supplements
The Carl and Veronica Carstens Foundation is providing EUR 600,000 for 2 research projects to identify effective so-called alternative medicine (SCAM) therapies for post-COVID syndrome. The one that I will focus on here is headed by a member of my ALTERNATIVE MEDICINE HALL OF FAME, Prof Dr Gustav Dobos, Essen University Hospital.
The project is entitled: Multimodal group programme based on Kneipp
It is being described as follows:
A team of researchers led by Prof Gustav Dobos and Dr Heidemarie Haller, in cooperation with Prof Mark Stettner and Prof Christoph Kleinschnitz from the Department of Neurology at Essen University Hospital, will conduct a single-blind, randomised controlled study with two arms. A total of 86 subjects with post-COVID syndrome will be included and randomly divided into two groups.
Group 1 will undergo a 10-week group programme based on the Kneipp therapy pillars. The subjects will meet once a week, so there will be two sessions for each Kneipp pillar. These will include an educational and a practical part with the aim of developing their own strategies for coping with illness and actively integrating these into their everyday lives.
- Plant-based wholefoods and medicinal teas will be used to strengthen convalescence.
- Mindful exercise sessions in nature should help to utilise the effect of daylight and vitamin D on the immune system.
- In the area of hydrotherapy, water treatments, dry brushing, wraps and compresses will be used.
- There will be medical advice on herbal medicine options for individual symptoms such as sleep disorders, digestive problems, pain, coughs, anxiety or circles of thought.
The aim is to facilitate a balance of lifestyle in professional, family and social areas by means of organisational therapy. Relaxation and meditation techniques, for example, are taught for this purpose. In order to consolidate what they have learnt, participants in group 1 also receive a self-help book and homework.
Group 2 is the control group and is initially placed on a waiting list. In both groups, standard therapy is (additionally) permitted at any time. A symptom and therapy diary will also be kept in both groups.
The primary aim is to test whether the group programme as an add-on to standard therapy can improve self-help skills and alleviate the burden of post-COVID symptoms more than standard therapy alone. Parameters of quality of life, cardiovascular and pulmonary performance and the so-called flourishing of the test subjects as motivated personalities are also recorded at 4 points in time before, during and up to 16 weeks after the end of the intervention phase.
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And why do I call this study ‘nonsensical’?
Mainly because the results of the trial are known before even the first patient was recruited!
How come?
Because, as we have previously discussed here at nauseam, A+B will always be more than B alone. Kneipp therapy plus usual care will have more effects than usual care alone, even if Kneipp therapy generates nothing but placebo effects. This is particularly true, of course, for subjective outcome measures.
So, the conclusion of the trial, once it is published, will state something like this:
Our study has shown that the multimodal group programme based on Kneipp is effective in reducing the symptoms of post-COVID.
And what is wrong with that?
Plenty!
It means that money and effort will be wasted, that science will be undermined, and that we will be potentially misled about the effectiveness of mixed bag of treatments called ‘Kneipp therapy’. Perhaps it is effective (beyond placebo), but perhaps it’s not – this study will not tell us either way.
Cancer often causes reduced resilience, quality of life (QoL) and poorer overall well-being. To mitigate these problems, so-called alternative medicine (SCAM) is often advocated for patients with cancer. This study aimed to evaluate the long-term effects of an interdisciplinary integrative oncology group-based program (IO-GP) on the resilience and use of SCAM in patients with cancer.
This was a prospective, observational, single-center study. Resilience (RS-13), SCAM usage (I-CAM-G), QoL (SF-12) and health-related lifestyle factor (nutrition, smoking, alcohol consumption and physical exercise) data were collected for 70 patients who participated in a 10-week IO-GP between January 2019 and June 2022 due to cancer. The IO-GP was offered at the setting of a university hospital and was open to adult patients with cancer. It contained elements from mind-body medicine and positive psychology, as well as recommendations on healthy diet, exercise and SCAM approaches. Patients who completed the IO-GP at least 12months prior (1-4.5years ago) were included in this study. Statistical analysis included descriptive analysis and parametric and nonparametric tests to identify significant differences (P<.05).
Resilience increased significantly ≥12months after participation in the IO-GP (n=44, P=.006, F=8.274) and had a medium effect size (r=.410). The time since the IO-GP was completed (“12-24months,” “24-36months,” and “>36months”) showed no statistically significant interaction with changes in resilience (P=.226, F=1.544). The most frequently used SCAM modalities within the past 12months were vitamins/minerals (85.7%), relaxation techniques (54.3%), herbs and plant medicine (41.1%), yoga (41.4%) and meditation (41.4%). The IO-GP was the most common source informing study participants about relaxation techniques (n=24, 64.9%), meditation (n=21, 72.4%) and taking vitamin D (n=16, 40.0%). Significantly greater levels of resilience were found in those practicing meditation (P=.010, d=−.642) or visualization (P=.003, d=−.805) compared to non-practitioners.
The authors concluded that IO-GPs have the potential to empower patients with cancer to continue using SCAM practices—especially from mind-body medicine—even 1 to 4.5 years after completing the program. Additionally, resilience levels increased. These findings provide notable insight into the long-term effects of integrative oncology interventions on resilience and the use of SCAM, especially in patients with breast cancer.
Really?
“Long-term effects of integrative oncology interventions”?
I am sorry, but I see no effects here at all. All I do see are correlations.
For all we know, the outcomes might have even been better if no SCAMs had been offered.
For all we know, the main reason for the observed changes is simply the passage of time.
CORRELATION IS NOT CAUSATION!
There is, of course, little wrong with conductiong studies of this nature – even though they are never really informative, in my view – but there is much wrong when the bias of the authors kicks in and they imply (in the title and throughout the text of their paper) that their interventions were the cause of the observed outcome. This does not provide “notable insight”, it merely misleads some people who are less able to think critically.
WISHFUL THINKING IS NOT SCIENCE!
Sadly, this simple lesson seems to be ever so hard to comprehend by SCAM researchers. One does not need to look far to find hundreds of SCAM studies that are plagued by the same or similar biases. As a result, SCAM research is gradually becoming the laughing stock of real scientists.
It has been reported that the American Board of Internal Medicine (ABIM) has revoked the certifications for two prominent US physicians. They are both (in)famous for leading an organization that promotes ivermectin as a treatment for COVID-19.
- Pierre Kory, MD, is no longer certified in critical care medicine, pulmonary disease, and internal medicine, according to the ABIM website.
- Paul Ellis Marik, MD, is no longer certified in critical care medicine or internal medicine.
Marik is the chief scientific officer and Kory is president emeritus of the Front Line COVID-19 Critical Care (FLCCC) Alliance, a group they founded in March 2020. The FLCCC gained notoriety during the height of the pandemic for advocating ivermectin as a treatment for COVID. It now espouses regimens of supplements to treat “vaccine injury” and also offers treatments for Lyme disease.
Kory and Marik stated, “we believe this decision represents a dangerous shift away from the foundation principles of medical discourse and scientific debate that have historically been the bedrock of medical education associations.” The FLCCC said in the statement that it, along with Kory and Marik, are “evaluating options to challenge these decisions.” Kory and Marik said they were notified in May 2022 that they were facing a potential ABIM disciplinary action. An ABIM committee recommended the revocation in July 2023, saying the two men were spreading “false or inaccurate medical information,” according to FLCCC. Kory and Marik lost an appeal. In a 2023 statement, Kory and Marik called the ABIM action an “attack on freedom of speech.”
To this, Wikipedia adds that, Marik is the inventor of the “Marik protocol”, also known as the “HAT” protocol, which proposes intravenous administration of hydrocortisone, ascorbic acid, and thiamine as a treatment for preventing sepsis for people in intensive care. Marik’s own initial research, published with four other authors in Chest in 2017, showed a dramatic evidence of benefit. The single-center, observational study compared outcomes of 47 consecutive sepsis patients who were treated with HAT during a 7-month period to 47 consecutive control patients during the preceding 7-month period. The study reported 19 deaths in the control group and 4 deaths in the treatment group. Marik’s findings received attention on social media and National Public Radio, but drew criticism from the wider medical community for being science by press conference. ER doctor Jeremy Faust was one of a number of skeptics of the results, noting the low reliability of the study design and potential for bias. The controversy prompted other groups to conduct studies of the HAT protocol. A systematic review of six randomized and five non-randomized controlled trials in 2021 eventually concluded that the claimed benefits of the protocol could not be confirmed.
In November 2022, Pierre Kory and the FLCCC began marketing a cocktail of supplements and drugs (e.g. ivermectin and nitazoxanide) for other viruses, influenza and Respiratory syncytial virus (RSV). Like the FLCCC-advocated COVID treatments, the recommendations lacked credible supporting scientific evidence. The cocktail could cost over $500.
Wikipedia also mentions that, in March 2024, Kory and Marik published an op-ed in The Hill claiming that long COVID was caused by COVID-19 vaccination instead of COVID-19 infection. The op-ed was republished by the German disinformation outlet Disclose.tv. The fact-checking website Health Feedback found that the op-ed relied on anecdotes that did not provide evidence to support the claim.
This study evaluated efficacy of krill oil supplementation, compared with placebo, on knee pain in people with knee osteoarthritis who have significant knee pain and effusion-synovitis. It was designed as a multicenter, randomized, double-blind, placebo-controlled clinical trial that took place in 5 Australian cities. Participants with clinical knee osteoarthritis, significant knee pain, and effusion-synovitis on magnetic resonance imaging were enrolled from December 2016 to June 2019; final follow-up occurred on February 7, 2020.
The patients received
- 2 g/d of krill oil (n = 130)
- or matching placebo (n = 132) for 24 weeks.
The primary outcome was change in knee pain as assessed by visual analog scale (range, 0-100; 0 indicating least pain; minimum clinically important improvement = 15) over 24 weeks.
Of 262 participants randomized (mean age, 61.6 [SD, 9.6] years; 53% women), 222 (85%) completed the trial. Krill oil did not improve knee pain compared with placebo (mean change in VAS score, -19.9 [krill oil] vs -20.2 [placebo]; between-group mean difference, -0.3; 95% CI, -6.9 to 6.4) over 24 weeks. One or more adverse events was reported by 51% in the krill oil group (67/130) and by 54% in the placebo group (71/132). The most common adverse events were musculoskeletal and connective tissue disorders, which occurred 32 times in the krill oil group and 42 times in the placebo group, including knee pain (n = 10 with krill oil; n = 9 with placebo), lower extremity pain (n = 1 with krill oil; n = 5 with placebo), and hip pain (n = 3 with krill oil; n = 2 with placebo).
The authors concluded that, among people with knee osteoarthritis who have significant knee pain and effusion-synovitis on magnetic resonance imaging, 2 g/d of daily krill oil supplementation did not improve knee pain over 24 weeks compared with placebo. These findings do not support krill oil for treating knee pain in this population.
This is a rigorous and well-presented study. Apart from the ineffectiveness of krill, it confirms two issues very clearly:
- Placebo effects plus regression to the mean can lead to symptomatic improvements.
- Adverse effects occur even with placebo therapy.
Krill is a small crustacean consumed by whales, penguins and other sea creatures. It is a source of omega 3 fatty acids. The alleged benefits of krill supplements include anti-inflammatory effects. So, it could theoretically help reducing the inflammation that is part of knee osteoarthritis.
A review including five trials with 700 patients using krill oil for knee pain was recently published. Results showed no significant difference between krill oil and placebo for knee pain, knee stiffness, and lipid profiles. However, krill oil demonstrated a significant small effect in improving knee physical function. Trial sequential analysis provided certainty that krill oil enhances knee physical function compared to placebo and indicated no improvement in knee pain, but the findings for knee stiffness need to be confirmed by further research. The authors concluded that krill oil supplementation did not significantly improve knee pain, stiffness, or lipid profile, although it may help knee physical function. Based on these findings, krill oil supplementation is not yet justified for knee pain.
The two papers should settle the issue: KRILL IS NOT EFFECTIVE FOR KNEE OSTEOARTHRITIS. Will this stop the many manufacturers of krill supplements selling their products to gullible consumers? I would not hold my breath.
When I still worked as a clinician, I have looked after athletes long enough to know that they go for everything that promises to improve their performance. It is thus hardly surprising that Olympians would try all sorts of so-called alternative medicine (SCAM) regardless of whether the therapy is supported by evidence or not. Skeptics are tempted to dismiss all of SCAM for improving fitness. But is that fair? Is it true that no evidence evists for any of them?
The short answer to this question is NO.
Here I have looked at some of the possibilities and show you some of the Medline-listed papers that seem to support SCAM as a means of improving fitness:
Acupuncture
Ashwagandha
Balneology
Cupping
Ginkgo biloba
Ice
Kinesiology tape
Massage guns
Percussion massage
Sports massage
Tai massage
Vibrational massage
Yoga
Please do not mistake this for anything resembling a systematic review of the evidence; it is merely a list to give you a flavour of what is out there. And please don’t assume that the list is complete; I am sure that there is much more.
Looking at the articles that I found, one could get the impression that there is plenty of good evidence to support SCAM for improving fitness. This, however, would be wrong. The evidence for almost every of the above listed therapies is flimsy to say the least. But – as I stated already at the beginning – in my experience, this will not stop athletes to use them.
The BBC has repeatedly misled the public on matters related to so-called alternative medicine (SCAM). Examples include:
- Dangerous BS from the BBC
- The BBC, Michael Mosely, air ionization, depression, and an appalling lack of critical thinking.
Recently the BBC published an article about Ashwagandha. Here it is in its untouched beauty:
Ashwagandha is a herb (Withania somnifera) in the nightshade family, which also includes tomatoes and chilli peppers. It has been used in traditional Indian medicine (Ayurveda) for thousands of years to make preparations for treating various ailments, from infectious diseases, like tuberculosis, to pain and inflammation, baldness and hiccups. In classic Ayurvedic texts, it’s also described as a ‘mental strength promoter’ (or ‘Balya’).
While lots of research has been done on ashwagandha, studies for specific conditions can be sparser. Perhaps the most recent assessment of its use for stress and anxiety comes from a 2022 review of studies by the Cochrane Collaboration, which is internationally recognised for its high-standard medical reviews. Although the Cochrane researchers were only able to find 12 studies on the subject, which together tested the herb on just 1,002 participants, their findings did suggest that ashwagandha can lower stress and anxiety. The researchers rated the ‘certainty’ of the evidence as ‘low’ and called for more detailed studies, though.
The benefits of ashwagandha are thought to be related to natural steroids called withanolides, but this group includes hundreds of compounds, with tens having been isolated from ashwagandha so far. As with any herbal remedy, the combination of compounds and the exact concoction you get depends on how and where the plant is grown, and how it’s prepared. This means that not all supplements based on the same plant are equal.
Remember, too, that herbal doesn’t mean risk-free. For some people, ashwagandha causes drowsiness and more serious side effects aren’t unknown. It’s best to treat it like a drug and not ‘just’ a herb.
The review cited in the article is this one:
Clinical trial studies revealed conflicting results on the effect of Ashwagandha extract on anxiety and stress. Therefore, we aimed to evaluate the effect of Ashwagandha supplementation on anxiety as well as stress. A systematic search was performed in PubMed/Medline, Scopus, and Google Scholar from inception until December 2021. We included randomized clinical trials (RCTs) that investigate the effect of Ashwagandha extract on anxiety and stress. The overall effect size was pooled by random-effects model and the standardized mean difference (SMD) and 95% confidence interval (CIs) for outcomes were applied. Overall, 12 eligible papers with a total sample size of 1,002 participants and age range between 25 and 48 years were included in the current systematic review and meta-analysis. We found that Ashwagandha supplementation significantly reduced anxiety (SMD: −1.55, 95% CI: −2.37, −0.74; p = .005; I2 = 93.8%) and stress level (SMD: −1.75; 95% CI: −2.29, −1.22; p = .005; I2 = 83.1%) compared to the placebo. Additionally, the non-linear dose–response analysis indicated a favorable effect of Ashwagandha supplementation on anxiety until 12,000 mg/d and stress at dose of 300–600 mg/d. Finally, we identified that the certainty of the evidence was low for both outcomes. The current systematic review and dose–response meta-analysis of RCTs revealed a beneficial effect in both stress and anxiety following Ashwagandha supplementation. However, further high-quality studies are needed to firmly establish the clinical efficacy of the plant.
This review is NOT a Cochrane Review; what is more (and more important), it seem rather uncritical.
The BBC article seems to down-play the safety issue related to Ashwagandha. As we have discussed on this blog, Ashwagandha is far from harmless. In fact, Ashwagandha has been shown to be a herb with a high risk of hepatobiliary toxicity as well as heart problems.
So, why does the BBC misinform the public?
Search me.
Whooping cough is on the rise in many parts of the world; and it’s far from harmless. It has been reported that 9 infants died from whooping cough in England between November last year and the end of May 2024. Altogether a total of 7599 cases of whooping cough have been confirmed in England this year, with cases continuing to rise from 555 in January to 920 in February.
In France too, cases of whooping cough are rising among all ages, the French health authority has warned, saying vulnerable groups should check their vaccinations are up to date. Cases of the illness – called coqueluche in French – have been rising since the start of 2024, states Santé publique France (SPF). It has called for people to be vigilant.
I have recently argued that this might be not least due to the irresponsible advice of homeopaths. But homeopaths are by no means alone in this.
According to advice from MOTHER EARTH LIVING several natural home remedies help alleviate whooping cough symptoms (as well as cold and flu symptoms) and clear the pertussis infection. A teaspoon of fresh garlic juice taken 2 to 3 times a day is a potent, effective treatment.
A pinch of the Indian curry spice turmeric, taken at least twice a day, relieves whooping cough symptoms and helps clear the bacterial infection. (Odorless garlic and turmeric capsules may not be as effective as fresh ingredients, whose odors can be minimized by chewing fresh mint).
Ginger has antiviral, antibacterial, antiparasitic, antifungal, anti-inflammatory and expectorant properties. It boosts the immune system, warms and induces sweating (which helps push fever and toxins out of the body), and calms coughs and sore throats quickly. It also stimulates appetite, which is important to sick individuals weakened by infection.
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There are numerous further SCAM-sites that give advice to use this or that SCAM. The recommended treatments all have one thing in common: they do not work to prevent or treat whooping cough.
If one member of your family has caught the infection, please do me a favour:
avoid SCAM and see a real doctor.
A new market report predicts that the worldwide market for so-called alternative medicine (SCAM) will grow from $100 billion in 2022 to $438 billion by 2032.
According to the report, the SCAM market is expected to see innovation and expansion through mergers, acquisitions, and partnerships among large companies. Companies that are capitalizing on these trends include health supplement companies, companies that specialize in Ayurvedic health, those that offer TCM solutions, and those that offer more general holistic solutions to health. Major supplement brands include Herb Pharm LLC, Gaia Herbs, NOW Foods, Life Extension, Pure Encapsulations, Douglas Laboratories, Nordic Naturals, Nordic Nutraceuticals, Quality of Life Labs, Nature’s Bounty Co., Valensa International, Herbo Nutra, and Emerson Ecologics.
Other major players mentioned in the report are:
- AYUSH Ayurvedic Pte Ltd, Dabur India Ltd., Himalaya Global Holdings Ltd., Banyan Botanicals, and Arya Vaidya Pharmacy offer Ayurvedic health and wellness products while aiming to advance the science behind Ayurveda.
- Sheng Chang Pharmaceutical Company produces traditional Chinese medicines and herbal products that is one of the largest TCM pharma companies.
- All and One Medical provides healthcare solutions that combine conventional medicine with complementary and alternative therapies to promote overall wellness and preventive care.
- The John Schumacher Unity Woods Yoga Center is another that focuses on enhancing physical and mental well-being through the practice of Iyengar Yoga and offers classes and workshops.
- New Life Chiropractic aims to improve overall health and well-being by providing comprehensive chiropractic care that focuses on spinal health and preventive wellness.
- The Chicago Body Works offers a range of therapies and treatments designed to enhance physical and mental well-being, including massage and bodywork services.
- Weleda AG aims to connect people with nature by producing natural organic products that support health, beauty, and overall wellness while practicing sustainability and social responsibility.
- Quantum-Touch Inc. teaches energy healing techniques that promote physical, emotional, and spiritual health.
- Spectrum Chemical Manufacturing Corporation focuses on delivering high-quality chemicals and laboratory supplies to support scientific research and innovation across various industries, including health and wellness.
I must admit, I do like these market reports. They never fail to amuse me – for two main reasons:
- They are as reliable as reading tea leafs.
- The only reliable info they do provide is that the SCAM proponents’ often-voiced argument, “we are very different from BIG PHARMA” is pure nonsense.
It has been announced that advertisements for three supplement brands claiming to treat a range of medical conditions, including autism and ADHD, have been banned in the UK.
A paid-for Facebook advert for Aspire Nutrition in April said: “The secret weapon parents of ASD kids swear by”, while text in the form of a review attributed to “Tara K. Verified Buyer”, read: “This has helped my five-year-old with level two autism so much. “Within the first week his meltdowns decreased by 80%. He is communicating so much better… he is starting to show kindness and empathy to his little sister.” Further text read: “As parents of children with autism, we all share the same dream: to see our children thrive in school.”
Another paid-for Facebook ad in January, for Drop Supplements, stated: “For people with stress, anxiety, brain fog, ADHD … Happy Mind Drops – your new secret adaptogen against stress! Prepare yourself to unleash your true potential and banish your mental barriers.”
A third paid-for Facebook ad for Spectrum Awakening stated: “My five-year-old son Scout is diagnosed with receptive expressive language disorder and sensory disorder. Until I found Spectrum Awakening he could barely put a sentence together with very limited speech and words and lots of jargon.” It went on: “The first supplement we tried was Power and Focus and within the first three days he started using way more words. Within a week he was speaking sentences. I’m absolutely amazed that I can’t wait to order more.”
The Advertising Standards Authority (ASA) found that the claims that each supplement, or substances in them, could help to prevent, treat or cure autism breached regulations after investigations.
Aspire Nutrition said they had stopped sending adverts to UK residents who visited their website and had withdrawn the ad entirely for all audiences after being informed of the complaint. Drop Supplements said their adverts featuring Happy Mind made no direct or implied statements about curing, treating or preventing ailments or diseases. However, the ASA said the advert’s claims would be understood by most consumers as implied claims that the product could prevent, treat or cure human disease. Spectrum Awakening did not respond to the ASA’s inquiries.
The ASA told each firm to ensure their future advertising did not claim that food – in these cases in the form of a supplement – could prevent, treat or cure human disease.
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Such work by the ASA is most laudable, in my view. Misleading advertising is endangering the health of consumers thousands of times every day. However, the firms affected by the ASA reprimands are probably not all that worried. In fact, I imagine that they are laughing their heads off:
- The chances of getting caught for misleading advertising are truly minimal.
- If they are unlucky and do get caught the punishment is negligible.
- There is little to stop them re-offending.
It is time that the ASA (and the equivalent organisations in other countries) get more power, more support and more money to effectively go after offenders in such a way that others think twice before breaking advertising rules.
People living with HIV (PLWH) are common users of so-called alternative medicine (SCAM). The main objective of this study was to study the frequency and patterns of SCAM natural products use in a large cohort of PLWH and to identify potential drug–drug interactions (DDIs) and the impact on their antiretroviral treatment (ART) adherence and efficacy.
This was a cross-sectional multicenter survey including 420 PLWH from different Spanish hospitals. Participants completed a face-to-face questionnaire on SCAM consumption and different sociodemographic and clinical data were collected. DDIs between SCAM and ART were identified and classified according to the Liverpool University Database and patient factors related to SCAM consumption were assessed.
In total, 420 participants were included (82.6% male, mean age 47 years); 209 patients (49.8%) were taking at least one SCAM. The most consumed SCAM were:
- green, black and red tea (n=146, 25.4%),
- ginger (n=26, 4.5%),
- fish oil (n=25, 4.4%),
- cannabis (n=24, 4.2%).
An ART based on integrase inhibitors was the only factor independently associated with SCAM consumption (OR 1.54, 95% CI 1.04 to 2.26). 50 potential SCAM–ART interactions in 43 (20.6%) patients taking SCAM were identified, being clinically significant in 80% of the cases. SCAM products most frequently involved with a potential significant DDI were supplements containing divalent cations (n=11) and garlic (n=7). No differences in ART efficacy and adherence were observed between patients with and without SCAM consumption.
The authors concluded that almost 50% of patients were taking at least one SCAM product and its use was associated with an integrase inhibitor based ART. One out of every six patients was at risk of presenting with an interaction between a SCAM and their ART, confirming the need to review continuously the use of SCAM as part of the medication review process.
So, the authors found that half of all PLWHs use some form of SCAM (whether I would classify tea as a SCAM is a different question). They also point out that this might put many PLWHs at risk. What I don’t understand is why they do not take the next logical step and ask what the benefits of the SCAMs for PLWHs are.
Allow me to answer this question: they are zero or very close to zero!
And this means that SCAMs generate a risk for PLWHs without creating any meaningful benefit. In other words the risk-benefit balance fails to be positive.
I think that this is an important point which needs to be stressed clearly in the conclusions. Therefore, I suggest to re-formulate them as follows:
Almost 50% of patients were taking at least one SCAM product. One out of every six patients was at risk of presenting with an interaction between a SCAM and their ART. The SCAMs used convey no appreciatable benefit. Therefore, SCAM use fails to generate more good than harm. It follows that responsible healthcare professionals should discurage SCAM use.
