Seth's Blog

• White rice associated with Type 2 diabetes.
• Whistleblower says drug company failed to report bad side effects. “She also claims that the company failed to report 28 of 100 cases of bladder cancers to the FDA, which she called a “serious discrepancy,” and that Takeda told her to change her notation that the cancers were “related” to “unrelated.” The suit says that she was fired after she complained to her supervisors about the company’s failure to report all serious adverse events.”
• Natto speed eating contest. Why do some foods (hot dogs, natto) get a speed-eating contest, but not others?
• Drinking olive oil with your nose held shut (short video).
• Is self-experimentation n=1? or is that misleading?

I recently came across a 2005 survey, done in Texas, that found people with poor sleep were far more likely to be depressed or anxious than people with better sleep. Huge risk ratios:

People with insomnia . . . were 9.82 and 17.35 times as likely to have clinically significant depression and anxiety [than persons without insomnia.]

Other studies have found similar results. For example, a 1979 survey interviewed the same people twice, one year apart. People who had insomnia both times were 40 times more likely to be newly diagnosed with major depression during the intervening year than those who did not have insomnia at either time.

A simple thing to say about the sleep/mood correlation is that it supports my theory of depression, which says depression is often due to malfunction of two circadian oscillators (one controlled by light, the other by faces). If they are working properly (in sync, with large amplitude) you sleep well and are in a good mood when you are awake. If they are not working properly (e.g., not in sync) then you do not sleep well and are in a bad mood at least part of the time while you are awake. What is called depression (e.g., not wanting to do anything) is actually a good thing in the middle of the night. Not wanting to do anything — being still — is necessary to fall asleep.

A sad and more complicated thing about this correlation is that it is ignored. It is not explained by any theory of depression popular among psychotherapists, such as cognitive-behavioral therapy, not to mention a dozen other explanations of depression (psychoanalytic, etc.) that psychotherapists favor. Nor is it explained by any pharmacological theory of depression. In other words, if you seek treatment for depression within our healthcare system the treatment you will receive will derive from a theory that cannot explain this result. Yet the correlation is so strong it must be telling us something important.

You can read endlessly about the high cost of health care. What if the high cost is not the core problem? What if it is only a symptom of something less obvious? What if health care costs a lot because we have a poor understanding of health and disease (as the failure of popular theories of depression to explain the sleep/mood correlation suggests)? What if we have a poor understanding of health and disease because health research is too concerned with allowing healthcare providers to make money?

A few weeks ago I blogged about the lame response of the American Medical Association to HealthTap, a website that solicits doctors’ answers to medical questions. Their criticism was so weak it amounted to praise.

More recently, the AMA was asked about its position on doctor rating websites. Here’s what happened:

Robert Mills, a spokesman, sent me a statement that he said was from the A.M.A.’s president, Dr. Peter W. Carmel, that read, in part, “Anonymous online opinions of physicians should be taken with grain of salt and should not be a patient’s sole source of information when looking for a new physician.” This, however, is almost exactly the same statement it provided to its own publication, American Medical News, in 2008, when it was attributed to Dr. Nancy H. Nielsen, the president-elect of the A.M.A. at the time.

Such plagiarism is more consistent with what Jane Jacobs in Systems of Survival called guardian values (where honesty is unimportant) than commercial values (where honesty is very important). When you grasp that doctors follow guardian values rather than commercial ones their behavior becomes far more predictable — and plainly in need of control by outsiders. That doctors are allowed to charge for their services resembles allowing policemen to write as many parking tickets as they like and pocket the fines.

Thanks to Bryan Castañeda.

• The high value of free food. “About 1 in 4 doctors take cash directly from drug companies or medical device makers and 2 out of 3 take free food  . . . Those who [do so] are more willing to prescribe drugs in unapproved or potentially risky ways.”
• Beware the North Carolina Board of Dieticians.
• Tonsils make T-cells. One more reason cutting off part of your immune system (your tonsils) is a terrible idea.
• Long-term Shangri-La Diet success. “I’ve been doing the Shangri-La “Diet” for over 5 years now (see here, here, and here). My weight went down right away, and it’s stayed down.”

Thanks to Anne Weiss.

Many people think that personal genomics will change medicine. Doctors will choose treatments based on your genome, learning your genome will tell you what diseases you are at high risk of so you can take precautions, and so on. One person who believes this is Eric Topol. In his new book, The Creative Destruction of Medicine, he writes:

The biggest leap came in the first decade of the twenty-first century. The six billion bases of the human genome were sequenced, and this led to the discovery of the underpinnings of over one hundred common diseases, including most cancers, heart disease, diabetes, autoimmune disorders, and neurologic conditions.

Here is the founder of a company that makes sequencers: ““I believe that the impact on the medical community of whole human genome sequencing at a cost comparable to a comprehensive blood test will be profound.”

I disagree. I have seen nothing that suggests genes make a big difference in any common disease and plenty that suggests environment makes a big difference. My self-experimentation led me to one powerful environmental factor after another, for example. Biologists have invested heavily in the study of genes for reasons that have nothing to do with practical applications, as Thorstein Veblen would be the first to point out.

In 1999, New Yorker staff writer Michael Specter wrote an admiring article about a neurology professor named Kari Stefansson. Stefansson had returned to his native Iceland to take advantage of Iceland’s genetic homogeneity to find genes for common diseases. “In the past, drugs were discovered almost by chance,” Specter wrote, as if this would soon change. The wishful thinking involved is indicated by passages like this:

[Stefansson] and Gulcher selected the five per cent of Icelanders among the hundreds of thousands in their genealogical database who had lived the longest— most of them over ninety. The database allowed the two scientists to seek an answer to a simple question: Are these people who live so long related to each other more often than the average in Iceland? The answer quickly became apparent. People over ninety are much more closely related to each other than people in the general population are, and their children are more likely to live longer than the children of others. That provides strong evidence that the trait is inherited.

“Strong” evidence? The “people over ninety” observation is strong evidence that longevity is inherited only if relatives share nothing but genes. The “their children are more likely” observation is strong evidence of genetic control only if parents pass on to their children only genes. Both assumptions are highly unlikely. For example, surely an Icelandic person lives closer to his relatives than to randomly selected Icelanders.

The article quotes no one with my view (geneticists are overstating the practical value of their work), but it does say that “Stefansson set out to raise capital at a time [1996] when investors had become skeptical about the many unfulfilled promises made by companies claiming that genetic research would solve the ills of humanity.”

Will reality overtake hype? Here is an indication this is happening:

Kari [Stefansson], a neurologist, was a Harvard professor when he co-founded deCODE in 1996. Two years later, Iceland’s parliament gave deCODE access to one of the country’s unique resources—health records of the genetically homogenous population. DeCODE debuted on the NASDAQ stock exchange in 2000, and it made dramatic discoveries of genetic factors associated with cancer, heart disease and other conditions. But the company never turned a profit and filed for bankruptcy protection in 2009.

From Amalgam Myths and Facts (amalgam here means mercury-containing amalgams used by dentists):

Myth 10: Amalgam has been banned in Germany and Sweden and therefore should be banned in the United States.

Fact 10: Dental amalgam has not been banned in any country in the European Union.

From a 2009 press release:

The [Swedish] Government today decided to introduce a blanket ban on mercury. The ban means that the use of dental amalgam in fillings will cease.

In response to the Swedish ban, the American Dental Association put out a press release that said such a ban was “not necessary” in America because dentists do such a good job recycling the amalgam that doesn’t go into your mouth. Moreover, “a recent economic impact study published in the journal Public Health Reports indicates dental care costs in the U.S. would increase up to $8.2 billion in the first year alone if amalgam use was discontinued.” I don’t know what “up to” means. Perhaps it means that dental care costs would increase by a trivial amount “up to” $8.2 billion. Mercury-containing amalgam fillings are about half mercury.

Soon after I had two mercury fillings removed, I slowly became faster at arithmetic.

I recently posted about how doctors act like predators, in the sense of having what Jane Jacobs called “guardian values” (e.g., loyalty to other doctors is more important than honesty to patients). Here is an example of medical behavior that coming from an ordinary business would be shocking:

On February 21 [2012], I had my evaluation for a kidney transplant at a university-affiliated medical center about 100 miles from where I live. The way this institution operates, it takes about 8 months to get from initial referral to evaluation and there are all kinds of diagnostic tests in between (see previous blogs for more details). Once you are an approved transplant candidate and an organ becomes available, you go to the hospital and have surgery. The average stay for a kidney transplant is about 3 days and then you are discharged to a local hotel for 5-7 days. During that time, you return to the hospital every day for blood work, monitoring of the immunosuppressive medications and patient education. Also, you must have a full-time caregiver. That can be a friend, family member, stranger off the street corner, but they must be with you at all times to ensure that you are eating, taking meds, bathing, etc. Also, driving is prohibited until about six weeks post-transplant so the caregiver is also a chauffeur and attends the educational activities as a back-up in case the patient becomes incapacitated or symptoms of rejection appear.

In short, your caregiver must be able to put their own life on hold for about two weeks with as little as two hours notice. When you think about it, that’s a pretty tall order to fill. I have a caregiver, he happens to be a member of this forum. He is a dear, dear friend and always will be if only for the fact that he is willing to undertake this role with only the merest of acquaintance. He is more than willing to put himself and his home at my disposal if necessary. I won’t call him out by name, he obviously knows of whom I speak, but I truly feel as though Karma has smiled on me since our paths have crossed.

So the evaluation finally rolls around. Caregivers must be present during the evaluation. We check in at the medical center and are shown to an exam room. We are seen by a barrage of clinicians; dietician, nephrology resident, nephrology attending (the doctor in overall charge of my medical care while at the transplant unit), and the transplant surgeon. There are physical exams (kind of interesting since my caregiver knows me pretty well, but not THAT well), an EKG and a side trip to the lab. At the lab, the phlebotomist doesn’t pay any attention to my advice about using a butterfly catheter and proceeds to draw 20 (count ‘em, 20) vials of blood for type, cross match, antigen levels, etc, etc through a Vaccutainer. About halfway through, my vein collapses and she has to switch to the other arm, this time with a butterfly. After that, a chest x-ray. Back up to the 9th floor for our final meeting of the day; the social worker.

Up until this time, everything had been encouraging. I can’t say enough good things about the clinical staff, they were all wonderful, professional, warm, willing to answer questions, etc. My transplant surgeon looks like he should be on a TV medical drama, he can unzip me any time! The good vibes ended the minute we sat down with the social worker. She informed me that I would be required to have a second caregiver, a backup so to speak. WTH? People that can call a halt to their lives don’t grow on trees. Talk about hitting a brick wall. Here’s a sample of the conversation:

Social worker: What will you do if you are discharged to home and you can’t take care of yourself?
LadyDoc: Well, if I can’t take care of myself then I guess I shouldn’t be discharged, should I?
Social worker: Well, you could always go into a nursing home.
LadyDoc: Over my dead body.

And there you have it, the standoff. I have looked through every single printed word and email that I have ever gotten from this institution (and I keep very good records) and there is NOT A SINGLE WORD about having a second caregiver. The only family I have in the area is my daughter and she has two little boys under the age of five at home, so I can hardly ask her. My circle of friends is painfully small, many are disabled and not up to the challenge and the others have lives of their own.

The social worker called me a few days later to see if I had changed my mind and it suddenly began to sound like a sales pitch. She was touting all the advantages of this particular institution but I just don’t see it. I am now turning my attention to medical centers where the inpatient stay is closer to 5-7 days and then the patient is discharge directly to home, none of this stay-in-a-hotel stuff. I can’t think of too many places where germs and nastiness run more rampant than a hotel. I am so frustrated, I feel as though the last 7 months of my life have been an utter waste of time. Furthermore, the evaluation day was wasted; if we had met with her first we could have simply gotten up and walked out and said “Thank you for playing, please try again”.

In case you needed any convincing that customers for health care differ from customers for other services. (The difference: they are more desperate.) Think of this example if you are sure that government-run health care must be worse than the current system. You can learn what happened next at the link.

SAMe is a drug well known to help depression. For example, “a popular dietary supplement called SAMe may help depressed patients who don’t respond to prescription antidepressant treatment, a new study shows.” But there’s something important few people know about SAMe.

While talking to a Seattle woman about how Vitamin D3 first thing in the morning helped her with depression, she told me the following story:

When I was 47, I just wanted to be healthier. I kept gaining weight. I knew what foods are healthy. I just didn’t seem to eat them. A naturopath suggested SAMe. I tried it — Twin Labs SAMe. That was really fabulous for me. For the first time I got a glimpse of what being not depressed was like. Cravings weren’t there any more. Went from a size 24 to a size 14. Lost 70 pounds. I’m 5′ 8″. I didn’t feel deprived. I was eating plenty of food. going to yoga. Feeling really great.

Then Twin Labs discontinued it. It was made in Japan. I tried every other SAMe out there, eight different brands. None of them worked. I gave each of them a month. I tried different dosages.

I started slipping back into depression. Not being able to cope. I was sleeping more. Sugar cravings returned.

[why did Twin Labs stop making it?]

It wasn’t a good seller for them. So fucking wrong. I wrote letters to try to get them to start making it again. I did a campaign. People found pockets of what was left in the country and sent it to me. But it finally ran out.

The moral(s) of the story? 1. So much for word of mouth. You might have thought it would make the good SAMe sell well, better than the bad SAMe. Apparently not. 2. So much for the placebo effect. 3. Clinical studies (e.g., of SAMe) may higher-quality versions of what they are testing than the versions available to the rest of us. 4. So much for quality control in the supplement industry — except maybe in Japan. There can be substantial quality variation among supplements, undetected by the industry. I have to believe the companies selling the useless SAMe didn’t realize it. Surely they thought that good SAMe would be a better product for them than bad SAMe.

This resembles the Vitamin D3 story I have been telling. Tara Grant said she’d heard countless times that Vitamin D is good. She hadn’t heard once that it must be taken in the morning. I’ve heard countless times that SAMe is good. This was the first time I heard about huge quality control issues. In both cases individual self-observation uncovered a crucial truth that an industry had overlooked. They didn’t want to miss it. The Vitamin D Council didn’t want to miss the time-of-day effect. They just did.

This also resembles what I said about ultrasound machines: A lot of them are broken, unbeknownst to their operators and the people (often pregnant women) being scanned. The countless “experts” (doctors) who recommend ultrasound don’t seem to know this.

Which is why personal science (trusting data, not experts) is more valuable than experts want you to think.

First do no harm . . . As Robin Hanson has said, what does that mean? In contrast, the rule illustrated by this story, from Bryan Castañeda, who works for a Los Angeles law firm, is quite clear:

At the old firm I used to work at, I was talking to one of the senior attorneys and the topic of medical malpractice cases came up. He said he avoids them. Why, I asked. He said — I’m paraphrasing here — “Because you won’t find a doctor who will testify against another doctor in open court. They may advise you in private, ‘Oh yeah, so-and-so definitely screwed up,’ but you won’t get them to say that on the stand. They all protect each other.”

Judging by this story, if your doctor makes a mistake, the only person who will suffer consequences is you. Thank heavens the rest of us have more power than ever before.  A recent survey of doctors found that  “more than a 10th (11.3%) admitted to telling patients something that was not true.” The survey did not ask about lies of omission (when silence is misleading); unwillingness to testify that someone else made a mistake is that sort of lie. The survey also showed that doctors (at least, those who took the survey) have a self-serving interpretation of the term not true. Although only about 10% said they had said something “that was not true” — meaning something that they knew wasn’t true — “more than half had described a patient’s prognosis more optimistically than warranted.” Apparently they consider such descriptions not instances of “not true”.

In Systems of Survival, Jane Jacobs described two moral systems (lists of rules/values): The guardian syndrome and the commercial syndrome. In certain areas of life (e.g., military), the guardian syndrome prevailed; in other areas (e.g., small business), the commercial syndrome prevailed. Loyalty (e.g., “never testify against a fellow doctor”) is a guardian value — indeed, the main guardian value. In contrast, honesty is the main commercial value. Jacobs said that the two syndromes corresponded to two ways of making a living: taking and trading. Doctors do not represent themselves as predatory (= taking). But, according to Jacobs, this sort of rule (“never testify against a fellow doctor”) puts them squarely in that camp.

I asked Jim Jacobs, one of Jane Jacobs’s sons, for comment. He replied:

Exactly right. Jane experienced this herself, unfortunately. It’s really a major problem. I see the very same behavior among medical researchers too.

About ten years ago my doctor pointed to a thin white line on my foot: That’s fungus, he said. Huh. He prescribed an  antifungal medicine, previously available only by prescription, that had recently become over-the-counter (OTC). I tried several OTC remedies from my drugstore. None worked. According to the directions, they were to be applied twice per day. My doctor said the reason for the failure was that I hadn’t precisely followed the directions. This reminded me of a doctor who said that fat people know what to do about being fat (eat less) and simply fail to do it. (more…)