparisons are fun, easy, and have taught me a lot. When I drink tea I notice more and like it more. I do about three comparisons per day. I blogged about the first results here. The most useful idea about these comparisons came from Carl Willat himself: Compare the same tea brewed differently (e.g., different amounts of tea, different brewing times, different water temperatures). Most of my comparisons vary amount of tea or brewing time.
These many comparisons have had several effects:
1. Yeah, I’m a snob. No more cheap tea. Yeah, I’m more nerdy about it.
2. I bought a scale (Camry EHA901, $12 in America) with a precision of 0.01 gram. No more heaping teaspoons. Mostly I use 1.5 grams of tea with about 170 ml water. For dense tea, 1.5 grams is roughly 1 teaspoon. Standard-size teabags contain about 2 g of tea.
3. Much different brewing times than recommended. The black tea I have now is Ahmad Tea English Tea No. 1 (in spite of the name, not expensive). The tin says “infuse 4-6 minutes.” I used to brew it (and all black tea) 5 minutes, now I prefer less than 3 minutes. I found that 2.75 minutes is better than 3 minutes. Around 3 minutes it starts getting bitter — I never noticed! Another example is American Tea Room‘s Choco Late, which contains cacao husks, vanilla, and rooibos. The package says brew 5 minutes. I prefer 30 minutes — 30 minutes tastes better than 20 minutes, I have found several times.
4. To make the comparisons as sensitive as possible I want to start with equal tea pots, so I need to clean them well after each use. This became boring. I could eliminate cleaning by using tea bags. I bought ordinary-size empty tea bags. Side-by-side comparisons (same tea, bagged versus loose) showed they made the flavor much worse. Too bad I’d bought 200. I bought much larger tea bags to use as liners rather than bags. That worked fine — no cleaning needed, taste just as good. However, they are too large, so I shorten them. The concept of a disposable tea liner (instead of tea bag) seems to be new. I cannot find any for sale. My connoisseurship has not only caused me to spend much more on tea, it has made me want an interesting new product. Tea pot makers could sell liners specially designed for their pots. Continuing revenue, like razor blades.
5. I stopped adding artificial sweetener (e.g., Splenda) to black tea. Now I prefer it without sweetener. I continue to add cream to black tea. This is the most surprising and intriguing change. Maybe sweetness is a distraction from the complexity of the flavor (which I now notice more and derive more pleasure from), but creaminess is not. I imagine the same thing is behind Richard Stallman’s “If it is tea I really like, I like it without milk and sugar.” And maybe the same thing is behind all sorts of artistic expression that strike outsiders as harsh and unpleasant. A few years ago I went to a BAM (Brooklyn Academy of Music) concert and was stunned how unpleasant it was. Yet the composer (who performed it) surely enjoyed it.
Regular readers know I think connoisseurship evolved because it increased technological innovation. My experience so far supports this. Thanks to the Willat Effect, I am more of a connoisseur. As a result of this change, I am spending more on high-end artisanal goods (expensive tea) and precision manufacturing (precision scale) and I want a new product (disposable tea liners).
People think of connoisseurs as having higher standards. The word connoisseur seems to mean exactly that. Iin some obvious ways, they do. Yet the sweetener change (I no longer want sweetener) is in a way a lowering of standards. Sweetness is pleasant. I no longer require, or even want, my tea to be sweet. As far as I can tell, something like this is true throughout the arts. Connoisseurs make unusual demands, yes, but in some ways they are easier to please than non-connoisseurs. Indie films are less pleasant than mainstream films. Yet film connoisseurs like them more. To most people, indie films are also much cheaper and more experimental than mainstream films. By supporting them — by preferring them — film connoisseurs are supporting innovation. The connoisseurs have lowered their standards for film in the sense that they can enjoy cheaper films. A friend of mine attends the San Francisco International Film Festival each year. He enjoys it. I wouldn’t. The SF film festival films don’t cost much, yet they have a certain innovative quality. (I”m not a film connoisseur, I barely understand it.) The source of pleasure has shifted from conventional sources (plot, music, dialogue, gorgeous actors, sets, and landscapes) to something else, perhaps novelty and complexity.
A Great Idea From Nassim Taleb: End Banker Bonuses
This is the best response to the 2008 financial crisis I have seen: An op-ed by Nassim Taleb that says end banker bonuses. They encourage risk-taking with other people’s money.
Separation of risk-taking from consequences (you gamble, if you lose, other people pay) is an ancient problem. The Chinese government would be wise to take a page from Hammurabi’s code, which Taleb quotes:
If a builder builds a house for a man and does not make its construction firm, and the house which he has built collapses and causes the death of the owner of the house, that builder shall be put to death.
During the Szechuan earthquake, hundreds of schoolchildren died when their schools collapsed. Surrounding buildings did not collapse. It turned out the schools were badly built. No builder was punished, much less put to death.
At the end of his op-ed, Taleb puts it very clearly and simply: “ bonuses and bailouts should never mix“.
Thanks to Dave Lull.
More Large areas of medicine consist of the doctor or someone else gambling with your health.
An especially clear example is surgery. Surgeon are paid per operation. The more operations they do, the more money they make. If an operation kills you, the surgeon is still paid. No penalty for a bad outcome. Wonderful for the surgeon, terrible for the rest of us. The more corrupt the surgeon, the more surgery they will recommend. Taleb’s idea suggests that surgeons pay a fine if a patient dies. The size of fines a surgeon would be willing to pay for bad outcomes would be helpful information for patients, who must decide what to do.
Drugs and medical devices are more subtle examples. You pay upfront for the drug or device, which are always expensive. They often have bad side effects, for which, of course, you pay. The drug company or device maker loses nothing. Wonderful for them, bad for the rest of us.
Assorted Links
- More about the Stapel fraud. The whole report.
- participatory action research. “A way to increase understanding of how change in one’s actions or practices can mutually benefit a community of practitioners.” More practical than most academic research. Edging toward group self-experimentation.
- At a Reed College alumni lunch, I sat next to a professor of economics. “What do you think of Jane Jacobs?” I said. “Who’s that?” she said. I am glad to learn that Elinor Ostrom, winner of a recent Nobel Prize in economics, was influenced by Jacobs. Ostrom is a political science professor.
- “ Science is the belief in the ignorance of experts.” A talk by Richard Feynman that I linked to recently. I first realized the power of self-experimentation when it showed my dermatologist was wrong.
- Monopolies of knowledge (Wikipedia entry).
Thanks to Bryan Castañeda, Lemniscate, Dave Lull and Reihan Salam.
The Verb “To Google”
I visited Google New York a few years ago. In conversation, an engineer used the verb to google — just like everyone else. Slightly amusing. Today I used the verb to google in an email. Gmail told me it was misspelled! Google is okay but google is not in their dictionary. Too modest!
Testing Treatments: Nine Questions For the Authors
From this comment (thanks, Elizabeth Molin) I learned of a British book called Testing Treatments (pdf), whose second edition has just come out. Its goal is to make readers more sophisticated consumers of medical research. To help them distinguish “good” science from “bad” science. Ben Goldacre, the Bad Science columnist, fulsomely praises it (“I genuinely, truly, cannot recommend this awesome book highly enough for its clarity, depth, and humanity”). He wrote a foreword. The main text is by Imogen Evans (medical journalist), Hazel Thornton (writer), Iain Chalmers (medical researcher), and Paul Glaziou (medical researcher, editor of Journal of Evidence-Based Medicine).
To me, as I’ve said, medical research is almost entirely bad. Almost all medical researchers accept two remarkable rules: (a) first, let them get sick and (b) no cheap remedies. These rules severely limit what is studied. In terms of useful progress, the price of these limits has been enormous: near total enfeeblement. For many years the Nobel Prize in Medicine has documented the continuing failure of medical researchers all over the world to make significant progress on all major health problems, including depression, heart disease, obesity, cancer, diabetes, stroke, and so on. It is consistent with their level of understanding that some people associated with medicine would write a book about how to do something (good science) the whole field manifestly can’t do. Testing Treatments isn’t just a fat person writing a book about how to lose weight, it’s the author failing to notice he’s fat.
In case the lesson of the Nobel Prizes isn’t clear, here are some questions for the authors:
1. Why no chapter on prevention research? To fail to discuss prevention, which should be at least half of health care, at length is like writing a book using only half the letters of the alphabet. The authors appear unaware they have done so.
2. Why are practically all common medical treatments expensive?
3. Why should some data be ignored (“clear rules are followed, describing where to look for evidence, what evidence can be included”)? The “systematic reviews” that Goldacre praises here (p. 12) may ignore 95% of available data.
4. The book says: “Patients with life-threatening conditions can be desperate to try anything, including untested ‘treatments’. But it is far better for them to consider enrolling in a suitable clinical trial in which a new treatment is being compared with the current best treatment.” Really? Perhaps an ancient treatment (to authors, untested) would be better. Why are there never clinical trials that compare current treatments (e.g., drugs) to ancient treatments? The ancient treatments, unlike the current ones, have passed the test of time. (The authors appear unaware of this test.) Why is the comparison always one relatively new treatment versus another even newer treatment?
5. Why does all the research you discuss center on reducing symptoms rather than discovering underlying causes? Isn’t the latter vastly more helpful than the former?
6. In a discussion of how to treat arthritis (pp. 170-172), why no mention of omega-3? Many people (with good reason, including this) consider omega-3 anti-inflammatory. Isn’t inflammation a major source of disease?
7. Why is there nothing about how to make your immune system work better? Why is this topic absent from the examples? The immune system is mentioned only once (“Bacterial infections, such as pneumonia, which are associated with the children’s weakened immune system, are a common cause of death [in children with AIDS]“).
8. Care to defend what you say about “ghostwriting” (where med school professors are the stated authors of papers they didn’t write)? You say ghostwriting is when “a professional writer writes text that is officially credited to someone else” (p. 124). Officially credited? Please explain. You also say “ghostwritten material appears in academic publications too – and with potentially worrying consequences” (p. 124). Potentially worrying consequences? You’re not sure?
9. Have you ever discovered a useful treatment? No such discoveries are described in “About the Authors” nor does the main text contain examples. If not, why do you think you know how? If you’re just repeating what others have said, why do you think your teachers are capable of useful discovery? The authors dedicate the book to someone “who encouraged us repeatedly to challenge authority.” Did you ever ask your teachers for evidence that evidence-based medicine is an improvement?
The sad irony of Testing Treatments is that it glorifies evidence-based medicine. According to that line of thinking, doctors should ask for evidence of effectiveness. They should not simply prescribe the conventional treatment. In a meta sense, the authors of Testing Treatments have made exactly the mistake that evidence-based medicine was supposed to fix: Failure to look at evidence. They have failed to see abundant evidence (e.g., the Nobel Prizes) that, better or not, evidence-based medicine is little use.
Above all, the authors of Testing Treatments and the architects of evidence-based medicine have failed to ask: How do new ideas begin? How can we encourage them? Healthy science is more than hypothesis testing; it includes hypothesis generation — and therefore includes methods for doing so. What are those methods? By denigrating and ignoring and telling others to ignore what they call “low-quality evidence” (e.g., case studies), the architects of evidence-based medicine have stifled the growth of new ideas. Ordinary doctors cannot do double-blind clinical trials. Yet they can gather data. They can write case reports. They can do n=1 experiments. They can do n=8 experiments (“case series”). There are millions of ordinary doctors, some very smart and creative (e.g., Jack Kruse). They are potentially a great source of new ideas about how to improve health. By denigrating what ordinary doctors can do (the evidence they can collect) — not to mention what the rest of us can do — and by failing to understand innovation, the architects of evidence-based medicine have made a bad situation (the two rules I mentioned earlier) even worse. They have further reduced the ability of the whole field to innovate, to find practical solutions to common problems.
Evidence-based medicine is religion-like in its emphasis on hierarchy (grades of evidence) and rule-following. In the design of religions, these features made sense (to the designers). You want unquestioning obedience (followers must not question leaders) and you want the focus to be on procedure (rules and rituals) rather than concrete results. Like many religions, evidence-based medicine draws lines (on this side “good”, on that side “bad”) where no lines actually exist. Such line-drawing helps religious leaders because it allows their followers to feel superior to someone (to people outside their religion). When it comes to science, however, these features make things worse. Good ideas can come from anybody, high or low in the hierarchy, on either side of any line. And every scientist comes to realize, if they didn’t already know, that you can’t do good science simply by following rules. It is harder than that. You have to pay close attention to what happens and be flexible. Evidence-based medicine is the opposite of flexible. “ There is considerable intellectual tyranny in the name of science,” said Richard Feynman.
Testing Treatments has plenty of stories. Here I agree with the authors — good stories. It’s the rest of the book that shows their misunderstanding. I would replace the book’s many pages of advice and sermonizing with a few simple words: Ask your doctor for the evidence behind their treatment recommendation. He or she may not want to tell you. Insist. Don’t settle for vague banalities (“It’s good to catch these things early”). Don’t worry about being “difficult”. You won’t find this advice anywhere in Testing Treatments. If I wanted to help patients, I would find out what happens when it is followed.
More Two of the authors respond in the comments. And I comment on their response.
Ten Reasons To Distrust Drug Companies
A reader of this blog who wants to be identified as Doctor’s Daughter wrote the following editorial and submitted it to KevinMD, which turned it down. KevinMD is aimed at doctors. One recent article (“ Why 99% of health care should be angry“) said this: “The real top earners in health care, however, are not physicians, but executives of big corporations, non-profit and especially for profit.” Here is what Doctor’s Daughter wrote:
(On Kevin MD’s website there was a recent piece entitled “How Can Pharma Earn the Trust of Patients?” which was submitted by Richard Meyer, the executive director of Online Strategic Solutions, which develops strategies for companies that engage in direct-to-consumer marketing. . . I feel compelled to offer a different viewpoint, focused on pharma’s actual business practices.)
Far too many pharmaceutical companies have:
1. Spent more money on marketing than on honest research and development.
2. Set exorbitant prices for drugs. For example, they have engaged in price-gouging for cancer drugs, with many costing more than $50,000 annually.
3. Tried to medicalize almost everything and, quelle surprise, they have a pill for that! Few of these drugs do anything to cure the condition; they just alleviate the symptoms.
4. Undermined the independence of guideline panels by making sure that the panels are filled with pharma friendly researchers and clinicians.
5. Unduly influenced the judgment of physicians and tried to undermine their integrity with gifts and cash.
6. Prevented lower-priced generics from coming on the market with “pay to delay” agreements and by other means.
7. Chosen profits over safety (remember the Heparin scandal?).
8. Designed studies that only report the supposed benefit of a particular drug and suppress information about adverse effects.
9. Exercised undue influence over panels that review the efficacy and safety of drugs.
10. Have continued to spend billions on advertising by saturating prime-time TV with Direct-To-Consumer ads to “Ask your doctor…”
With these kinds of abusive practices, should anybody trust these guys?
A reasonable list of complaints.
Flaxseed Oil Heals Bleeding Gums, Again
In response to this post, which went up three months ago, a reader named Tara has just written:
I started taking 2 TB of flax oil daily about four days ago and now my gums are barely bleeding at all after I brush and floss. My gums were red, swollen and would bleed after I brushed and flossed and are now pink and healthy looking.
I’ve had this problem for years and I could not understand why it would keep happening even though I was consistent with my dental routine. I take the berry flavored Barlean’s flax oil mainly because it tastes good and so I look forward to taking it- if it was gross I would not be consistent with taking it.
Anyhow, thanks for the information! I wish dentists would look into this but they probably won’t so I’m glad that you do.
I agree about the Barlean’s, by the way. Their Omega Swirl flaxseed oil does taste good. The Omega Swirl webpage does not list healthy gums as one of its benefits. Instead it lists a bunch of benefits, such as “Heart Health” that are nearly impossible to verify.
Someone recently told me something fascinating about flaxseed oil: It made it much easier to kneel on the floor. Before he started taking it, his knees would hurt after a few seconds. Now they don’t. I don’t remember my knees hurting quickly but I consume 66 g/day of ground flaxseed (= about 2 T flaxseed oil) and can kneel without pain for minutes.
The tiny fact reflected in Tara’s comment — an easily-available supplement (flaxseed oil) quickly cures a common problem (bleeding gums) but hardly anyone knows this — is a devastating comment on our health care system.
1. Dentists haven’t managed to figure this out. Flaxseed oil is not an obscure supplement. Dentists are not making money giving people much worse advice (“floss regularly”).
2. Nutrition professors haven’t managed to figure this out. Omega-3 is not an obscure nutrient. Nevertheless, the 2010 USDA Dietary Guidelines says omega-3 fats are “essential” but says nothing about how much you need. Inflammation is believed to be the cause of many diseases, including heart disease. By getting this one thing (minimum omega-3 intake you need to be healthy) right, the USDA could do a world of good. Instead they tell people to eat less animal fat (“consume less than 10 percent of calories from saturated fatty acids”).
To be fair, professional researchers are starting to figure this out. A 2010 study of 9000 people found that “participants in the middle and upper third for omega-3 fatty acid consumption were between 23 percent and 30 percent less likely to have gum disease than those who consumed the least amount of omega-3 fatty acids.” With the right dose, I believe gum disease becomes 100% less likely. But at least they noticed a connection.
Vitamin D, Sunlight, and Sleep: More
In the comments on yesterday’s post (“Can Vitamin D Replace Sunlight? A Stunning Discovery”), two commenters (John and Aaron Blaisdell) noted that Nephropal had said something similar. They’re right. Here’s what Nephropal said in 2009:
Vitamin D taken at night causes insomnia. This is a complaint of a few of my patients. Moreover, when they switch to morning dosing, the insomnia subsides. Thus, Vitamin D should be taken in the morning.
That’s a great observation, but not the same as Primal Girl’s. Here is her observation, shortened for clarity:
I usually took my supplements mid-afternoon. I vowed to take them first thing every morning. I tried it the next day and that night I slept like a rock. And the next night. And the next.
The two observations support each other. Both support the idea that the timing of Vitamin D matters. But there are also big differences. Paleo Girl had been taking her Vitamin D in mid-afternoon, not at night. She shifted to first thing in the morning, which is more specific than morning. I changed the title of yesterday’s title to make clearer what is new here: the idea that Vitamin D can substitute for sunlight.
Lots of things cause insomnia if you take them in the evening. Caffeine and other stimulants, for example. A comment on yesterday’s post said that B vitamins and calcium cause insomnia if taken in the evening. This is why Nephropal’s observation, although very important, is not a stunning surprise. You stop taking X in the evening, your sleep improves — I won’t be astonished, no matter what X is.
Vitamin D is not a stimulant or is at best a mild stimulant. Taking Vitamin D in the afternoon should not cause trouble sleeping. Yet Primal Girl had trouble sleeping. And she was getting little morning sunlight. It is a real insight that first-thing-in-the-morning Vitamin D could have the same effect as first-thing-in-the-morning sunlight — in other words, could substitute for missing sunlight. Against all odds, the results supported this idea.
One commenter on yesterday’s post said Primal Girl’s results were both unproven and obvious. Vitamin D is technically a hormone! Melatonin is a hormone, said the comment. I have not heard anyone propose taking melatonin first thing in the morning to improve sleep. It is standard to take melatonin in the evening. The accepted view among circadian rhythm researchers is that sunlight produces its effects on circadian rhythms via nerves, not blood. For example, hundreds of experiments have found that destroying the suprachiasmatic nucleus of rats destroys their circadian rhythms. The suprachiasmatic nucleus receives neural input from the eyes — that’s why these lesions were first made (by Irv Zucker, a Berkeley colleague of mine).
Lots of people think Vitamin D improves sleep. That’s not new. Here’s what one of them said, in a post promisingly titled “ When is the best time to take your Vitamin D supplement?“:
In an effort to boost absorption of vitamin D, individuals were asked to take their vitamin D supplements with the largest meal of the day. After 2-3 months, vitamin D levels were checked again.At the end of the study period, vitamin D levels had risen to an average of 47.2 ng/ml (118 nmol/l) – an average i ncrease in vitamin D levels of about 57 per cent. . . It seems sensible, I think, for individuals who are currently supplementing with vitamin D to take this with their largest evening meal.
Can Vitamin D Replace Sunlight? A Stunning Discovery
Primal Girl is a stay-at-home mom. I met her at the Ancestral Health Symposium. Her sleep was bad. I made recommendations. One of them was to get an hour of sunlight soon after you wake up. She can’t do that — too busy being a mom. So she decided to take Vitamin D early in the morning. After all, sunlight exposure produces Vitamin D. Here’s what happened:
One day as I was taking my supplements, I was thinking about how many units of Vitamin D your skin produces in 30 minutes of sun (20,000 I believe). I looked aghast at the 10,000 units of Vitamin D I was taking. It was 7 o’clock at night! I was essentially giving my body 15 minutes worth of bright sunlight energy. No wonder I was waking up in the middle of the night! I was telling my body that it wasn’t really time for bed, it was still the middle of the day. I wondered what would happen if I only took my Vitamin D first thing in the morning. It wouldn’t be an hour naked in the sun, but 15 minutes is better than nothing. That night I slept like shit. Worse than normal.
I usually took my supplements mid-afternoon. I vowed to take them first thing every morning. If I forgot, I would not take the Vitamin D at all that day. I tried it the next day and that night I slept like a rock. And the next night. And the next. Days I forgot and skipped the D3, I still slept great. That was the only change I made to my lifestyle and my sleep issues completely resolved. [emphasis added]
OMG! Double OMG! Like Primal Girl, I have never heard anything like this. Even I am stunned that such a simple safe easy change could have such a positive effect. (Taking Vitamin D at sunrise is a lot easier than standing on one leg four times!) I’ve read lots about circadian rhythms. Many studies showed that a drug would be much more powerful at certain times of day. Most of these studies were with rats. It never occurred to me that the time you take a vitamin could matter so much.