From The Atlantic- An article discussing placebo effects in veterinary patients

A Crucial Blind Spot in Veterinary Medicine

While the placebo effect is a well-established phenomenon in human patients, it’s an underappreciated one in veterinary medicine. And the particular way it plays out in veterinary care highlights how unconscious cognitive biases can mislead humans when we care for other species. Even when pet owners are determined to provide first-rate care for the animals they love, these blind spots can undermine their best efforts. “The stories that we tell about our pets often aren’t really reflecting what’s happening to their bodies,” says Brennen McKenzie, a veterinarian and the author of SkeptVet, a blog dedicated to evidence-based veterinary medicine.

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Dr. Marty Goldstein’s Nature’s Feast Raw Diet: A Look at the Infomercial

A client recently asked one of my colleagues for an opinion on an infomercial by Dr. Marty Goldstein for his new commercial raw cat food, Nature’s Feast. There was little new or surprising in this video, but since Dr. Goldstein has a lot of prominence in the media, cat owners may run across this video and be inclined to believe the claims made in it, so I felt it worthwhile to provide some context.

Who is Dr. Marty Goldstein?
I have written a bit about him before as a contributor to the propaganda film The Truth About Pet Cancer, which I havepreviously critiqued in detail

Dr. Goldstein is another celebrity participant, a veterinarian to the stars. He is also a strong advocate of the bait-and-switch known as “integrative medicine.” This means he will sometimes use science-based treatments, but then often gives the credit for any improvement to homeopathy, acupuncture, raw diets, herbs, and other alternative treatments he also employs.

Dr. Goldstein, much like Jean Dodds, is one of those alternative practitioners who is so nice and caring and respected (at least by celebrity clients and alternative medicine advocates) that it is considered almost taboo to point out that much of what he sells is unproven at best and, in some cases, complete nonsense. His use of homeopathy clearly demonstrates his lack of concern for a science-based approach to medicine, and most of the claims he makes about nutrition are unproven at best or clearly wrong at worst.

He justifies his claims almost entirely with personal anecdotes and beliefs, not with any objective scientific evidence. I have discussed the unreliability of anecdotes many times, as well as many of the flimsy arguments he uses in this infomercial, such as the Appeal to Nature Fallacy, so I will only address them briefly here. Dr. Goldstein is clearly convinced that his personal experience and beliefs are sufficient evidence for rejecting the conclusions of scientific research and nutrition experts, and that alone makes any claim he makes suspect.

The most egregious story he tells is about a dog named Kaiser. Dr. Goldstein convinced this dog’s owners to switch form a commercial to a homemade diet. For a couple of weeks after that, supposedly anybody who touched the dog developed a skin rash, and then the dog’s hair all fell out. Rather than seeing this as a problem or a sign of serious illness, Dr. Goldstein interpreted it as a sign the dog was “detoxing,” releasing harmful chemicals through its skin due to the diet change. Such a dangerously bizarre interpretation of potentially serious symptoms does not suggest a rational or reliable medical judgment.

As for the specific claims he makes in his infomercial, here are a few of the most important.

Grains are Bad for Cats
Grains are popular villains in alternative narratives about nutrition these days. The ratio of the three macronutrients—carbohydrates, fat, and protein— are a key element in the formulation of pet diets. None of these are inherently “good” or “bad,” and while the precise balance among them does have health implications, especially in pets with specific medical conditions, such as diabetes or kidney disease, the idea that commercial diets generally contain “too much sugar” or other carbohydrates and that this causes disease is simply not consistent with the evidence. 

Unlike humans, dogs and cats can live with little or no carbohydrate in their diet. However, they can also use this class of macronutrient perfectly well as a source of calories. Some non-digestible carbohydrates (often known as “fiber”) can have beneficial effects on the microbes that live in our pets’ guts, which can influence health, as well as on weight, stool consistency, and other aspects of health. Demonizing an entire class of nutrient is not rational or justified.

As far as the claims that dietary carbohydrates of grains lead to cancer or other disease in pets, these are pure speculation. There are only a few studies looking at diet and cancer risk in dogs and cats, and most of these rely owner recollections for data about diet, which has proven a very unreliable approach in people. There are no studies at all showing restricting dietary carbohydrates reduces the risk of developing cancer in dogs and cats.

There are lab animal studies and epidemiologic research in humans which suggest possible relationships between carbohydrates in the diet and cancer. There are interesting features of the metabolism of cancer cells that suggest diet might have some influence on cancer progression and response to treatment. But there is no real-world, clinical trial evidence that supports the claim that dietary carbohydrates cause cancer in pets or that lower carbs will prevent or help treat cancer. 

Carbohydrates are often seen as particularly dangerous to cats, who are truly obligate carnivores and so would naturally eat a high-fat/high-protein diet with few carbohydrates or grains in it, other than those found in the digestive system of herbivorous prey animals. However, research has demonstrated that cats can make use of carbohydrates in food as an energy source, and that these are not a significant risk factor for diabetes or other diseases often blamed on too much carbohydrate in commercial cat food. 

Perhaps the pet food ingredients most reviled in criticism of commercial pet foods are corn and wheat. The obsession in popular human nutrition lore about gluten has certainly contributed to this. However, many of the fears about gluten, in human and animal health, are unfounded.  People with celiac disease can have negative health effects associated with eating gluten, and there are documented genetic cases of gluten sensitivity in a couple of dog breeds.

However, just as most people are not harmed by eating gluten, there is no evidence that this is a risk factor for disease in dogs and cats. Abandoning wheat as a macronutrient source because of such fears simply leads to the substitution of other sources, and there is no guarantee these are safer or healthier. There is even some evidence that avoiding gluten can cause problems in people who do not have celiac disease. 

I have also heard advocates of alternative diets talk about “the menacing power of corn” as if it were inherently poisonous. This is simply silly, and it ignores decades of nutrition research showing the contrary. Like every other food ingredient, corn is not inherently good or bad. It can contribute calories, protein, and essential fats to the diet, and it can be a safe ingredient in a balanced diet for both dogs and cats. It is obviously not appropriate as the sole food source for our pets, but no one is suggesting we use it that way, and claims that pet foods are “mostly corn” are demonstrably untrue.

Artificial Preservatives
This is a claim I have addressed repeatedly in previous articles. A variety of synthetic antioxidants have been used in pet foods over the years to prevent spoilage, and the risk of food poisoning that goes with it. These substances are sometimes feared as potential causes of cancer based on studies in rats or mice where enormous quantities are fed to the animals to evaluate potential risks. However, extensive research on these substances as they are actually used as preservatives in human and pet foods has failed to find such risks in the real world. This is another example of the dangers in putting too much stock in the predictive value of laboratory studies. 

Some companies have moved to using “natural” preservatives, such as Vitamin E, and this is what Dr. Goldstein recommends. These may be less effective, and there is no clear evidence that they are safer, but the pet food industry is often forced to respond to the fears of consumers, stoked by claims from proponents of alternative diets, regardless of the evidence for or against the concerns. 

Raw Food is Healthier than Cooked Food
This is another claim I have responded to many, many times, and there is still no evidence to support it and plenty of evidence against it. As with most alternative health practices, there are a variety of theories and specific beliefs behind raw feeding, but there are several consistent themes that most proponents of the approach adhere to and use in promoting it.

The first is the claim that commercial diets are nutritionally inappropriate and unhealthy. All of the criticisms of conventional diets I have addressed elsewhere on the blog (e.g. 12) and in detail in my book, are put to the service of convincing people raw diets are a better choice. While commercial pet foods are not perfect or without risks, the evidence clearly shows they are healthy and nutritionally appropriate for the vast majority of dogs and cats, and millions of pets live long and healthy lives eating these foods. 

The other main theoretical argument for raw diets is our old friend the Appeal to Nature Fallacy. The argument runs something like this: Cats are carnivores and they, or their ancestors, ate whole prey in the wild. Evolution has adapted carnivores to this diet, so it is the optimal diet for them. Our pet cats are essentially the same in their nutritional needs as their wild cousins or ancestors, so a diet as much like raw, whole prey as possible is the healthiest diet for them.

Cats have generally been altered far less by their association with humans than dogs. While dogs are most properly classified as omnivores, or facultative carnivores, cats are true carnivores in terms of their anatomy and physiology. Domestic cats do likely have nutritional needs very similar to wild felines. So does this mean they are better off if fed a raw diet?

Well, the Appeal to Nature Fallacy is a fallacy precisely because what happens in nature doesn’t predict what is good or bad in terms of health. The diet wild animals eat is not the perfect diet designed for their long-term health and happiness, it is simply the diet that is available to them. Evolution works by an impersonal process in which animals do their best to meet their physical needs with what is available in their environment and then reproduce. The individuals who are best at meeting these needs leave more offspring and genes behind, and over time the population comes to be more like the more successful individuals because their genes become more common. Species and their environments are always interacting and changing, and there is never an ideal moment in which a species is optimally suited for its environment and every individual is perfectly happy and healthy.

Animals typically live longer, healthier lives in captivity compared to their wild relatives. Wild carnivores frequently suffer from malnutrition, often starving when they can’t catch sufficient prey to meet their calorie and other needs. They also suffer from parasites, infectious diseases, and injuries from catching and consuming whole prey, and they endure this either suffering or die from it. This is not a perfect, blissful state of nature our pets should aspire to, it is simply the way things are in nature. 

Humans no longer live like our stone age ancestors, and we have altered our homes, our clothes, and our diets significantly from that “natural” state. As a result, we suffer less and live longer, healthier lives because of “artificial” practices such as washing and cooking and refrigerating our feed and providing ourselves with nutrients that were once hard to come by. The reduction of scurvy and rickets in modern children compared to those of our ancestors is a good thing, and similarly the reduction in parasites and malnutrition in our pets thanks to “artificial” feeding practices is a positive change. 

Raw feeding is often associated with other alternative medicine beliefs and practices. Surveys show that pet owners who feed raw diets are less likely to trust nutrition advice from veterinarians and are also less likely to adhere to other recommendations, such vaccination and parasite prevention, than owners who feed traditional commercial diets. Veterinarians who promote raw feeding and condemn conventional diets are also often suspicious of vaccines and other science-based medical therapies and frequently advocate alternative medical practices. It is not surprising, then, that theories and beliefs which underlie other alternative practices are also found in arguments for raw diets. 


None of these theoretical justifications for a raw diet, that commercial diets are unhealthy, that our pets are essentially identical to wild carnivores, that a diet as close as possible to that they would eat in nature is best for their health, or that raw food contains some intangible but essential spiritual nutrient lacking in cooked food, hold up very well to logical scrutiny. So is there any actual evidence that raw diets have health benefits?

A few small and short-term studies have been done in which dogs and cats have been fed raw foods. These show some interesting changes in the bacteria living in the guts of these subjects, in stool, and in metabolism and other variables. However, these studies simply show that some small things change when the diet is changed, not that raw diets have meaningful health effects or that whatever effects are seen are due primarily to the lack of cooking. One study has suggested some possible benefits for dental health in dogs fed a raw diet, but another study identified dental disease and broken teeth caused by such diets.

Overall, there is no convincing research evidence to support the theories and claims for why raw diets should be better for our pets than cooked homemade or conventional commercial diets. 

Unlike the benefits of raw diets, which are theoretical and unproven, the risks are well documented. Commercial raw diets which meet industry standards are likely to be nutritionally complete, but many raw advocates feed home-prepared diets, and just like other homemade foods, these diets are frequently nutritionally unbalanced and incomplete. There is even one report of a whole-prey diet (whole ground rabbit) which was studied in cats as a representative of a “natural” diet but which turned out to generate severe heart disease due to taurine deficiency in the cats eating it. So much for “natural” meaning “healthy!” 

The most significant risk of raw diets is from food-borne infectious disease. Numerous studies have shown raw diets to be frequently contaminated with potentially dangerous bacteria. While such pathogens can contaminate cooked diets as well, the risk is significantly higher for raw foods. Other studies have shown that animals eating these diets often shed these dangerous organisms in their feces, which exposes humans and other animals to the risk of infection.

Most importantly, serious illness and death in cats and dogs, and in their owners, have been caused by pathogens found in raw pet diets. While the number of confirmed cases of pets and humans suffering or dying from food-borne illness caused by raw diets is small, this is a very serious health hazard. While healthy adult pets may be able to resist these organisms to some extent, there is no absolute immunity in dogs and cats to food-borne illness. Very young, old, and sick animals, and their human caregivers, are at even higher risk. 

Dr. Goldstein claims that the freeze-drying of his pet food “completely eliminates” this risk, but that is just his opinion based on anecdote, and this is disputed by both veterinary nutritionists and veterinary infectious disease specialists

He also claims that cooking destroys nutrients in food, including taurine, which is essential for normal heart health in cats. He claims that the vitamin supplementation done to compensate for this is not effective, but there is ample evidence this is untrue and that supplementation prevents any micronutrient deficiencies in commercial diets. In fact, his claim that cardiomyopathy, or heart muscle disease, is common due to taurine deficiency is completely false. Taurine deficiency can case a disease called dilated cardiomyopathy (DCM) in cats, but this disease has almost completely disappeared since commercial diets are supplemented with taurine (unlike the cats eating whole rabbit carcasses, who did develop it in one study). Hypertrophic cardiomyopathy is an entirely different heart disease, which is still fairly common, but this is not associated with taurine deficiency, and Dr. Goldstein appears to be mistakenly conflating the two conditions in his ad.

Euthanized Pets in Commercial Pet Food
This is perhaps the most extreme example of efforts to frighten pet owners about commercial diets. Promoters of this story take a few facts and weave them into an unlikely, but shocking narrative. Most countries have pretty strict regulations about the ingredients that can go into commercial pet foods, and these broad rules cover the use of euthanized animals as a food ingredient even if this is not explicitly mentioned in the law. Industry groups, as well as regulators, also have policies prohibiting this practice. Even apart from such rules and policies, though, the claim makes little sense for other reasons.

Food animals, such as cattle, pigs, sheep, and poultry, are the most common and economical source of animal ingredients for pet foods. These are mostly produced in large operations intended to produce food for humans. Apart from being an ethically terrible and unhealthy ingredient for pet foods, euthanized dogs and cats, presumably harvested from animal shelters or picked up by the roadside, would be an unreliable and expensive raw material compared to the ingredients produced by the food animal industry. And, of course, any company caught using dead pets in their pet food would be destroyed by public outrage and likely run out of business. What motivation these companies might have, then, for using such an ingredient is hard to fathom.

There have been several attempts to investigate commercial pet foods and look for evidence of dog or cat DNA, which might suggest there is some truth to this claim. So far, however, none of these investigations have found evidence that cats and dogs have been used as components of pet foods. The U.S. Food and Drug Administration (FDA), for example, found no evidence of dog or cat DNA in pet foods it tested in 2002. While this can’t definitively prove this practice never happens, it is yet another piece of evidence against it.

So how did this idea get started? It’s impossible to know for certain, but the evidence often cited in support of the claim that euthanized pets are used in pet food tends to be open to interpretation, and those inclined to be suspicious of commercial diets and the companies that produce them seem to take the darkest possible view of this evidence. 

For example, most of the laws and regulations that would prohibit using euthanized pets in pet food don’t actually address that issue directly. The law doesn’t explicitly prohibit the practice precisely because there’s little evidence it is actually occurring. Instead, the laws prohibit unsanitary and unsafe ingredients, potentially dangerous chemicals such as euthanasia drugs, and other general types of ingredients which would naturally include euthanized dogs and cats. Critics of commercial pet foods tend to claim that because the practice isn’t named in the regulations it must actually be happening, which is not a particularly convincing claim.

Animals euthanized at shelters or killed by cars and not claimed are sometimes disposed of at rendering plants, where the bodies are broken down at high temperature into basic components, such as fats and simple proteins. These components are used in a variety of ways, from fats used as industrial lubricants to proteins being used in shrimp and fish farming. This is considered a more environmentally acceptable means of disposal than burning or burying the remains, but it is understandably disturbing to think about. 

Because the parts of food animals not eaten by people are also rendered and are sometimes used in pet foods, there have been concerns that rendering products from euthanized dogs and cats might make their way into pet diets. This is prohibited, again by both regulations and industry policies, and there has not yet been any conclusive evidence that it occurs, but this may be one source of the belief that deceased pets are used as pet food ingredients.

Another, and very serious issue is that the drug pentobarbital, an anesthetic originally used for surgery but now most often used for euthanasia, does sometimes turn up as a contaminate in pet foods. In most of these instances, the amount has been too low to be considered a hazard, but there have been rare cases in which dogs have been sickened and even killed but pentobarbital in canned foods. Investigations into the source of this contamination have typically traced it to the accidental inclusion of euthanized cattle or horses in rendering products intended as pet food ingredients. Once again, no evidence has yet been found showing that euthanized dogs and cats have been the source of pentobarbital contamination of pet foods, but again this may be one source of the belief that this is happening. 

Ultimately, like so many of the concerns raised by critics of science-based medicine and conventional nutrition, it is not possible to conclusively prove that the concern is never true under any circumstances. However, the consistent failure to find evidence for the claim despite repeated investigations over decades certainly makes it an unlikely occurrence and not a reason to fear commercial diets or choose untested alternatives with far less evidence for their safety and nutritional value.

Miscellaneous Claims
Dr. Goldstein uses fear to promote his claims. He tells a sad story about the death of one of his cats from urinary tract obstruction, and claims that commercial cat food caused this, but there is little evidence to support such a claim. He also claims that “more cats are getting sick than ever before,” which is the same kind of mythologizing of the “good old days” that alternative vets often peddle to make people fear the health effects of modern life. I have addressed this claim before in regards to cancer in pets, and there is no evidence to support it and some to suggest that our pets, like us, are healthier than in the past.

Dr. Goldstein also argues that cats should be fed organ meats high in Vitamin D partly because they may become deficient from living indoors or in cold climates due to inadequate sun exposure. This is an idea translated directly from human physiology that simply doesn’t apply to cats. While humans make a lot of our Vitamin D in our skin under the influence of sunlight, cats do not, and they always need to get this from dietary sources regardless of lifestyle (e.g. 34). As I have already mentioned, there is plenty of evidence that cooked commercial diets meet this need effectively.

Bottom Line
Dr. Goldstein is basically trying to sell both a product and the ideology behind it in this infomercial. While I have no doubt he is sincere, there is plenty of reason to doubt he is correct. His claims are based on faulty reasoning and anecdote and often contradicted by established scientific knowledge. There are clear risks to raw diets such as Nature’s Feast, and there is yet no real evidence for any of their purported benefits. Advocates of these diets would better serve the pet population by supporting legitimate, rigorous research to show definitively whether their claims are true or not than by inventing and selling products based on gut feelings and anecdotes and ignoring the science and the real nutrition experts.

Posted in Nutrition | 10 Comments

SkeptVet TV: Vaccine Risks- Real & Imaginary

Research Studies Identifying General Vaccine Risks

Gershwin LJ. Adverse Reactions to Vaccination: From Anaphylaxis to Autoimmunity. Vet Clin North Am Small Anim Pract. 2018 Mar;48(2):279-290. 

Valli JL. Suspected adverse reactions to vaccination in Canadian dogs and cats. Can Vet J. 2015 Oct; 56(10): 1090–1092. 

Moore GE, Hogenesch H. Adverse vaccinal events in dogs and cats. Vet Clin North Am Small Anim Pract. 2010 May;40(3):393-407.

Day MJ. Vaccine side effects: fact and fiction. Vet Microbiol. 2006 Oct 5;117(1):51-8. Epub 2006 Apr 25.

Autoimmune Disease and Vaccines

Cecinati V. Hum Vaccin Immunother. Vaccine administration and the development of immune thrombocytopenic purpura in children. 2013 May;9(5):1158-62.

Huang AA, et al. Idiopathic immune-mediated thrombocytopenia and recent vaccinations in dogs. JVIM 2012; 26: 142-148.

Naleway AL. et al. Risk of immune hemolytic anemia in children following immunization. Vaccine. 2009 Dec 9;27(52):7394-7.

Davidow EB, et al. Risk factors for development of IMHA-A prospective case-control study. Abstract. VECCS 2004.

Carr AP, et al. Prognostic factors for mortality and thromboembolism in canine immune-mediated hemolytic anemia: A retrospective study of 72 dogs. J Vet Internal Med.2002;16:504-509.

Reimer ME, Troy GC, Warnick LD. Immune-mediated hemolytic anemia: 70 cases (1988-1996). J Am Anim Hosp Assoc. 1999;35:384-391.

Duval D et al. Vaccine-associated immune-mediated hemolytic anemia in the dog. J Vet Internal Med. 1996;10:290-295.

Klag AR, et al. Idiopathic immune-mediated hemolytic anemia in dogs: 42 cases (1986-1990). J Am Vet Med Assoc. 1993;202:783-788.

SkeptVet post about Thimerosal 

SkeptVet Posts about Vaccine Dose (12)

All SkeptVet Vaccine Articles

Posted in SkeptVet TV, Vaccines | 5 Comments

No Good News for Veterinary Probiotics

I have covered the subject of probiotics many times in the ten years since the beginning of this blog. I last summarized the evidence in a 2017 post reviewing all of my previous articles as well as the results of a narrative review published that year. My conclusion at that time was:

  • There are few studies, and those that have been done have significant limitations and often conflict.
  • There is reasonable evidence for some clinical benefit in acute diarrhea associated with stress or antibiotic use.
  • There is no high-quality, consistent evidence for most suggested uses of probiotics.
  • The unregulated probiotic products on the market today are plagued with inaccurate labeling and poor quality control. This means that even if probiotics might be beneficial in some cases, it is unclear if the actual products available could achieve these benefits.
  • There do not yet appear to be significant risks to probiotics, though the evidence for this safety also quite limited.

Just this month, a systematic review of probiotics for gastrointestinal (GI) disease in dogs has been published which critically evaluates and summarizes all of the research to date on this subject. 

Jensen AP. Bjornvad CVR. Clinical effects of probiotics in prevention and treatment of gastrointestinal disease in dogs: A systematic review. J Vet Int Med. 2019;33:1849-1964.

Since the most common use of probiotics in veterinary medicine is for gastrointestinal disease, and dogs are the most common species treated (though many cats are treated with probiotics for gastrointestinal problems as well), this is a very relevant and useful review. Given the results of several studies showing that the most common treatment for diarrhea in dogs, the drug metronidazole, probably isn’t effective (1,2,3) probiotics are often seen as a viable alternative, so reliable evidence concerning their effects is needed. Systematic reviews are the most reliable form of evidence summary available, and they can give an accurate overview of the strength of evidence for particular, specific issues in medicine. 

Unfortunately, the news is not good. The review found only 17 clinical studies relevant to whether or not probiotics are useful in canine GI disease. These studies were mostly small and often plagued by significant methodological limitations. The overall conclusions of this review were:

  • the evidence points toward a limited and possibly clinically unimportant effect for prevention or treatment of acute gastrointestinal disease.
  • for chronic gastrointestinal disease, dietary intervention remains the major key in treatment, whereas probiotic supplement seems not to add significant improvement
  • this conclusion is based on a limited number of studies, with a wide methodological diversity, and mainly low sample sizes.
  • there is a high risk that most of the studies evaluated in the current review were severely underpowered especially taking into consideration that baseline characteristics of study groups were generally very poorly documented
  • 12 of the [17] studies reported industry involvement; with such a high degree of industry involvement, there is a risk of publication bias as the incentive to publish studies showing no effect of probiotics could be low

This doesn’t necessarily mean that probiotics aren’t useful or effective for GI disease in dogs. What it does mean is that there isn’t yet any good evidence supporting the use of probiotics for treating or preventing acute or chronic GI disease in dogs, and the evidence we do have is not very reliable. It is very frustrating to see so many research studies done in veterinary medicine that are too small or have other flaws that make it impossible to trust their findings. It is a waste of resources and ethically questionable to conduct studies that don’t do a reasonable job of answering the question they are designed to answer.

At this point, the best we can say about probiotics is that they might be useful but we don’t yet have real evidence to show this, individual products are often mislabeled and quality control is poor, and the risks appear to be low but these haven’t been effectively studied. Ten years since I first wrote about this subject, that is a disappointing level of evidence, and it is frustrating to still be guessing about this treatment.

Posted in Herbs and Supplements | 5 Comments

Placebos for Pets? The Truth about Alternative Medicine in Animals Hits #1!

There are two more weeks until the release of Placebos for Pets?, and the book is now the #1 New Release in veterinary medicine on Amazon! Thanks all for your support!

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Vaccination for Cats

My latest video from SkeptVetTV covering vaccine recommendations for cats. Below are some resources for further information.

American Academy of Feline Practitioners (AAFP) Vaccination Guidelines

World Small Animal Veterinary Association (WSAVA) Vaccination Guidelines

AAFP Guidelines for Feline Injection-Site Sarcoma (FISS)

Vaccine-associated feline sarcoma: current perspectives.

Feline Injection Site Sarcomas: Data from Switzerland 2009-2014.

The incidence of feline injection site sarcomas in the United Kingdom.

Posted in SkeptVet TV, Vaccines | 3 Comments

What’s the Point of Acupuncture?

Acupuncture is one of the most well-known alternative therapies. While only 5-10% of Americans have had acupuncture treatment, most people are familiar with the practice, and surveys show many people, including medical professionals, have a positive view of acupuncture and its benefits.1–4

Like many other therapies, acupuncture has been adapted for veterinary use from its origins in human medicine, and it appears to be growing in popularity among pet owners and veterinary professionals. It is recommended in the American Animal Hospital Association pain control guidelines5 and included in the curricula and practice of a number veterinary colleges. Training programs in veterinary acupuncture are common, and lectures on the subject are included in most mainstream veterinary continuing education conferences. 

You may be surprised, then, to learn that a sizeable number of scientists and clinicians in both human and veterinary medicine remain unconvinced of the benefits of acupuncture.6–8 This is not for want of research. There are thousands of published clinical trials investigating acupuncture in humans, and several dozen veterinary trials have been reported. However, not all research studies produce equally reliable and convincing results, and acupuncture is particularly challenging to study in a rigorous scientific manner. 

Though I am certified in veterinary medical acupuncture and use the method in practice, I remain skeptical about its value. Whatever benefits acupuncture may have can only be identified if the uncertainties about the practice and associated research are understood and if reliable, high-quality research evidence is generated. Therefore, I want to highlight here some problems with the theory and practice of acupuncture and the research evidence used to justify it in order to balance the misleading information put forward by some proponents and the positive, but often uninformed, view many have about the practice.

The Roots of Acupuncture

Acupuncturists often claim veterinary acupuncture is an ancient Chinese practice. This is somewhat misleading. Acupuncture certainly originated in China long ago. However, it was originally a bloodletting practice which evolved over time into the modern treatment using ultrafine needles.6,9,10 The current collection of ideas, methods, and therapies included under the label Traditional Chinese Medicine (TCM) is actually a mélange of competing folk medicine traditions collated and marketed by the Chinese government under Chairman Mao for largely political reasons.11,6

The theoretical roots of TCM are a mix of Daoist, Confucian, Buddhist, and other religious and philosophical systems. The core concepts informing diagnosis and treatment involve balancing spiritual forces (e.g. Ch’i, Yin and Yang) and adjusting the strength and function of elements in the body corresponding to the elements that make up the universe (e.g. Fire, which is associated with the heart, summer, bitter flavors, and the early afternoon, and Wood, which is associated with the liver, sour flavors, springtime, and the early morning hours).6,9,10,12

Similar beliefs have underlain many pre-scientific systems of folk medicine. The theories of TCM resemble the philosophy of European humoral medicine, with its own bloodletting and herbal practices. Historical communication between cultures and universal features of human cognition have led to great similarity between folk medicine traditions in different cultural and historical settings.9

However, such beliefs are unproven and unfalsifiable, and they are not compatible with science-based medicine.13 Folk medicine has never been very effective, and the dramatic improvements in our health and life-expectancy over the last two centuries have been achieved by abandoning such systems and replacing them with scientific evaluation of medical therapies. It is naïve and misguided to portray the mystical notions of TCM theory as a legitimate foundation for modern medical treatment. 

Of course, many acupuncturists claim that TCM is merely a set of metaphors used to describe practices that have actually been studied and validated in conventional scientific ways. However, such claims are disingenuous. If there are sound physiologic rationales for how acupuncture is employed, why is there any need to learn a complex and imaginary set of explanations for disease and treatment in order to practice acupuncture? 

Nearly all veterinary acupuncture organizations explicitly endorse the TCM approach. And regardless of the extensive scientific research done on acupuncture, most acupuncturists still think in terms of TCM concepts and still make diagnoses and plan their treatments according to this system. This is misleading to our clients and undermines rigorous scientific evaluation of acupuncture. 

What’s the Evidence?

Acupuncture research is a complex field difficult to summarize both briefly and accurately. From the basic science to clinical trials, the evidence is inconsistent in quality and results. Even the foundational task of identifying and defining acupuncture points has proven difficult.14–17 Various acupuncture traditions locate points quite differently. Some needle only in limited areas, such as the hand of the ear, while others use points widely distributed all over the body. Apart from the eyeballs and the genitals, there is hardly a spot anywhere that has not been claimed as an acupuncture point. And the features often cited to show such points are anatomically or functionally distinct are also widespread and found in many places not considered to be acupuncture points. 

Despite extensive effort, a consistent set of anatomic or physiologic features that convincingly define the existence of acupuncture points has not been demonstrated. Furthermore, many studies find the effects of needling to be as strong in sham locations used as controls for “true” acupuncture points.18–20 It is difficult to characterize and evaluate acupuncture as a coherent system for stimulating specific locations with predictable results if we cannot even prove that these locations exist or that it matters where the needling is done.

Clinical Studies of Acupuncture
There are thousands of clinical trials studying acupuncture in humans. Many claim positive results. Many also have severe methodological weaknesses. It is very difficult to create a “placebo” acupuncture intervention that fools patients, and it is impossible to create one that fools the acupuncturist. For this and other reasons, proving that real acupuncture is more effective than sham or placebo acupuncture has been difficult. Most positive results tend to be for outcomes such as pain, nausea, and subjective symptoms that are most susceptible to placebo effects, which undermines confidence in these results.

Over sixty systematic reviews of acupuncture research have been published by the Cochrane Collaboration, and none have concluded that there is strong, consistent evidence for meaningful benefits.6,14,21,22 When study quality, risk of bias (both within studies and in the preferential publication of positive results), and other quality criteria are evaluated, much acupuncture research is not reliable. The highest-quality studies often find no difference between verum and sham acupuncture.

The veterinary clinical trial literature is smaller and even more methodologically unreliable. Reviews of the veterinary literature have failed to find convincing evidence of clinically significant benefits.23,24 In 2016, the American Board of Veterinary Specialties rejected the application of veterinary acupuncture organizations for medical specialty recognition because of the lack of a sufficient scientific basis for acupuncture. The ABVS also recently rejected a similar petition from the American College of Veterinary Botanical Medicine, and most ACVBM members and practices rely on the same unscientific TCM principles as acupuncture. 

Scientific Medical Acupuncture?

A minority of acupuncturists disavow the folk medicine roots of the practice and approach it in a more rigorously scientific fashion. The former author of this column, Dr. Narda Robinson, is a leader of this effort, and it is her training course I completed in order to take as thorough and fair a look at acupuncture as I could. I believe using the principles, methods, and terminology of conventional science is the most promising way to evaluate acupuncture. 

Unfortunately, there is still not consistent and reliable evidence to show the value of acupuncture in veterinary patients regardless of the underlying theory. Studies frequently lack blinding and effective placebo controls, they often measure multiple outcomes and then dredge the data for statistically significant differences of questionable clinical relevance, and investigators inevitably interpret results as supportive of acupuncture even when they clearly are not. 

A recent study25, for example, predicted acupuncture would increase gastric motility in dogs. A small difference in motility was seen between treatment and control interventions, though only at three of the twelve time points assessed. This difference was statistically significant, but it was actually in the opposite direction from that predicted, with motility being slower in the acupuncture group at these times. The most likely explanation for this finding is that the hypothesis was wrong and the difference identified was not meaningful. 

The authors, however, instead chose to interpret the findings “based on the underlying theories of acupuncture” and suggested that further study and clinical applications may be appropriate because needling might “balance” physiologic systems, altering them in whichever direction is appropriate for restoring homeostasis in a given patient. This is simply the Daoist notion of spiritual balance from TCM couched in scientific terminology. It is an implausible interpretation of the data and shows how the religious concepts of TCM pervade the thinking of even ostensibly science-based acupuncture practitioners and interfere with objective, useful generation and interpretation of scientific research evidence.

Bottom Line

Most acupuncture treatment is still based on unscientific religious and philosophical principles. Despite extensive research over many decades, plausible scientific explanations for how traditional acupuncture might work have not been clearly validated. Clinical studies in humans have failed to find clear evidence of meaningful benefits for most conditions compared with sham interventions. 

There is little high-quality clinical research on veterinary acupuncture, and the widespread belief that it is an effective therapy is based mostly on anecdote and low-quality evidence. Better research evidence has been challenging to generate due both to the difficulty in creating an effective placebo comparator for acupuncture and to the impact of entrenched bias and unscientific beliefs among acupuncturists evaluating the practice.

References

1.        Mann B, Burch E, Shakeshaft C. Attitudes Toward Acupuncture Among Pain Fellowship Directors. Pain Med. 2015;17(3):pnv001. doi:10.1093/pm/pnv001

2.        Chen L, Houghton M, Seefeld L, Malarick C, Mao J. A Survey of Selected Physician Views on Acupuncture in Pain Management. Pain Med. 2010;11(4):530-534. doi:10.1111/j.1526-4637.2010.00815.x

3.        Halpin SN, Perkins MM, Huang W. Determining attitudes toward acupuncture: a focus on older U.S. veterans. J Altern Complement Med. 2014;20(2):118-122. doi:10.1089/acm.2013.0229

4.        Burke A, Upchurch DM, Dye C, Chyu L. Acupuncture Use in the United States: Findings from the National Health Interview Survey. J Altern Complement Med. 2006;12(7):639-648. doi:10.1089/acm.2006.12.639

5.        Epstein ME, Rodan I, Griffenhagen G, et al. 2015 AAHA/AAFP Pain Management Guidelines for Dogs and Cats. J Feline Med Surg. 2015;17(3):251-272. doi:10.1177/1098612X15572062

6.        Magalhães-Sant’Ana M, Magalhães-Sant’Ana, Manuel. The Emperor’s New Clothes—An Epistemological Critique of Traditional Chinese Veterinary Acupuncture. Animals. 2019;9(4):168. doi:10.3390/ani9040168

7.        Colquhoun D, Novella SP. Acupuncture is theatrical placebo. Anesth Analg. 2013;116(6):1360-1363. doi:10.1213/ANE.0b013e31828f2d5e

8.        McGeeney BE. Acupuncture Is All Placebo and Here Is Why. Headache J Head Face Pain. 2015;55(3):465-469. doi:10.1111/head.12524

9.        Buell PD, May T, Ramey D. Greek and Chinese horse medicine: déjà vu all over again. Sudhoffs Arch. 2010;94(1):31-56. http://www.ncbi.nlm.nih.gov/pubmed/21294441. Accessed November 13, 2018.

10.      Ramey DW, Rollin BE, eds. Complementary and Alternative Veterinary Medicine Considered. Ames, Iowa, USA: Iowa State Press; 2003. doi:10.1002/9780470344897

11.      Levinovitz A. Chairman Mao Invented Traditional Chinese Medicine. Slate. October . https://slate.com/technology/2013/10/traditional-chinese-medicine-origins-mao-invented-it-but-didnt-believe-in-it.html.

12.      Schoen AM, Wynn SG. Complementary and Alternative Veterinary Medicine?: Principles and Practice. 1 ed. St.Louis (Misuri): Mosby; 1998. https://www.worldcat.org/title/complementary-and-alternative-veterinary-medicine-principles-and-practice/oclc/991736718&referer=brief_results. Accessed November 14, 2018.

13.      McKenzie BA. Is complementary and alternative medicine compatible with evidence-based medicine? J Am Vet Med Assoc. 2012;241(4). doi:10.2460/javma.241.4.421

14.      ERNST E. Acupuncture – a critical analysis. J Intern Med. 2006;259(2):125-137. doi:10.1111/j.1365-2796.2005.01584.x

15.      Zhang H, Bian Z, Lin Z. Are acupoints specific for diseases? A systematic review of the randomized controlled trials with sham acupuncture controls. Chin Med. 2010;5(1):1. doi:10.1186/1749-8546-5-1

16.      Ramey DW. A Review of the Evidence for the Existence of Acupuncture Points and Meridians. In: Proceedings of the Annual Convention of the American Association of Equine Practitioners. ; 2000:220-224. http://www.ivis.org/proceedings/aaep/2000/220.pdf.

17.      Molsberger AF, Manickavasagan J, Abholz HH, Maixner WB, Endres HG. Acupuncture points are large fields: The fuzziness of acupuncture point localization by doctors in practice. Eur J Pain. 2012;16(9):1264-1270. doi:10.1002/j.1532-2149.2012.00145.x

18.      Moffet HH. Sham Acupuncture May Be as Efficacious as True Acupuncture: A Systematic Review of Clinical Trials. J Altern Complement Med. 2009;15(3):213-216. doi:10.1089/acm.2008.0356

19.      MacPherson H, Maschino AC, Lewith G, et al. Characteristics of Acupuncture Treatment Associated with Outcome: An Individual Patient Meta-Analysis of 17,922 Patients with Chronic Pain in Randomised Controlled Trials. Eldabe S, ed. PLoS One. 2013;8(10):e77438. doi:10.1371/journal.pone.0077438

20.      Gorski DH. Integrative oncology: really the best of both worlds? Nat Rev Cancer. 2014;14(10):692-700. doi:10.1038/nrc3822

21.      Jiao S, Tsutani K, Haga N. Review of Cochrane reviews on acupuncture: how Chinese resources contribute to Cochrane reviews. J Altern Complement Med. 2013;19(7):613-621. doi:10.1089/acm.2012.0113

22.      Derry CJ, Derry S, McQuay HJ, Moore RA. Systematic review of systematic reviews of acupuncture published 1996-2005. Clin Med. 6(4):381-386. http://www.ncbi.nlm.nih.gov/pubmed/16956145. Accessed November 14, 2018.

23.      Habacher G, Pittler MH, Ernst E. Effectiveness of acupuncture in veterinary medicine: systematic review. J Vet Intern Med. 20(3):480-488. doi:10.1892/0891-6640(2006)20[480:eoaivm]2.0.co;2

24.      Rose WJ, Sargeant JM, Hanna WJB, Kelton D, Wolfe DM, Wisener L V. A scoping review of the evidence for efficacy of acupuncture in companion animals. Anim Heal Res Rev. 2017;18(2):177-185. doi:10.1017/S1466252317000068

25.      Radkey DI, Writt VE, Snyder LBC, Jones BG, Johnson RA. Gastrointestinal effects following acupuncture at Pericardium-6 and Stomach-36 in healthy dogs: a pilot study. J Small Anim Pract. 2019;60(1):38-43. doi:10.1111/jsap.12935

Posted in Acupuncture | 18 Comments

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Canine Vaccination- What, When, & Why

American Animal Hospital Association (AAHA) Guidelines

World Small Animal VeterinaryAssociation (WSAVA) Guidelines

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Posted in SkeptVet TV, Vaccines | 8 Comments

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