Seth's Blog

In the 1960s, Edmund Wilson reviewed Vladimir Nabokov’s translation of Eugene Onegin. Wilson barely knew Russian and his review was a travesty. Everything was wrong. Nabokov wondered if it had been written that way to make sense when reflected in a mirror.

I thought of this when I read recent remarks by “celiac experts” in the New York Times. The article, about gluten sensitivity, includes an example of a woman who tried a gluten-free diet:

Kristen Golden Testa could be one of the gluten-sensitive. Although she does not have celiac, she adopted a gluten-free diet last year. She says she has lost weight and her allergies have gone away. “It’s just so marked,” said Ms. Golden Testa, who is health program director in California for the Children’s Partnership, a national nonprofit advocacy group. She did not consult a doctor before making the change, and she also does not know [= is unsure] whether avoiding gluten has helped at all. “This is my speculation,” she said. She also gave up sugar at the same time and made an effort to eat more vegetables and nuts.

Fine. The article goes on to quote several “celiac experts” (all medical doctors) who say deeply bizarre things.

“[A gluten-free diet] is not a healthier diet for those who don’t need it,” Dr. Guandalini [medical director of the University of Chicago’s Celiac Disease Center] said. These people “are following a fad, essentially.” He added, “And that’s my biased opinion.”

Where Testa provides a concrete example of health improvement and refrains from making too much of it, Dr. Guandalini does the opposite (provides no examples, makes extreme claims).

Later, the article says this:

Celiac experts urge people to not do what Ms. Golden Testa did — self-diagnose. Should they actually have celiac, tests to diagnose it become unreliable if one is not eating gluten. They also recommend visiting a doctor before starting on a gluten-free diet.

As someone put it in an email to me, “Don’t follow the example of the person who improved her health without expensive, invasive, inconclusive testing. If you think gluten may be a problem in your diet, you should keep eating it and pay someone to test your blood for unreliable markers and scope your gut for evidence of damage. It’s a much better idea than tracking your symptoms and trying a month without gluten, a month back on, then another month without to see if your health improves.”

Are the celiac experts trying to send a message to Edmund Wilson, who died many years ago?

A link from dearieme led me to a recent study that found low-carb high-protein diets — presumably used to lose weight — associated with heart disease. The heart disease increase was substantial — as much as 60% in those with the most extreme diets. (A critic of the study, Dr. Yoni Freedhoff, called the increase in risk “incredibly small“.) Four other studies of the same question have produced results consistent with this association. No study — at least, no study mentioned in the report — has produced results in the opposite direction (low-carb high-protein diets associated with a decrease in heart disease).

I find this interesting for several reasons.

1. I learned about the study from a Guardian article titled “What doctors won’t do”. A doctor named Tom Smith said, “I would never go on a low-carbohydrate, high-protein diet like Atkins, Dukan or Cambridge.” Fine. He didn’t say what he would do to lose weight. The psychological costs of obesity are huge. The popularity of low-carb diets probably has a lot — or everything — to do with the failure of researchers to find something better. I have never seen people who criticize low-carb diets appear aware of this. I disagree with a lot of Good Calories Bad Calories but I completely agree with its criticism of researchers. (more…)

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

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

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

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

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

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

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

Two thought-provoking paragraphs from Matt Ridley:

From ancient Egypt to modern North Korea, always and everywhere, economic planning and control have caused stagnation; from ancient Phoenicia to modern Vietnam, economic liberation has caused prosperity. In the 1960s, Sir John Cowperthwaite, the financial secretary of Hong Kong, refused all instruction from his LSE-schooled masters in London to plan, regulate and manage the economy of his poor and refugee-overwhelmed island. Set merchants free to do what merchants can, was his philosophy. Today Hong Kong has higher per capita income than Britain.

In July 1948 Ludwig Erhard, director of West Germany’s economic council, abolished food rationing and ended all price controls on his own initiative. General Lucius Clay, military governor of the US zone, called him and said: “My advisers tell me what you have done is a terrible mistake. What do you say to that?” Erhard replied: “Herr General, pay no attention to them! My advisers tell me the same thing.” The German economic miracle was born that day; Britain kept rationing for six more years.

This is standard libertarianism. I like the stories but I don’t agree with the interpretation. I don’t think it is “economic planning and control” that causes stagnation in these examples.  I believe  it is expertise — more precisely, rent-seeking experts who know too little and extract too much rent. There are libertarian experts, too. They too are capable of doing immense damage (e.g., Alan Greenspan), contradicting Ridley’s view that “economic liberation” always causes  prosperity. In both of Ridley’s examples, the experts give advice that empowers the experts. In the first example, Cowperthwaite is told by “LSE-schooled” economists to “plan, regulate and manage the economy.” All that planning, regulation and management require expertise, in particular expertise similar to that of the experts who advised it. Which you cannot buy — you have to rent it. You must pay the experts year after year after year to plan, regulate, and manage. Because the advice must empower the experts, there is  a strong bias away from truth. That is the fundamental problem. (more…)

New York magazine commenters are usually smart and well-informed. Which is why this comment, on an article about “the forgotten victim”, Nancy Lanza, the shooter’s mother, stands out:

They say money cannot buy happiness [Adam's father is apparently rich], but when dealing with someone with a mental illness, it can go a long way toward paying to fix unhappiness — it can pay for good doctors, proper medication [emphasis added], care-givers/guardians, all the tools required to secure a property and keep the “patient” safe, AND giving the mentally ill person his ideal living situation, limiting the snits and tantrums that can lead to real anger, which, in turn can lead to acting out.

No doubt this particular commenter is smart and well-informed. Which makes the fact that he or she is perfectly sure that “proper medication” exists so scary, at least if this person had any control over me or anyone who mattered to me. It reminds me of people who think that if you’re fat all you have to do is eat less.

This fascinating blog post by Josh Mittledorf points out that antioxidants, once believed to reduce aging by reducing oxidative damage, have turned out to have the opposite effect. By reducing a hormetic effect, they make things worse. I’m a friend of Bruce Ames, one of main proponents of the free radical theory of aging. I’ve heard him talk about it a dozen times. The turning point — the beginning of the realization that this might be wrong — was this 1994 study, which found that beta-carotene, a potent antioxidant, increased mortality. Bruce did not have a good explanation for the counter-theoretical result. However, Mittledorf doesn’t mention an important fact which doesn’t fit his picture. Selenium, a potent antioxidant, also powerfully reduces cancer. Don’t stop taking selenium.

I also like this theoretical paper by Mittledorf  about why aging evolved (turning off certain genes reduces aging) and how its evolution — not easily explained by conventional evolutionary ideas — is part of a range of phenomena that the conventional ideas cannot explain. One reason, maybe the main reason, that aging is adaptive is very Jane Jacobsian: it makes the community more flexible. Less likely to repeat old ways of doing things.

Thanks to Ashish Mukarji.

Health experts call bacteria “good” and “bad”. Bad bacteria make us sick. Good bacteria help us digest food, and a few other things. Let me propose another view. Any bacteria (i.e., bacterial species) will make us sick if it becomes too numerous — so all bacteria are “bad”. All bacteria protect us against other bacteria — so all bacteria are “good”. The terms “good” and “bad” are misleading. It is like saying a person is inherently rich or poor. Anyone, given a lot of money, becomes rich. Anyone whose money is taken away becomes poor. Low bacterial diversity or reduction of diversity makes it more likely that one bacterial species can overwhelm its competitors, producing sickness. When this happens, to say that the species (e.g., H. pylori) that became numerous “caused” the sickness (e.g., ulcers) is to seriously misunderstand what happened and how to prevent it from happening. We are taught that our immune system protects us from infection. We should be taught that bacterial diversity does the same thing. (more…)

The San Jose Mercury News recently ran a story by Lisa Krieger about a father (Hugh Rienhoff) who found a single-amino-acid mutation that he believes causes his daughter’s growth difficulties.

Born with small, weak muscles, long feet and curled fingers, Beatrice confounded all the experts.

No one else in her family had such a syndrome. In fact, apparently no one else in the world did either.

Rienhoff — a biotech consultant trained in math, medicine and genetics at Harvard, Johns Hopkins and the Fred Hutchinson Cancer Research Center in Seattle — launched a search.

He combed the publicly available medical literature, researching diseases, while jotting down each new clue or theory. Because her ailment is so rare, he knew no big labs or advocacy groups would be interested.

He did some of his own lab work in his San Carlos home, borrowing tools or buying them used online.

A few commercial labs, like the San Diego-based biotech Illumina, offered him help for free. And a wide array of pediatricians, geneticists and neurologists volunteered their opinions.

Over time, he zeroed in on a stretch of genes that control a growth hormone responsible for muscle cell size and number. And he knew he could further target his search — saving time and money by not sequencing Bea’s entire genome, but only the exomes, which are the genes that code for proteins.

This is not a simple upbeat story. The father is a genetic researcher and doctor. I agree,  he has made considerable progress in understanding the cause of his daughter’s problem. Not addressed are two questions: 1. Why is he sure he has the right mutation? Perhaps his daughter has other mutations. I’m sure the father understands this, the journalist may not. 2. What about environmental causes? As Aaron Blaisdell’s story shows — Aaron has/had a single-gene genetic disease that vanished when he changed his diet — single-gene diseases may respond to environmental changes. Early work with bacteria emphasized this. If Rienhoff had spent equal effort in trying to find environmental changes that help, he might be further along in discovering them. An obvious place to start would be testing different diets. There is no sign he has done that. His knowledge of genetics, plus the brainwashing that doctors undergo (they are told genes are incredibly important), may have led him to waste a lot of time. Someone with less understanding of genetics may realize better than Rienhoff that knowing what genes have changed may be very little help in finding helpful environmental changes.

Thanks to Allan Jackson.

Persons with Type 2 diabetes have an increased risk of heart disease and stroke. They are usually overweight. A study of about 5000 persons with Type 2 diabetes who were overweight or worse asked if eating less and exercise — causing weight loss — would reduce the risk. of heart disease and stroke. The difficult treatment caused  a small amount of weight loss (5%), which was enough to reduce risk factors. The study ended earlier than planned because eating less and exercise didn’t help: “11 years after the study began, researchers concluded it was futile to continue — the two groups had nearly identical rates of heart attacks, strokes and cardiovascular deaths.” (more…)