MD, PhD, FMedSci, FRSB, FRCP, FRCPEd

commercial interests

No, I kid you not!

This abstract was actually published in the leading chiro-journal. The authors include three professors from the Canadian Memorial Chiropractic College, Research, Toronto, Canada. Its title is impressive but made my alarm bells ring a bit:

A Randomized Pragmatic Clinical Trial of Chiropractic Care for Headaches With and Without a Self-Acupressure Pillow.

And the actual texts does not disappoint those looking for of pure pseudo-science:

The purpose of this study was to determine if the addition of a self-acupressure pillow (SAP) to typical chiropractic treatment results in significantly greater improvement in tension-type and cervicogenic headache sufferers.

METHODS:

A pragmatic randomized clinical trial was conducted in a chiropractic college teaching clinic. Thirty-four subjects, including tension-type and cervicogenic headache sufferers, 21 to 60 years of age, male or female, completed the study. Group A (n = 15) received typical chiropractic care only (manual therapy and exercises), and group B (n = 19) received typical chiropractic care with daily home use of the SAP. The intervention period was 4 weeks. The main outcome measure was headache frequency. Satisfaction and relief scores were obtained from subjects in the SAP group. Analysis of variance was used to analyze the intergroup comparisons.

RESULTS:

Owing to failure of randomization to produce group equivalence on weekly headache frequency, analysis of covariance was performed showing a trend (P = .07) favoring the chiropractic-only group; however, this was not statistically significant. Group A obtained a 46% reduction of weekly headache frequency (t = 3.1, P = .002; d = 1.22). The number of subjects in group A achieving a reduction in headaches greater than 40% was 71%, while for group B, this was 28%. The mean benefit score (0-3) in group B of the use of the SAP was 1.2 (.86). The mean satisfaction rating of users of the SAP was 10.4 (2.7) out of 15 (63%).

CONCLUSION:

This study suggests that chiropractic care may reduce frequency of headaches in patients with chronic tension-type and cervicogenic headache. The use of a self-acupressure pillow (Dr Zaxx device) may help those with headache and headache pain relief as well as producing moderately high satisfaction with use.

Where to begin?

Perhaps it is best, if I simply concentrated on the bizarre research question: is chiropractic care plus the largely uncontrolled use of an ‘acupressure cushion’ better than chiropractic care alone? To savour the lunacy of it, we need to consider that:

  • chiropractic is not plausible;
  • chiropractic care is not proven to be effective for headaches;
  • acupressure is not plausible;
  • acupressure is not proven to be effective;
  • a self-administered acupressure cushion is also unproven and even less plausible;

This, I fear, renders the study one of the most nonsensical trials I have seen for a very long time. To make the bonanza in pseudo-science complete, the article is supplemented with a most bizarre conclusion about the effectiveness of chiropractic (which, of cause, cannot be examined in a trial of chiro vs chiro).

All this leads me to fear that:

  • the best journal of chiropractic is rubbish;
  • a professorship in a chiro school may not mean that the professor has the slightest idea about research methodology;
  • chiropractors will try to squeeze a conclusion that is favourable for their trade even out of a dead horse.

Not long ago, Peter Fisher fired me from the editorial board of ‘his’ journal ‘HOMEOPATHY’. I thought that this was a surprisingly daft move, particularly as we used to have respect for each other and even published together as co-authors (for instance here). But perhaps I should not have been surprised because, already in 2007, he published an important, potentially libellous falsehood about me.

In this article which he published as Dr. Peter Fisher, Homeopath to Her Majesty, the Queen, he wrote: There is a serious threat to the future of the Royal London Homoeopathic Hospital (RLHH), and we need your help…Lurking behind all this is an orchestrated campaign, including the ’13 doctors letter’, the front page lead in The Times of 23 May 2006, Ernst’s leak of the Smallwood report (also front page lead in The Times, August 2005), and the deeply flawed, but much publicised Lancet meta-analysis of Shang et al…

If you have read my memoir, you will know that even the hostile 13-months investigation by my own university did not find me guilty of the ‘leak’. The Times journalist who interviewed me about the Smallwood report already had the document on his desk when we spoke, and I did not disclose any contents of the report to him. But the truth in homeopathy seems often highly diluted.

More recently, Peter Fisher could be heard on UK radio and TV (for instance here) making further claims which, in my view, are false. Specifically, I am thinking of two of his statements which would mislead the public, if they stood uncorrected:

  1. He said that the studies unanimously show that integrating homeopathy into conventional medicine improves outcomes and saves money.
  2. He also claimed that most of the homeopathic remedies available in the high street still contain small amounts of active ingredients.

POINT NUMBER 1

It seems obvious that adding homeopathy with its lengthy, compassionate encounters to conventional care can easily generate positive outcomes. But costs? I don’t see unanimously positive evidence here at all.

Dr Fisher must know the literature on homeopathy very well. Therefore I assume that he is aware of the most up-to-date systematic review of economic evaluations of this subject. Its authors from the ‘School of Health and Related Research’, University of Sheffield concluded that “it is… not possible to draw firm conclusions based on existing economic evaluations of homeopathy“.

Fisher knows and likes to quote Claudia Witt’s work on homeopathy. Why does he not cite this recent paper then?

OBJECTIVES:

The aim of this study was to compare the health care costs for patients using additional homeopathic treatment (homeopathy group) with the costs for those receiving usual care (control group).

METHODS:

Cost data provided by a large German statutory health insurance company were retrospectively analysed from the societal perspective (primary outcome) and from the statutory health insurance perspective. Patients in both groups were matched using a propensity score matching procedure based on socio-demographic variables as well as costs, number of hospital stays and sick leave days in the previous 12 months. Total cumulative costs over 18 months were compared between the groups with an analysis of covariance (adjusted for baseline costs) across diagnoses and for six specific diagnoses (depression, migraine, allergic rhinitis, asthma, atopic dermatitis, and headache).

RESULTS:

Data from 44,550 patients (67.3% females) were available for analysis. From the societal perspective, total costs after 18 months were higher in the homeopathy group (adj. mean: EUR 7,207.72 [95% CI 7,001.14-7,414.29]) than in the control group (EUR 5,857.56 [5,650.98-6,064.13]; p<0.0001) with the largest differences between groups for productivity loss (homeopathy EUR 3,698.00 [3,586.48-3,809.53] vs. control EUR 3,092.84 [2,981.31-3,204.37]) and outpatient care costs (homeopathy EUR 1,088.25 [1,073.90-1,102.59] vs. control EUR 867.87 [853.52-882.21]). Group differences decreased over time. For all diagnoses, costs were higher in the homeopathy group than in the control group, although this difference was not always statistically significant.

CONCLUSION:

Compared with usual care, additional homeopathic treatment was associated with significantly higher costs. These analyses did not confirm previously observed cost savings resulting from the use of homeopathy in the health care system.

To speak about unanimously positive evidence is simply not true! And Fisher, I suspect, must know it.

POINT NUMBER 2

This point is even clearer, I think. The most commonly used homeopathic potency is surely a ’30C’ – it was already Hahnemann’s favourite. A small statistic proves my point: of the 24 products listed on the Nelson site, 21 are ’30C’ and just three are ‘6C’. For Ainsworths, all 33 of their listed standard products are ’30C’. Helios have 70 ’30C’ products and 27 ‘200C’ products

The likelihood that a ’30C’ contains a single molecule of what it says on the bottle is precisely zero. In fact, this applies already to all remedies beyond ’12C’. Fisher knows that, of course, I assume; if not he should not be a homeopath.

MY CONCLUSION OF ALL THIS

I do not take any pleasure in calling anyone a liar – and it is, of course, far from me to use this word in connection with the Queen’s homeopath. Therefore, in the interest of the scientific truth, medical ethics and honesty, I would like to give Dr Fisher the opportunity to comment on the above issues and herewith invite him to correct the three errors/falsehoods/inaccuracies/misunderstandings mentioned above by supplying the evidence for his statements or by withdrawing them. Then we won’t have to call him names which he might feel are hurtful.

A friend alerted me to this website: Hungarian Academy of Sciences statement proposing the same scientific standards for homeopathic drug registration as for normal drugs

Members of the Section of Medical Sciences of the Hungarian Academy of Sciences (HAS) voted unanimously on 9 November 2015 for supporting the earlier proposal of the Royal Swedish Academy of Sciences. The Swedish statement requested that the homeopathic remedies should go through the same efficacy trials as normal drugs should.

The Hungarian statement refers to various recent scientific statements for example to the study of the Australian Government’s National Health and Medical Research Council that analysed 175 publications and concluded that there was no reasonable scientific proof for the efficacy of homeopathy for any health conditions. The HAS also refers to the European Academies Science Advisory Council that is allegedly considering an investigation among the academies of the UN countries about this topic. The statement points out that another Hungarian scientific body (Health Science Committee – Egészségügyi Tudományos Tanács) had made a similar statement already in 1991 and opposed using and registering those drugs for that efficacy had not been proved and that had not gone through adequate research procedures.

József Mandl – biochemist, member of HAS, president of Health Science Committee said: “The Australian and Swedish statements had raised the interest of the Hungarian scientific community and now members of the Medical Sciences Section of the Hungarian Academy of Sciences voted unanimously to join the Swedish initiation… Science has well defined, rigorous methods and systems. Homeopathy can’t be fitted to these. Homeopathic remedies don’t meet the criteria of evidence based medicine. There might be various hypotheses, theories, but everything should be proved. This is what science means and this is what we would like to highlight now.”

Well said, indeed!

It is high time that the authorities concede that there can be only one standard in medicine regulation. The ‘free ride’ homeopathy has had for 200 years must now come to an end.

This notion also seems to be increasingly supported by the legal profession. An Australian lawyer just published this abstract:

The 2010 report of the United Kingdom Science and Technology Committee of the House of Commons and the 2015 report of the Australian National Health and Medical Research Council have overtaken in significance the uncritical Swiss report of 2012 and have gone a long way to changing the environment of tolerance toward proselytising claims of efficacy in respect of homeopathy. The inquiry being undertaken in the United States by the Food and Drug Administration during 2015 may accelerate this trend. An outcome of the reports and inquiries has been a series of decisions from advertising regulators and by courts rejecting medically unjustifiable claims in respect of the efficacy of homeopathy. Class actions have also been initiated in North America against manufacturers of homeopathic products. The changing legal and regulatory environment is generating an increasingly scientifically marginalised existence for homeopathy. That new environment is starting to provide effective inhibition of assertions on behalf of homeopathy and other health modalities whose claims to therapeutic efficacy cannot be justified by reference to the principles of evidence-based health care. This has the potential to reduce the financial support that is provided by insurers and governments toward homeopathy and to result in serious liability exposure for practitioners, manufacturers and those who purvey homeopathic products, potentially including pharmacists. In addition, it may give a fillip to a form of regulation of homeopaths if law reform to regulate unregistered health practitioners gathers momentum, as is taking place in Australia.

As though this is not enough, today it was reported that the UK NHS is considering to blacklist homeopathic remedies:

The Good Thinking Society has been campaigning for homeopathy to be added to the NHS blacklist – known formally as Schedule 1 – of drugs that cannot be prescribed by GPs. Drugs can be blacklisted if there are cheaper alternatives or if the medicine is not effective. After the Good Thinking Society threatened to take their case to the courts, Department of Health legal advisers replied in emails that ministers had “decided to conduct a consultation”. Officials have now confirmed this will take place in 2016.

It seems to me that the position of homeopathy as a form of health care is less and less tenable. Its place is in the history books. To satisfy the need for consumer/patient choice, the remedies should be moved to the confectionary shelves of the supermarkets.

Having just finished reading an ‘satirical esothriller’ entitled ‘VIER FRAUEN UND EIN SCHARLATAN’ (it’s a good book but it’s in German, I’m afraid), I have been thinking more than usual about charlatans. A charlatan is defined as a person who falsely pretends to know or be something in order to deceive people. In the book, the charlatan character is deliberately exaggerated as a dishonest, immoral crook. I have met such people; in fact, I have met plenty of such people in alternative medicine. But I have to admit that, in my experience, there are other charlatans too; in particular, I am talking of ‘honest’ quacks who pretend to know while also being utterly convinced to know.

Come to think of the categories of charlatans, I think the matter is really quite simple: as far as I can see, in alternative medicine, there are essentially just two types.

THE CROOK

This type of charlatan is the one we think of first when we mention the term. He (usually it’s a male) has a range of remarkable features:

  • he is dishonest;
  • he is entirely rational;
  • he knows about evidence and has prepared all the necessary pseudo-arguments to belittle science vis a vis his followers;
  • he is only interested in himself;
  • he is immoral;
  • he wants to make money;
  • he employs all the means available to achieve his aims, including PR, advertising, branding, merchandising etc.
  • he does not believe in his ‘message’;
  • he systematically studies and exploits his target group;
  • he does not live by his own rules;
  • when he is implicated in harming a patient, he consults his lawyers;
  • he is cynical;
  • his ‘charisma’, if he has any, is well-studied and extensively rehearsed;
  • when challenged, he sues.

THE FANATCIST

This type is very different from the crook and would be deeply shocked by the crook’s behaviour and attitude. She (often it is a female) can be described as follows:

  • she is convinced to be profoundly honest;
  • she is deluded, often to the point of madness;
  • she ignores the evidence totally and argues that science is just one of several ways of knowing;
  • she feels altruistic;
  • she thinks she is on the moral high ground;
  • she is not primarily out to make money and might even offer her services for free;
  • she does not seek fame;
  • she is religiously convinced of the correctness of her message and wants to save mankind through it;
  • her message is for everyone;
  • she strictly adheres to her own gospel and thinks that those who don’t are traitors;
  • when she is implicated in causing harm, she consults her ueber-guru;
  • she abhors cynicism;
  • her charisma, if she has any, is real and a powerful tool for convincing followers;
  • when challenged, she feels hurt and misunderstood.

As I indicated already, this is a SIMPLE classification. Between the two extremes, there are all shades of grey. In fact, it is a continuous spectrum.

Why should any of this be important?

Charlatans of both types cause immeasurable harm, and it is impossible to decide which type is more dangerous. Our aim must be to prevent or minimise the harm they do. I think, this aim can best be pursued, if we know who we are dealing with. Identifying where precisely on the above scale a particular charlatan or quack is situated, might help in the prevention of harm.

Anyone who has read ‘A SCIENTIST IN WONDERLAND’ will know that I stood up for science more than once in my life. In fact, I strongly believe that this is what scientists ought to do, and I frequently get irritated to see that some of my colleagues seem to disagree [if not even we scientists can stick our necks out for science, how can we expect others to do it?]. Being thus convinced, I surprised myself recently when I was invited to do my bid for science – and declined to comply. Here is the story:

On 16 October, I received the following invitation by email out of the blue:

Hi Dr. Ernst,

My name is John Jackson. I am Executive Director of the Adolph Coors Foundation in Denver, the charitable arm of the Coors family (not the brewery).

I would like to invite your participation in a debate on integrative medicine which will be held Sunday evening, March 20, 2016, at the Hyatt Regency in Denver. The debate will be the keynote event of our Pioneers in Health conference. Your debate partner will be Dr. Andrew Weil. As our conference precedes Dr. Weil’s annual Nutrition and Health Conference, we expect excellent attendance of 700-800, possibly more.

The debate topic: “Fad or the Future: Will Integrative Medicine Play a Growing Role in the Future of Health Care?”

If you are willing to join us, we plan the following debate format: Opening statements with responses by each of you, questions put to each other, and responses by each of you to pre-submitted questions from the audience and, finally, closing statements. (Audience participation will be limited to questions submitted via an app, not by microphone.) We intend to invite a prominent journalist/business leader to moderate. Dr. Weil has recommended CNN’s health reporter but this has not been confirmed.

I have read numerous articles you have authored on this website and feel you would offer an excellent counterpoint to Dr. Weil. Indeed, Dr. Weil also feels you would be an ideal debate partner. I have also read your ground rules for debate (on this website). Dr. Weil and our foundation share your insistence on respect and politeness, whether it’s a blog post or a public debate.

In the interest of full disclosure, our foundation funds several institutions which are studying various “alternative” practices, including the recent study of the use of electro-acupuncture for hypertension on which you and others have commented. We have also funded a project involving Dr. Weil and the University of Arizona. You can read more about our interest in integrative medicine and who we fund at www.coorsfoundation.org.

Of course, if you agree to participate, we would cover your travel, meals and lodging expenses and are willing to negotiate a reasonable honoraria.

If you would like to discuss this further by phone, please feel free to give me a call. I can be reached in Denver at 303-388-1636.

Thank you, Dr. Ernst. I look forward to your response.

John Jackson
Adolph Coors Foundation
Denver

I have to admit, I was flattered and tempted in equal measure. This could be a great occasion to reach a large US audience and get a few important points across. But, at the same time, I had my doubts, and these doubts grew faster by the minute. There were several hints in this seemingly innocent email to suggest that there was more to this story than a straight forward invitation. Was this a set-up to give integrative medicine more credibility than it deserves?

Being uncertain, I asked several American friends for advice. They all seemed horrified and very strongly advised me not to accept the invitation. But I was still not entirely convinced – even if these people are a bit strange, even if it is a set-up, even if I do not ‘win’ the debate, it might be an interesting experience and I might learn (and earn!) something.

I clearly needed to find out more. I know Andrew Weil, of course, and I had seen him twice before in similar public debates. So I had no illusions that his charisma and slick rhetoric, combined with an audience full of admirers, would win the day. But I did not necessarily mind all that much; it could still be an occasion to make my arguments known and it might turn out to be a fascinating experience.

However, I certainly did not want to lend, through my presence, undue credibility to people or organisations who don’t deserve it. So, what about the organisers? What do the Adolph Coors Foundation stand for, and who are they?

One of my US friends alerted me to an eye-opening website. Other websites were even less complimentary and mentioned homophobic, racist, and anti-labor practices in relation to the funders. This made up my mind, and I wrote the following response to Jackson’s invitation:

Dear Mr Jackson,

as you may know, I do like a challenge. Therefore I was very tempted to accept your offer to debate with Andrew.

On second thought, however, I developed doubts that the event outlined in your email can be a fair debate of the issues around integrative medicine. The audience gathered for Andrew’s conference would be entirely on the side of their ‘guru’, and even the moderator would be Andrew’s choice. It is notoriously problematic to discuss scientific evidence with quasi-religious believers pretending facts were a matter of opinion.

I fear that a life debate in Denver would be akin to a discussion between an evolutionary scientist and a crowd of rampant creationists.

Since you know my blog, I suggest we conduct such a debate in writing there. This would have the advantage of a much wider, more diverse audience and provide the opportunity to check the evidence for any claims made by the discussants.

Meanwhile, I thank you for this invitation but, unless you can convince me that my fears are unfounded, I have to decline.

Regards
E Ernst

I was not at all sure whether to expect a response. Therefore I was pleasantly surprised that, on 25 October, the following email reached me:

Dr. Ernst,

Thank you for your response to our invitation. I apologize for the tardy reply. I have been travelling and generally avoid using my iPhone to respond to important emails. I have been burned once-too-often by the iPhone’s embarrassing auto-INcorrections.

Your hesitation about participating in the debate is totally understandable and, frankly, I would have been surprised if you had NOT asked for more detail. 

Dr. Weil certainly does have a substantial following of loyal and passionate followers. And there will be a healthy contingent of them in the audience. Dr. Weil’s team estimates that 200-300 of those attending his Nutrition and Health Conference will also attend our conference, including the debate. That means the remaining attendees (400-500) will be those who sign up through our public portal which will be launched in a few weeks. Our marketing is targeting Colorado’s health community, including medical providers. We also expect our conference cosponsor, Americans for Prosperity Foundation (AFPF), to attract attendees through their outreach efforts. AFPF is a grassroots organization that has virtually nothing to do with any kind of medicine, conventional or integrative. AFPF’s interest is promoting innovations in the delivery of health care (more health care choice) which will be the focus of a panel earlier in the day. For what it is worth, you are more than welcome to encourage your readers to attend. We plan to keep the conference fee very low (somewhere between $25 and $50), a figure that does not even cover the food and beverage costs. So, while I cannot guarantee applause for your debate points, I believe you will find our audience open to a wide range of perspectives on the future of integrative medicine.

With regard to the debate format and moderator, we believe the format is conducive to a healthy exchange of ideas. You both make opening statements, you both respond to each other’s opening statements, you ask each other questions, you both answer questions from the moderator and the audience and you both will be given equal time to offer closing statements. Our foundation — not Dr. Weil — will select the moderator. He recommended a health writer at CNN although he has not provided a specific name. If you want to suggest a name, please feel free. We may or may not choose a moderator that either of you recommend.

Long story short, the Coors Foundation shares your interest in having a robust debate on this topic. That is exactly why we tendered the invitation to you. We hope that you will reconsider your initial declination. Since we are nearing the date at which we will launch our registration portal and agenda, we respectfully request a response at your earliest possible convenience. If we have not heard from you by Wednesday, October 28, we will assume your initial decision stands and will extend the invitation to our second choice.

Thank you Dr. Ernst. We look forward to your reply.

John Jackson
Adolph Coors Foundation
Denver

I found it impossible to be convinced by Jackson’s arguments; on the contrary, some of my suspicions were confirmed, and I did a little further research – this time on the ‘Americans for Prosperity Foundation’. I found numerous websites about them and even a Wikipedia page. What I learnt in the course of my inquiries made my alarm bells ring loud and clear. I decided to sleep over it and then sent this email as my final response:

Dear Mr Jackson,

I am afraid your second email did not manage to change my mind.

It was important for me to learn about the co-sponsor of the event. I did some research on both your and the co-sponsoring organisations and found that I share virtually none of their views. I am reluctant to give credibility through my presence in Denver to two prominent right wing lobby groups.

Furthermore I am not at all convinced that the event is designed to generate a balanced debate. On the contrary, by your description of it, I might even fear for my personal safety after presenting facts which contradict or deride the opinions of large parts of the audience, the organisers and Dr Weil.

Lastly I am still convinced that factual issues around integrative medicine cannot be debated fruitfully by pretending they are merely matters of opinion. A debate in writing, where all the arguments can be checked for their evidential basis, would surely be much preferable. I find it regrettable that you do not even comment on my offer to conduct such a debate on my blog. The offer, however, still stands.

I thank you again for inviting me. I do like to stand up for science but, in this particular instance, I fear the costs would be too high.

Regards
E Ernst

So far, I have not had a reply, and I do not expect to receive one soon.

The whole affair is little more than a triviality, of course. Yet it raises at least two important questions, I think:

  • Should we stand up for science wherever we can, or is the price occasionally simply too high?
  • What are these mysterious links between alternative medicine in the US and the far right?

I would be most interested to hear your views.

I am probably more used to nonsensical statements by promoters of alternative medicine than the average person. But the ‘ALTERNATIVE MEDICINE ZONE’ just broke my BS-meter. Here are a few samples from their most remarkable website, all relating to homeopathy:

There has always been a debate whether allopathic treatment methods of the modern age are more beneficial or are the natural homeopathic treatment ways more reliable. The goal of healing the sick is the same in both these groups of treatment, but there is a strong contrast in the methods use, the ideology behind the treatment and the detailed theories. The following is a detailed comparison between homeopathy and Allopathy for those who wish to pick between the two:

Beliefs

Allopathic practitioners aim to target that part of the body that has been affected by a problem or disease and they do so by identifying the causing agent. On the other hand, in Homeopathy, doctors believe that emotional stress or psychological reasons make the body more susceptible to diseases and use more of a holistic approach of treatment.

Medicines

Allopathic doctors make use of those medications which are produced by pharma companies or are man-made. On the other hand, Homeopathy uses natural supplements and cures such as herbs, dietary changes and other such ways to cure a disease. Allopathic doctors use an aggressive approach whereas homeopathic doctors consider one dose enough to treat a disease.

Surgeries

While on one hand, allopathic doctors consider surgeries to be very important for removal of tumors etc. or correcting problems inside the body, Homeopathic doctors almost never use surgery as a treatment method. Only when certain tissue in the body has become seriously damaged they practice this technique.

Allopathic surgeons heavily rely on surgical procedures in case of serious diseases which cannot be cured by medicines or any other approach. Homeopathic doctors try to treat each and every condition with a natural method or by recommending strong dietary changes.

Origins

Homeopathy is basically based on beliefs of German Physician Samuel Hahnemann whereas Allopathic system of treatment or cure of diseases is based on the principles of the ancient Greeks, for example Hippocrates. Allopathic is considered to be regular medicine in many countries such as US but Homeopathy is argued to be a natural and holistic way of cure.

Controversy

Both these schools of medicine consider the other to be non-beneficial. Homeopathy thinks that allopathic medicines tend to make people even sicker in the long run whereas Allopathy doctors believe that Homeopathy only uses Placebo as its mechanism to cure people. Supporters of both schools are often seen defending their preferred method of treatment.

The ‘ALTERNATIVE MEDICINE ZONE’ also does not shy away from giving concrete medical advice on their website. Two examples will have to suffice:

HOMEOPATHY FOR SHINGLES

Compare to anti-viral medicines, homeopathy has proved more effective for shingles and chicken pox. It offers rapid and successful approach in treating this infection. People with weak immune system are more prone to get shingles. Homeopathy medicines influence the immune system efficiently from within and improve body’s healing capacity. The homeopathy medicines are also capable of defusing pain, discomfort in body due to shingle. It also refrain shingles from spreading.

HOMEOPATHY FOR PILES

The homeopathic treatment is considered much better than surgery because it corrects the problem from the root which is not the case in surgery. Homeopathy is considered very useful in the early cases of piles and can help in complete healing. However as the problem becomes complex, it can only help in the healing of the symptoms.

Both articles finish by giving a list of homeopathic remedies that are recommended for the two conditions.

So there we have it!

My BS-meter has just broken.

Who can I sue?

On this blog, we have already discussed the good news that the US Federal Trade Commission (FTC) is considering whether advertisements for homeopathic products have any evidence to back the numerous claims that are being made for them. A meeting took place on 21 September, and now the first details are emerging.

Michelle Rusk, senior staff attorney in the FTC advertising practices division, said in this public hearing on over-the-counter homeopathic products that advertisements lauding the health benefits of medical products need to be based on competent, reliable, and rigorous scientific support.

“As a general rule, for treatment claims, we expect randomized, double-blind, placebo-controlled human clinical studies—not in vitro studies, not animal studies, not anecdotal evidence, no matter how compelling it is,” she said. “Second, we expect the studies to be internally valid. That means well-designed, reliably conducted, using procedures accepted in the field of research. It also means that results are not just statistically significant but also strong enough to be clinically meaningful. Third, the evidence has to match the product and the specific claim.”

In the context of any form of health care, such statements would amount to mere platitudes: the fact that we cannot possibly tolerate double standards in medicine is almost too obvious to mention. In the realm of homeopathy, however, these words amount to a revolution!

Could it be that the days of bogus claims for homeopathic products are counted?

Could it be that consumers might soon be protected from unscrupulous entrepreneurs exploiting the vulnerable?

Could it be that, one day, we will have one standard only?

The ‘INTERNATIONAL CHIROPRACTIC PEDIATRIC ASSOCIATION’ (ICPA) is, according to their website, ‘a nonprofit organization whose mission is to advance chiropractic by establishing evidence informed practice, supporting excellence in professional skills and delivering educational resources to the public. It fulfills this mission by engaging and serving family chiropractors worldwide through research, training and public education.’

It fulfils its mission by, amongst other things, tweeting links to other pro-chiropractic activities. It is via such a tweet that I recently found the Pathways to Family Wellness (PFW). This is a quarterly print and digital magazine whose mission is to support you and your family’s quest for wellness.

This sounds exciting, I thought, and decided to have a closer look. I found that, according to its website, the magazine ‘collaborates with consciousness leaders, cutting-edge scientists and researchers, families on their conscious path, holistic practitioners and dynamic non-profit organizations to bring the most current insights into wellness to our readers.’

The Executive Editor and Publisher of PFW is Dr. Jeanne Ohm. She has ‘practiced family wellness care since 1981 with her husband, Dr. Tom. They have six children who were all born at home and are living the chiropractic family wellness lifestyle. Ohm is an instructor, author, and innovator. Her passion is: training DC’s with specific techniques for care in pregnancy, birth & infancy, forming national alliances for chiropractors with like-minded perinatal practitioners, empowering mothers to make informed choices, and offering pertinent patient educational materials.’

My suspicion that this is an outlet of chiropractic nonsense is confirmed as I read an article by Bobby Doscher, D.C., N.D. on the subject of chiropractic treatment for children with neurological problems. The article itself is merely promotional and therefore largely irrelevant. But one short passage is interesting nevertheless, I thought:

Chiropractic Based on Scientific Fact

Since its beginning, chiropractic has been based on the scientific fact that the nervous system controls the function of every cell, tissue, organ and system of your body. While the brain is protected by the skull, the spinal cord is more vulnerable, covered by 24 moving vertebrae. When these bones lose their normal motion or position, they can irritate the nervous system. This disrupts the function of the tissues or organs these nerves control; this is called vertebral subluxation complex.

I thought this was as revealing as it was hilarious. Since such nonsensical notions are ubiquitous in the chiropractic literature, I am tempted to conclude that most chiropractors believe this sort of thing themselves. This makes them perhaps more honest but also more of a threat: sincere conviction renders a quack not less but more dangerous.

Don’t get me wrong, I have nothing against systematic reviews. Quite to the contrary, I am sure they are an important source of information for patients, doctors, scientists, policy makers and others – after all, I have published more than 300 of such papers!

Having said that, I do dislike a certain type of systematic review, namely systematic reviews by Chinese authors evaluating TCM therapies and arriving at misleading conclusions. Such papers are currently swamping the marked.

At first glance, they look fine. On closer scrutiny, however, most turn out to be stereotypically useless, boring and promotional. The type of article I mean starts by stating its objective which usually is to evaluate the evidence for a traditional Chinese therapy as a treatment of a condition which few people in their right mind would treat with any form of TCM. It continues with details about the methodologies employed and then, in the results section, informs the reader that x studies were included in the review which mostly reported encouraging results but were wide open to bias. And then comes the crucial bit: THE CONCLUSIONS.

They are as predictable as they are misleading. let me give you two examples only published in the last few days.

The first review drew the following conclusions: This systematic review suggests that Chinese Herbal Medicine as an adjunctive therapy can improve cognitive impairment and enhance immediate response and quality of life in Senile Vascular Dementia patients. However, because of limitations of methodological quality in the included studies, further research of rigorous design is needed.

The second review concluded that the evidence that external application of traditional Chinese medicine is an effective treatment for venous ulcers is encouraging, but not conclusive due to the low methodological quality of the RCTs. Therefore, more high-quality RCTs with larger sample sizes are required.

Why does that sort of thing frustrate me so much? Because it is utterly meaningless and potentially harmful:

  • I don’t know what treatments the authors are talking about.
  • Even if I managed to dig deeper, I cannot get the information because practically all the primary studies are published in obscure journals in Chinese language.
  • Even if I  did read Chinese, I do not feel motivated to assess the primary studies because we know they are all of very poor quality – too flimsy to bother.
  • Even if they were formally of good quality, I would have my doubts about their reliability; remember: 100% of these trials report positive findings!
  • Most crucially, I am frustrated because conclusions of this nature are deeply misleading and potentially harmful. They give the impression that there might be ‘something in it’, and that it (whatever ‘it’ might be) could be well worth trying. This may give false hope to patients and can send the rest of us on a wild goose chase.

So, to ease the task of future authors of such papers, I decided give them a text for a proper EVIDENCE-BASED conclusion which they can adapt to fit every review. This will save them time and, more importantly perhaps, it will save everyone who might be tempted to read such futile articles the effort to study them in detail. Here is my suggestion for a conclusion soundly based on the evidence, not matter what TCM subject the review is about:

OUR SYSTEMATIC REVIEW HAS SHOWN THAT THERAPY ‘X’ AS A TREATMENT OF CONDITION ‘Y’ IS CURRENTLY NOT SUPPORTED BY SOUND EVIDENCE.

The search for an effective treatment of obesity is understandably intense. Many scientists are looking in the plant kingdom for a solution, but so far none has been forthcoming – as we have already discussed on this blog before (e. g. here, and here). One herbal slimming aid is currently becoming popular: Yerba Mate also called Ilex paraguariensis, a plant many of us know from teas and other beverages. Our review concluded that the evidence for it was unconvincing but that it merited further study. This was 10 years ago, and meanwhile the evidence has moved on.

The aim of a recent study was to investigate the efficacy of Yerba Mate supplementation in subjects with obesity. For this purpose, a randomized, double-blind, placebo-controlled trial was conducted. Korean subjects with obesity (body mass index (BMI) ≥ 25 but < 35 kg/m(2) and waist-hip ratio (WHR) ≥ 0.90 for men and ≥ 0.85 for women) were given oral supplements of Yerba Mate capsules (n = 15) or placebos (n = 15) for 12 weeks. They took three capsules per each meal, total three times in a day (3 g/day). Outcome measures were efficacy (abdominal fat distribution, anthropometric parameters and blood lipid profiles) and safety (adverse events, laboratory test results and vital signs).

During 12 weeks of Yerba Mate supplementation, statistically significant decreases in body fat mass and percent body fat compared to the placebo group were noted significant. The WHR was significantly also decreased in the Yerba Mate group compared to the placebo group. No clinically significant changes in any safety parameters were observed.

The authors concluded that Yerba Mate supplementation decreased body fat mass, percent body fat and WHR. Yerba Mate was a potent anti-obesity reagent that did not produce significant adverse effects. These results suggested that Yerba Mate supplementation may be effective for treating obese individuals.

These are encouraging results, but the conclusions go way too far, for my taste. The study was tiny and does therefore not lend itself to far-reaching generalisations. What would be helpful, is a review of other evidence. As it happens, such a paper has just become available. Its authors evaluated the impact of yerba maté on obesity and obesity-related inflammation and demonstrate that yerba maté suppresses adipocyte differentiation as well as triglyceride accumulation and reduces inflammation. Animal studies show that yerba maté modulates signaling pathways that regulate adipogenesis, antioxidant, anti-inflammatory and insulin signaling responses.

The review authors concluded that the use of yerba maté might be useful against obesity, improving the lipid parameters in humans and animal models. In addition, yerba maté modulates the expression of genes that are changed in the obese state and restores them to more normal levels of expression. In doing so, it addresses several of the abnormal and disease-causing factors associated with obesity. Protective and ameliorative effects on insulin resistance were also observed… it seems that yerba maté beverages and supplements might be helpful in the battle against obesity.

I am still not fully convinced that this dietary supplement is the solution to the current obesity epidemic. But the evidence is encouraging – more so than for most of the many other ‘natural’ slimming aids that are presently being promoted for this condition by gurus like Dr Oz.

What we needed now is not the ill-informed, self-interested voice of charlatans; what we need is well-designed research to define efficacy, effect size and risks.

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