Dr. Karen Becker Offers Some Classic Veterinary Detox Quackery

Yesterday, I wrote about some environmental chemicals that may play a role in causing disease. While this sort of environmental risk factor is a real and recognized phenomenon supported by good science, it can easily be cited to lend support to a bit of popular pseudoscience that may appear quite similar but which is actually something quite different: detoxification. Detoxification is one of the classic bogus pseudoscientific concepts of alternative medicine, and since I brought up the subject of environmental toxins, I thought it worthwhile to illustrate today some of the differences between the legitimate field of environmental toxicology and the quackery that is detoxification.

The notion of detox suggests that our bodies accumulate harmful substances, either from environmental toxins or the waste products of our own normal metabolism, and that these need to be removed or neutralized by some therapeutic process in order to prevent or cure disease. The details about what is toxic, how we come by it, and what we should do to detox vary widely according to the many and mutually inconsistent theories of different alternative practitioners.

At the heart of this notion is the emotion of disgust, and inherent reaction we have evolved to encourage avoidance of potential sources of harm, particularly infectious disease. Though there is controversy about the details, it is commonly argued that this innate emotional reaction has been generalized to cultural and moral domains, and this has led to the social constructs of contamination and purification. Detox schemes are portrayed as healthcare, but they are really a set of purification rituals intended to ward off harm magically like some religious practices.

The problem with this and many other alternative medicine ideas that are more religion than science or medicine is that evidence for or against specific proposed toxins or therapies becomes irrelevant. It’s not that there is no such thing as a toxin, since there are many well-characterized by science. And it’s not that we can’t remove or neutralize some toxins with medical treatment, because in some cases we can. The issue is that the specific claims about detoxification are often made up completely or extrapolated wildly and irrationally from small pieces of actual scientific knowledge, and they become self-sustaining components of a belief system rather than hypotheses that can be confirmed or disproved.

A typical example of this kind of pseudoscience, which mixes distorted but real science with complete nonsense, comes from the ever-reliable source of pseudoscience, Dr. Karen Becker at Mercola.com. Dr. Becker produces a steady stream of advice for pet owners. It ranges from the perfectly reasonable to the unproven but plausible all the way to the completely ridiculous, often all jumbled together. The key is that real evidence is almost never needed or heeded, and her claims are based predominantly on opinion, hers or that of the other alternative practitioners she interviews.

 

The  Big Scare

Her detoxifications creed begins with The Big Scare, that classic snake-oil sales technique in which the CAM advocate tries to convince an audience that they and their pets are swimming in a toxic soup constantly threatening ruin to our fragile health and well-being. Without this fear, we might not realize that our apparently perfectly healthy pets were actually in terrible danger and that we need to act now to save them! We might be at risk of coming to believe that not all bad things that happen can be avoided if we just do the right things and that those who become ill have only their own poor lifestyle choices and inaction to blame.

It’s actually mind-boggling to think about all the different ways our pets are exposed to toxins in today’s world…. If you’re wondering if your own pet is carrying a toxin load, sadly there’s no doubt he is. The truth is that virtually every pet has measurable amounts of chemicals in their body, because they walk through chemicals, they sleep on them, they breathe them in, and they eat and drink them. And unfortunately, veterinarians prescribe and inject them on a regular basis as well.

Dr. Becker lists a host of the usual bogeymen of alternative medicine, from medicines that actually protect your pet’s health and prevent disease, like antibiotics and parasite preventatives, to poisonous commercial dog food that carry cancer in every bite, to the invisible threat of—gasp!— electromagnetic fields! Some of the specific things mentioned do have potential harmful effects, depending on dose, exposure route, species, lifestage, and many, many other variables. After all, anything, including such necessities of life as oxygen and water, can be harmful under the right circumstances.  Others, such as fluoride in drinking water and electromagnetic fields have been thoroughly investigated and not found to be dangerous. But again, we are dealing with a faith-based, not evidence-based belief system here.

Pretend Science

After The Big Scare, Dr. Becker moves on to explaining precisely how these toxins harm your pet. Well, not precisely, more like generally. Well actually, it’s more like using some vague science-y words that imply stuff without actually meaning anything.

When your pet’s body accumulates too many toxins, it stores them for future elimination. For many pets, that future opportunity never arrives and the toxic load begins to impede the body’s ability to function. Ultimately, toxic overload can interfere with the immune system to the point where cellular abnormalities like tumors and cysts develop. Other serious diseases may also show up as cells degrade and organ function is impaired.

Side effects of an accumulating toxin load cover a wide range of diseases, from skin conditions to organ failure. There can be behavior problems associated with toxicosis, endocrine disease, autoimmune disease, and even cancer.

So basically, your pets is constantly besieged by all sorts of toxins that are everywhere and in everything, and they can cause almost any disease if not eliminated. And while she admits that your pet has its own systems for dealing with toxins (since it would be hardly to explain how any suggests that they can’t be relied on. This, again, is a necessary step in selling you something which you can do to defeat this terrible threat and which will work better than the natural systems evolved over millennia which have kept us all alive so far.

A Magic List
Everyone likes lists. Just put “10 Steps to…” in front of almost any advice, and it will be more fun to read and more persuasive. The only trouble here is that most of these steps are either too vague to be meaningful, unproven hypotheses, or total nonsense.

1. Improve Your Pet’s Diet

What Dr. Becker means by “improve” is really “change to what is recommended by my favorite nutrition mythology.” Avoiding commercial food, which is full of those pesky toxins, and switching to home-cooked, grain-free, ideally raw diets despite the complete lack of evidence to support the claim that any of these changes actually improves health or reduces disease risk. I’ve addressed a number of these myths and claims before, and they are far more about ideology than science.

2. Provide Clean Drinking Water

Presumably, you are unaware that the drinking water we get from the tap here in the U.S., which has eliminated numerous infectious diseases that have plagued humanity for millennia and continue to trouble the developing world, is actually a toxic brew that will poison your pet. Fluoride, in particular, is mentioned as a risk despite the overwhelming evidence that it is safe and effective at dramatically educing dental disease. No evidence needed here, just pure belief!

3. Beware the Air!

Apparently, the very air you breathe in your home is full of perils as well. Avoiding smoking is a sound and well-established way to reduce disease risk. Other than that, the notion that every cleaning product that doesn’t call itself “green” on the label is a poison for your pet and that you can somehow find a magic combination of products and purifiers to ward of sinister unseen toxins in normal household air is just another arrow in the quiver of The Big Scare.

4. Make Your Pet Exercise

The benefits of exercise for humans are well-established, and it is likely that our pets could stand a good deal more physical activity than many of them get. There isn’t actually much research for dogs to tell us how much of what kind of activity is ideal, and the notion that our cats should workout more is pretty far-fetched. Still, among the very real benefits of exercise is not “helping the body’s detoxification efforts.” Suggesting that without more exercise your pet will not urinate, defecate, circulate blood to the liver and kidneys, or breathe sufficiently to perform ordinary removal of waste products is just nonsense.

5. Avoid Pollutants and Chemicals

A perfectly sound bit of advice, except for the problem that everything is made of “chemicals,” and Dr. Becker’s notion of what is a “pollutant” is pretty vague. Sure, washing off your dog’s feet when they come in the house is fine, but there’s no reason to imagine it will dramatically affect their health or ward off any terrible illness.

6. Say No to Drugs!

Dr. Becker recommends avoiding “unnecessary” “drugs,” by which she usually means vaccines and medicines. I too recommend avoiding unnecessary medical treatment, but I suspect we have different definitions of what this is. I have written extensively about the issues involved in deciding what to vaccinate for and how often, and it is a far more complex subject than simply “avoid yearly vaccinations” as Dr. Becker recommends. And while antibiotics and steroids are probably overused, they are also important and beneficial medicines, and it is dishonest to sow fear of them without being clear and evidence-based in presenting both the risks and benefits and without defining “unnecessary” in any way. Making people afraid of medicine doesn’t make their pets healthier. Similarly, there are risks as well as benefits to parasite prevention, as well as to eschewing such prevention, but the “safe, natural alternatives” Dr. Becker mentions are not proven substitutes.

7. Brush & Bathe Your Pet

Sure, why not? But ignore this bit of nonsense: “Your cat or dog eliminates toxins through his skin, and regularly brushing or combing will remove loose fur and debris and help his skin breathe.” Oh, and don’t forget not to use shampoos that contain “toxins.” Make sure they are “natural.” *sigh*

8. Support Your Pet’s Liver and Kidneys

Here’s where the poor logic behind the detoxification scam shows itself especially clearly. We are warned that “chemicals” and all kinds of substances in our food, water, and air are bad for us and should be avoided, despite the lack of evidence in most cases that this is true. We are warned of the dangers of medicines are parasite preventatives without any discussion of the benefits and with no consideration given to the abundant evidence showing that these generally do much more good than harm. And then, after all this fear mongering without good evidence, we are told to protect our pets by giving them a bunch of untested and unproven chemicals! I have collected an enormous volume of evidence showing that the chemicals(!) in herbs and supplements and even needed compounds like vitamins and minerals can cause serious harm. Without proper testing, these cannot simply be assumed to be safe and effective. Giving such substances without this evidence and warning people away from substances for which good evidence of safety is available is bizarre and misleading. Only the fundamentally faith-based nature of the detox myth could explain such inconsistent and illogical recommendations.

9. Support Your Pet’s Immune System

Boosting the immune system is one of the other classic bits of alternative dogma and nonsense nicely dealt with already elsewhere. It suffers from many of the same problems with faith above evidence and illogic as the detox scam.

Dr. Becker lists a number of specific “detoxing” agents, and not surprisingly several of them have come up here before, including Chinese Herbal Medicine, turmeric, resveratrol, and others. None of these have good clinical trial evidence to show that they “detoxify” anything, and while there are some suggestive tidbits of research that some might have some legitimate medical uses, there are not clinical trials showing any to be safe and effective at preventing serious disease in apparently healthy animals. Their use is based entirely on anecdote or entirely unproven theories about health, not real evidence.

Finally, Dr. Becker recommends regular detoxing with these unproven chemicals if your pet has any exposure to supposed toxins, which of course is unavoidable since these malignant substances are everywhere, except apparently in the chemicals she recommends giving to detox your pet.

Bottom Line
The whole notion of detoxification is a non-scientific concept that is part of an ideology which has more in common with religion than science-based medicine. The theories are unproven or outright false, and the specific claims made about toxins and detox treatments are made without real evidence. The strategy is no different in its essence than warding off bad luck or evil spirits, and it serves more to assuage the anxiety of humans than protect the health of pets. Here are some useful resources on the subject for further reading:

The Detox Scam: How to spot it, and avoid it

You can’t “detox” your body: It’s a myth. So how do you get healthy?

Detoxification Schemes and Scams

The Detox Delusion

Detoxification Therapies

 

 

 

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Evidence Update: Flame Retardants (PBDEs) and Hyperthyroidism in Cats

The words “chemical” and “toxin” are among the most popular and misused words in the alternative medicine lexicon. They are often more a vague code for “evil spirits” rather than a specific reference to true environmental health hazards, and they are frequently used to frighten people into avoiding conventional medical therapies or employing unproven or quack treatments. “Toxins” are often more an ideological shibboleth than a useful scientific concept.

That said, there are unquestionably real environmental compounds that cause disease. Many of these have been identified by meticulous and rigorous scientific research. Undoubtedly some remain unidentified, quietly increasing our risk of illness without our knowledge. The trick is knowing what is truly dangerous, to whom, in what form, at what time, and so on. The details matter. If we waste our time avoiding and being afraid of the wrong things, or everything, we aren’t focusing our efforts effectively at identifying and controlling true environmental risks. Science, not scare tactics, is the best way to deal with the problem of environmental toxins.

Which brings me to a recent article which has added a bit of information to an ongoing debate about an all-too-common disease, feline hyperthyroidism.

Jessica Norrgran, Bernt Jones, Anders Bignert, Ioannis Athanassiadis, and Åke Bergman. Higher PBDE Serum Concentrations May Be Associated with Feline Hyperthyroidism in Swedish Cats. Environ. Sci. Technol., 2015, 49 (8), pp 5107–5114

Hyperthyroidism is the most common glandular disease in cats. It involves an excess of thyroid hormone produced by a benign tumor of the thyroid gland. The consensus is that the disease is much more common than it was a few decades ago, though there are not reliable numbers and, as always, it’s not completely clear the degree to which more cases are actually occurring versus more cases being diagnosed since we’ve discovered the disease and started testing for it readily. It is, in any case, a significant cause of illness, and though it is very treatable, it causes a great deal of discomfort for cats and expense and worry for their owners.

The problem of hyperthyroidism is especially frustrating because we do not know precisely why cats get the tumors that cause it, or why it appears to have become more common. Whenever there is this sort of uncertainty, the door is wide open for theories, from the plausible to the ridiculous, and there is little basis on which to discriminate among them. Lots of theories have been proposed for the cause of feline hyperthyroidism, and the fact that no single one has been confirmed suggests that multiple risk factors and causal pathways are involved. However, environmental contaminates are considered a significant potential risk factor, and this study adds some support to the concerns previously expressed about one in particular, polybrominated diphenyl ethers (PBDEs).

The authors selected blood samples from cats seen at a Swedish university and measured the levels of 11 different PBDEs and related compounds. These levels were compared with those found in humans in Sweden as well as between cats with and without diagnosed hyperthyroidism. They found higher levels overall in cats than in humans, higher levels of 4 of these compounds in cats with hyperthyroidism, and different patterns of the relative amounts of the different chemicals in cats compared to humans and in hyperthyroid and normal cats. Other compounds did not differ between the two groups of cats. And one compound was found in all of the cats despite having been banned over a decade previously in Europe and not having been detected in house dust or human blood since.

The authors are careful to point out that these data cannot be used to confirm that PBDEs cause hyperthyroidism because there are a number of potential sources of error that are not controlled for in this kind of study. Much more extensive data exist in humans, and yet it is still not clear what role, if any, these chemicals play in causing thyroid disease. Nevertheless, showing that at least in a small number of cats those with thyroid disease appear to have higher levels of PBDEs that those without does suggest some relationship, and further study is certainly warranted to sort out the details.

Research has suggested a relationship between PBDEs, in the environment and possibly in cat food, and the appearance of hyperthyroidism in cats before, though not all studies have found evidence to support this hypothesis. It seems likely that multiple factors are involved, including environmental, genetic, and possibly nutritional variables.

This complexity is frustrating, as it prevents identifying a single, simple cause that can be avoided. The bulk of the PBDE exposure is believed to come from ingestion of house dust through self-grooming. PBDEs have been incorporated into a bewildering variety of household items, and while many of these compounds are no longer manufactured or used, it is likely indoor cats will continue to be exposed to them through these sources for some time. However, there are a host of other, and generally more severe, health problems associated with letting cats roam outdoors, so this is not a great solution.

Similarly, there is some concern about PBDE exposure through canned cat food. However, there is also some limited evidence that canned foods are better for cats than kibble in terms of other health risks. And while fresh, homemade diets may be ideal in theory, in practice most owners cannot put the time and energy into making truly nutritionally balanced and safe homemade diet.

If PBDEs are a significant part of the cause for, hopefully further research will clarify their role and give us the detailed information we need to reduce exposure and disease risk. Any action we take on this subject, however, needs to be thoughtful and based on solid data, since making dramatic changes in how we feed or otherwise manage our feline companions without a strong foundation in science will very likely lead us into simply exchanging one set of risks for another.

 

 

 

Posted in Science-Based Veterinary Medicine | 6 Comments

Vaccine Confidence in the United States: A New Report

Introduction
As I have been quite involved in the struggle to reform our vaccination exemption laws here in California, I’ve been spending a lot of time reading about childhood vaccination lately. While this is only tangentially related to my usual veterinary focus, I thought I would share an interesting document I found.

Assessing the State of Vaccine Confidence in the United States: Recommendations from the National Vaccine Advisory Committee, DHSS. Draft Report

The purpose of this report was to evaluate the degree of confidence parents in the U.S. have in the recommended vaccination protocols, how this is assessed, and what we might be able to do to increase confidence and improve vaccination rates. There weren’t a lot of surprises in the report, but it’s a concise summary of the situation.

The Good News
One persistent problem with media coverage of most issues, including vaccination, is that it is easy for small numbers of vocal, passionate people to be disproportionally represented and to thereby create an inaccurate impression of how widespread their views are. In the case of vaccine confidence, the vast majority of parents trust and follow the recommendations of the medical community, and this level of adherence has been stable for many years. 80-90% of parents have their children fully vaccinated, which is far more of a consensus than on just about any other hot-button political issue. The emphasis on the exceptions, and the desire to improve vaccine compliance is not a reflection of a widespread resistance to vaccination but a function of the need to have very high rates, generally well over 90%, in order to reap the benefits of herd immunity and protect those who cannot have vaccines for medical reasons or for whom vaccination is not 100% protective.

It is important to remind ourselves that vaccinating your children is not only a good idea for their health and the health of others, it is also a normative social behavior. While people should, ideally, make rational and evidence-based decisions independent of the beliefs of others, the reality is that people are influenced strongly by what they perceive to be the beliefs of other members of their community. If parents mistakenly believe that vaccine-refusal is mainstream, they may take it more seriously despite the misguided and mistaken foundations of anti-vaccine attitudes. However, if people understand that vaccination is not, in fact, controversial but accepted by the overwhelming majority of American parents, they may be more comfortable rejecting the scare tactics and specious arguments of vaccine opponents.

This study also found that there is a high degree of confidence in reliable sources of information about vaccines, especially healthcare providers. Most parents trust their pediatrician’s advice, and many who have reservations about vaccines but ultimately decide to follow the guidelines do so because of information and counseling given by their children’s doctor.

Vaccination has been the most successful preventative healthcare intervention in history, and the high rates of vaccine acceptance in the U.S. have allowed more than one generation to grow up ignorant of the dangers of many infectious diseases that routinely injured and killed children for millennia before the development of vaccines. Even though the number of people who have firsthand experiences with these diseases is few and dwindling in the developed world, most parents still understand the importance of vaccinating their children to prevent the resurgence of these infections.

The Bad News
Despite the overall high and stable levels of acceptance of science-based vaccination guidelines, confidence in vaccination varies dramatically by region. The problem today is not widespread rejection of vaccines but high levels of rejection in localized communities. These communities have proven to be sources of outbreaks of otherwise well-controlled infectious diseases. Regional and demographic factors which are partially but not completely understood have led to such pockets of vaccine rejection in which vaccination rates are low enough to undermine herd immunity and facilitate outbreaks. I know because, sadly, my own child goes to school in such a pocket, with vaccination rates well below the average for the state and the other schools in the district.

As mentioned earlier, the formation of such pockets of mistrust in vaccines are facilitated by the impression they create that suspicion of vaccination is common and mainstream. Even in my community, 84% of children are fully vaccinated, yet the remaining 16% of families are able to sustain misguided beliefs about vaccines within a supportive echo chamber that helps insulate them from the information and arguments that the rest of the community offers in support of vaccination.

Though the report does not address this, I have the subjective impression that there is a strong correlation between vaccine refusal and more general pseudoscientific attitudes and beliefs. Most of the individuals arguing against the scientific consensus on vaccines in my community, for example, also proclaim homeopathy and other alternative therapies to be safer and more effective alternatives. And the organized voice for chiropractors in California, the California Chiropractic Association, has come out in opposition to reforming the state’s vaccine exemption laws and recently gave a hero’s welcome to disgraced physician Andrew Wakefield, who launched the modern anti-vaccine movement:

The California Chiropractic Association is actively lobbying against California Senate Bill 277, which would end the state’s “personal belief” exemption against ten types of vaccinations now required to begin school. [Mason M. Chiropractors lobby against bill ending belief exemptions for vaccines. Los Angeles Times, March 5, 2015] CCA’s Web site advises members to say that they are “NOT anti-vaccine we are pro-inform consent and choice.”

Life Chiropractic College West sponsored a talk by Andrew Wakefield, who lost his British medical license for unprofessional conduct related to vaccine scaremongering. The San Francisco Chronicle has reported that he received standing ovations after he advised hundred of students that SB 277 was a step toward mandatory vaccination that could have dire consequences. The paper also noted that the school’s president was considering hiring buses and canceling classes so students could attend a Senate hearing. consent and choice.”

The importance of legislation like SB277, the initiative to eliminate non-medical exemptions to school vaccination requirements in California, is also emphasized in the report. Such exemptions, particularly those that require only a “philosophical” objection and are easy to get, have increased significantly, and they are directly associated with the growth of local clusters of vaccine refusal, and the subsequent outbreak of vaccine-preventable disease. Such exemptions serve no legitimate purpose because they essentially eliminate vaccination requirements altogether and undermine the public health value of immunization. The legal and scientific legitimacy of such mandates has been settled for over a century, and recent efforts to undermine them by extending vaccine exemptions is supported only by misinformation and fear.

Conclusions & Recommendations
The report concludes that while overall confidence in vaccination and trust in doctors and public health officials is high, there are communities in which misinformation and misguided distrust have taken root, and this represents a real threat to public health. The committee made a number of recommendations for monitoring and improving confidence in vaccination:

  • Objective and standardized measures of vaccine confidence should be developed and ongoing surveillance of these should be conducted by public health agencies
  • Doctors, public health officials, and parents who support vaccination should continue to communicate the benefits of vaccination and reinforce that it is a social norm accepted by the vast majority of Americans. These communication efforts should be supported with evidence-based materials and training.
  • Vaccine exemptions for non-medical reasons should only be available if parents are adequately informed about the safety and efficacy of vaccination and the risks of not vaccinating.

Personally, I don’t believe this final recommendation goes far enough. Given the evidence that accurate information rarely changes entrenched anti-vaccine beliefs, I think the degree to which education requirements will reduce vaccine exemptions is too small to be effective. Such exemptions should not be allowed without sound medical justification. People may have the right to choose not to vaccinate their children, even if the choice is based on inaccurate beliefs and fears, however they do not have the right to then endanger others by sending their children to schools and daycare centers with other people’s children

 

 

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Coconut Oil for Pets?

Healthcare and nutrition fads are an unfortunate fact of life. People are always looking for miracle cures and for clear, defined villains they can blame for illness and try to avoid. The media contributes to the process of fads coming and going by ignoring subtlety, nuance, and uncertainty in scientific research and presenting every new study as a dramatic paradigm shift that replaces existing error with absolute truth. The slow, halting, progress in real knowledge brought about in fits and starts by the scientific process and the community of science over time is still real progress, and it has yielded true revolutionary improvements in health. But it is harder to understand and to narrate and less emotionally satisfying than quick-well-quick schemes and medical bogeymen that we can blame for all our ills.

Healthcare fads in humans readily make the transition to fads among pet owners. Even though human health problems, and their causes and solutions, are often quite different from the health problems our pets experience, people naturally tend to think that if something is good or bad for them it must be similarly good or bad for their pets. Often, even when there is some real scientific evidence for the benefits or risks of some healthcare practice in people, there is little or no evidence to support claims about these practices applied to our pets. Extrapolation from people to pets is inevitable, but it is also very risky.

One fad that has been going on for a few years now in human nutrition, and which is being touted for pets as well by proponents of alternative medicine, is the use of coconut oil to prevent or treat a wide variety of health problems. Some sites, including the ever-unreliable Dogs Naturally Magazine, claim coconut oil can prevent or treat skin disease, allergies, gastrointestinal problems, infections, diabetes, and cancer, and can even help with weight loss. Let’s have a look at this supposed “superfood” and what it can or can’t do for us and our pets.

What Is It?
Coconut oil comes, not surprisingly, from coconuts. Conventionally, it has been produced from dried coconut meat through a process that often includes hydrogenation, however sites promoting coconut oil for health often prefer “virgin” oil obtained through cold pressing of fresh coconut. Coconut oil consists primarily of saturated fats, mostly a fat called lauric acid. These fats range from long-chain to medium-chain triglycerides (MCT). It does not contain trans-fats.

The types of fat in coconut oil are the center of discussions about its health effects. At one time, it was considered the worst type of dietary fat because saturated fats had been generally linked to increased risk of cardiovascular disease (CVD). As the evidence has accumulated and been refined, however, it has turned out that different kinds of saturated fats have different potential health effects. Trans fats and long-chain fatty acids appear to elevate the type of cholesterol (low-density lipoproteins) which increase CVD risk. Other fats, such as medium-chain triglycerides, seem to increase high-density lipoproteins, which may be protective against CVD. Many foods once considered likely to increase CVD risk, such as nuts and avocados, are now believed to be neutral or even possibly protective with regard to CVD.

Some of the fats in coconut oil are MCTs, and this is the foundation for most claims about the potential health benefits of coconut oil. However, only about 15-20% of the fats in coconut oil are true MCTs, and the effects of the most prevalent, lauric acid, on cholesterol are the subject of debate.

Most of the claims about health effects in humans for coconut oil focus on prevention of heart disease, treatment of diabetes and Alzheimer’s disease, and beneficial effects on weight loss. However, all kinds of other dramatic claims are easily found. In pets, CVD is a far different and generally less common entity, so the claims are more general, focusing especially on skin health, gastrointestinal health, and infections, though some vets claim they have cured cancers with it.

Does It Work?
The evidence for beneficial effects from coconut oil in humans is almost all indirect. Studies looking at MCTs in the diet show some potential benefits, and the proponents of coconut oil then extrapolate to assume that this product must have these benefits because it contains MCTs. This is a tenuous type of extrapolation at best. Claims for coconut oil are also often supported mostly by in vitro or lab animal research, which unfortunately can only prove an effect is possible, not that it will actually, reliably, and safely be seen in human patients.

One excellent summary of the existing research summarizes the evidence this way:

Coconut oil is not a cure-all. Research supporting claims of its role in preventing, reducing risk for, or curing HIV/AIDS, diabetes, thyroid disease, or Alzheimer’s disease is sparse or non-existent. There is little evidence to suggest it has a significant effect on inflammation or bacterial infection when consumed in food. And the pre-clinical research in cancer is mixed. Considerable research is needed to determine whether such claims may one day be substantiated. Further research may also help to clarify the potentially beneficial effect of coconut oil on HDL cholesterol levels and waist circumference. In order to reduce cardiovascular disease risk through diet, it will be necessary to determine the appropriate balance of dietary fatty acids that will favorably affect a range of cardiovascular risk factors. It is possible to include coconut oil in a healthful diet. Rather than focus on the saturated fat content of this single food ingredient, it is important to acknowledge that coconut oil contains a blend of fatty acids and other nutrients. It should not replace a significant amount of other plant oils in the diet. Those who enjoy the flavor of coconut oil may consider using it in place of butter or shortening, or paired with other cooking oils. Coconut oil can be one of a wide variety of plant-based foods that are included to support health and wellness, keeping in mind that only small amounts should be consumed.

As usual, there is almost no research available in dogs and cats, and the claims made for coconut oil in these species are extrapolated from human medicine, where we have seen the evidence is not strong to begin with. One study that added coconut oil to dog food to see if it would help with weight loss found that dogs on the diet with coconut oil lost less weight and had more body fat than dogs on diets with other sources of fat. Another study looked at various fats, including coconut oil, and exercise and how they affected the odorant detecting ability of dogs. It isn’t clear this has any clinical relevance to anything, but in any case the dogs getting the coconut oil seemed to have some decline in odorant detecting ability.

Some research has suggested that coconut oil shampoo may be effective against some common parasites in dogs. Another study indicated effectiveness against mange mites. However, both studies were conducted by the same research group with a strong bias in favor of such “natural” treatments and without some key controls for bias, so they need to be replicated to confirm these findings.

There is no clinical research of any kind showing a significant benefit from dietary or topical coconut oil in the prevention or treatment of any significant health problem.

Is It Safe?
No significant short-term risks have been identified for dietary coconut oil in humans in reasonable quantities, though diarrhea and other gastrointestinal problems have been reported. Long-term safety and effect on obesity, CVD< and other health risks hasn’t been determined.

Similar gastrointestinal symptoms have been reported in dogs, and there are anecdotal reports of more serious problems such as pancreatitis. There is no controlled research evidence investigating the safety of coconut oil in dogs and cats.

Bottom Line
There are some theoretical reasons to think the types of fat found in non-hydrogenated coconut oil might have health benefits in humans, but there is no conclusive research to support this. There is virtually no research on coconut oil in dogs and cats, apart from some studies looking at topical use for treatment of parasites. Therefore, the health effects, both risks and benefits, are unknown and supported only by unreliable anecdotal evidence.

 

Posted in Nutrition | 12 Comments

Evidence-Based Veterinary Medicine: What is it & Why Does it Matter?

The Equine Veterinary Journal and Equine Veterinary education journal have just launched a new open-access evidence-based medicine resource, including systematic reviews, critically-appraised topic reports (CATs) and editorials. This includes my most recent editorial on the subject, which I can now share here since it is an open access publication:

McKenzie, B. (2014), Evidence-based veterinary medicine: What is it and why does it matter?. Equine Veterinary Education, 26: 451–452. doi: 10.1111/eve.12216

The term ‘evidence-based medicine’ (EBM) began to appear in the human medical literature in the early 1990s. Since then, both the term and approach have become ubiquitous in human medicine. Although there has been controversy and debate about EBM, it has been widely adopted and almost universally endorsed by medical associations, specialty boards, patient advocacy groups and government agencies (Claridge and Fabian 2005).

References to ‘evidence-based veterinary medicine’ (EBVM) did not become common until nearly 10 years later. The term is now widely used, and references to EBVM are common in veterinary journals and continuing education meetings. However, the principles and practices of EBVM have not yet been endorsed or employed widely in veterinary medicine (Vandeweerd et?al. 2012).

Like other advances in human medicine, EBM must be adapted to meet the unique and varied needs of veterinary practitioners. However, once properly ‘translated’ into veterinary medicine, EBVM offers many benefits to veterinarians and our patients and clients.

What Is It?

At its heart, EBVM is the formal application of the philosophy and methods of science to generating knowledge and making decisions in veterinary medicine. As clinicians we need information to evaluate our patients’ health problems and provide effective preventative and therapeutic interventions. Evidence-based veterinary medicine provides tools and guidance to those who generate this information (through clinical research), those who disseminate it (through publication, continuing education, clinical practice guidelines, etc.) and those who utilise it (in clinical practice as well as public health and policy making). With better information and more efficient information management we are able to make better decisions and provide the best patient care possible.

Traditionally, veterinarians have relied on personal experience and the wisdom of mentors, teachers and opinion leaders to guide their clinical practices. Formal scientific research has played a role in informing clinical practice, but often the use of this resource has been inconsistent and indirect, filtered through the opinions of experts relied on by practitioners to interpret the scientific literature.

Evidence-based veterinary medicine is predicated on the understanding that this approach, which might be characterised as ‘opinion-based medicine,’ involves significant and predictable sources of error. Controlled scientific research effectively overcomes many of the limitations of individual judgement that lead us to the wrong conclusions and decisions.

Therefore, EBVM is partly a system for facilitating the effective use of controlled research to inform clinical practice. In addition to supporting the production of high quality research, EBVM promotes the dissemination of such research in a form which is practical and useful to clinicians. The scientific literature must be accessible to be useful, so EBVM proponents encourage open access publishing models. Since most clinicians lack the time and training to search and appraise the research literature personally, EBVM provides tools for synthesising this information in useful forms such as systematic reviews and clinical practice guidelines.

The main functions of EBVM are to facilitate the production of relevant, high quality scientific research, the effective dissemination of this research in a useful form and the integration of this information with clinical experience, client goals and values and the unique circumstances of each individual patient in order to inform decision-making and optimise patient care.

Why Does It Matter?

There is a robust literature evaluating the causes of error in clinical decision-making by physicians. This literature shows that the most significant sources of error are precisely those EBVM is designed to mitigate: the limitations of individual perception and judgement and inefficiencies of traditional information management approaches (McKenzie 2014). The same limitations and the same strategies for overcoming them likely apply to veterinary medicine.

Even the smartest, most highly trained clinician operates with all the limitations and quirks of the human brain. Science helps to compensate for these and improve the quality of the information available to us. Evidence-based veterinary medicine does not replace the judgement of the individual clinician. The practitioner is always the one to determine the information needed to help a particular patient, the relevance and reliability of the available scientific research and the best course of action within existing constraints, such as the interventions available, the values and resources of the client and other ‘real-world’ variables. However, ready access to relevant, high-quality scientific research supports the clinician in making the most effective diagnostic and therapeutic plan.

Evidence-based veterinary medicine also provides an approach to managing the information needed to make clinical decisions. The traditional approach is the ‘Just in Case’ model (Cockcroft and Holmes 2003). We endeavour to acquire and retain an enormous body of knowledge about health and disease and the interventions currently available just in case we need some of that information to help a given patient. This is an inefficient strategy that places a tremendous burden on the individual practitioner and provides much opportunity for error.

Evidence-based veterinary medicine promotes the ‘Just in Time’ model instead (Cockcroft and Holmes 2003). The clinician is trained to identify the information needed to manage a particular case and is given the tools and skills to locate that information and evaluate its relevance and reliability when it is needed. This reduces the cognitive burden on the practitioner and the opportunity for mistakes.

There is evidence in human medicine that both better information and more efficient information management provided by EBM improve patient outcomes and reduce medical errors and stress for clinicians (Bahtsevani et?al. 2004; Amarasingham et?al. 2009). Veterinarians and their patients would likely also benefit from wider use of these methods.

Finally, there is an ethical dimension to the use of EBVM. Of course, veterinarians are obligated to provide the best patient care possible and EBVM can facilitate this. However, there is also an ethical expectation that we should obtain informed consent from our clients before employing our interventions (Fettman and Rollin 2002). Such consent cannot be truly informed without explicit discussion of the uncertainties involved in a particular situation. Only through deliberate assessment and communication of the quality and limitations of the evidence for a particular intervention can we meet our obligation to properly inform our clients so they can make choices about the care we provide for their animals.

Evidence-based veterinary medicine provides practitioners with more useful and reliable information to support decisions, reduces error and stress, improves patient care and helps us meet our ethical obligations to our clients and patients. Evidence-based medicine is a well developed system widely employed in human medicine and, with appropriate adaptation, EBVM can be a similarly widespread and useful approach in veterinary medicine.

References

  • Amarasingham, R., Plantinga, L., Diener-West, M., Gaskin, D.J. and Powe, N.R. (2009) Clinical information technologies and inpatient outcomes: a multiple hospital study. Arch. Intern. Med. 169, 108114.
  • Bahtsevani, C., Udén, G. and Willman, A. (2004) Outcomes of evidence-based clinical practice guidelines: a systematic review. Int. J. Technol. Assess. Health Care 20, 427433.
  • Claridge, J.A. and Fabian, T.C. (2005) History and development of evidence-based medicine. World J. Surg. 29, 547553.
  • Cockcroft, P.D. and Holmes, M.A. (2003) Handbook of Evidence-based Veterinary Medicine, Blackwell Publishing, Oxford, UK and Malden, MA.
  • Fettman, M.J. and Rollin, B.E. (2002) Modern elements of informed consent for general veterinary practitioners. J. Am. Vet. Med. Ass. 221, 13861393.
  • McKenzie, B.A. (2014) Veterinary clinical decision-making: cognitive biases, external constraints, and strategies for improvement. J. Am. Vet. Med. Ass. 244, 271276.
  • Vandeweerd, J.M., Kirschvink, N., Clegg, P., Vandenput, S., Gustin, P. and Saegerman, C. (2012) Is evidence-based medicine so evident in veterinary research and practice? History, obstacles and perspectives. Vet. J. 191, 2834. doi:10.1016/j.tvjl.2011.04.013.
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SB277- Eliminating Personal Belief Vaccine Exemption in California

I’m stepping outside of my usual territory as a veterinarian to raise a human healthcare issue– vaccination exemptions. In my state of California, it is very easy for misinformed parents with unfounded concerns about the safety and efficacy of vaccinations to choose not to vaccinate their children and yet send those children to school where they can pose a health risk to others. In the wake of the recent measles outbreak centered at Disneyland, the California state legislature is considering legislation to eliminate the “personal belief” exemption from vaccination requirements for schoolchildren. As a parent and a scientist, I support this legislation and am advocating for it in my community. I have put together some information and links on the subject for others in the state who wish to contact their legislators and urge passage of this bill.

I have started a petition to the CA State Senate and State Assembly which I encourage supports of SB277 to sign:

iloveimmunity

 

Here is my letter to the parents in my own child’s school:

Parents,

The CA State Assembly is currently considering SB277, a bill that originated in the state senate and is intended to reduce the risk of vaccine-preventable disease in California by preventing children from attending schools, daycare centers, or other such institutions if they are not appropriately vaccinated. The legislation allows exemptions for medical reasons but not on the basis of the personal beliefs of parents. As this issue significantly affects all of us as parents of school-aged children, I urge members of the community to inform themselves about this legislation and to make their views known to their representatives.

I have collected some useful links below with additional information about the legislation and with reliable sources of information concerning the relevant vaccines. While parents have the right to refuse vaccination for their children, even when this decision is based on misinformation or fear, they do not have the right to endanger other children or vulnerable individuals through this choice. Opponents of this legislation include extreme anti-vaccine activists who have likened the measure to the Nazi Holocaust and have threatened violence against legislators who support it. Though misguided and misinformed, these views could intimidate politicians into not taking action on this important issue, so it is important that they hear from more moderate citizens with all points of view.

Thank you,

SB 277
http://www.vaccinatecalifornia.org/sb277_faqs

How to Contact Your Representatives
http://findyourrep.legislature.ca.gov/

Reliable Information About Vaccines
http://www.vaccines.gov/
http://www.cdc.gov/vaccines/vac-gen/howvpd.htm
http://vec.chop.edu/service/vaccine-education-center/home.html
http://www.vaccine.org/

Parents Supporting Appropriate Vaccination
http://www.voicesforvaccines.org/
http://shotofprevention.com/
http://valueofvaccination.org/

Herd Immunity
http://www.cdc.gov/vaccines/parents/vaccine-decision/prevent-diseases.html
http://www.vaccines.gov/basics/protection/
http://www.who.int/bulletin/volumes/86/2/07-040089/en/
http://eziz.org/assets/docs/IMM-1056.pdf
http://cid.oxfordjournals.org/content/52/7/911.full

Here are some statistics on the risks associated with previously common childhood illnesses and the effects of vaccination on these. I think it is clear that we SHOULD prevent these diseases:

http://www.cdc.gov/measles/about/complications.html
http://www.cdc.gov/mumps/about/complications.html
http://www.cdc.gov/pertussis/about/complications.html
http://www.cdc.gov/chickenpox/about/complications.html
http://www.ncbi.nlm.nih.gov/pubmed/18000199
http://www.cdc.gov/mmwr/preview/mmwrhtml/mm6316a4.htm

Vaccines and Autism

  1. A recent study of over 95,000 children looked at those at highest risk for ASD, siblings of those with the syndrome, found no link to vaccination, confirming yet again the results of other studies involving millions of children:

http://jama.jamanetwork.com/article.aspx?articleid=2275444

Conclusions and Relevance  In this large sample of privately insured children with older siblings, receipt of the MMR vaccine was not associated with increased risk of ASD, regardless of whether older siblings had ASD. These findings indicate no harmful association between MMR vaccine receipt and ASD even among children already at higher risk for ASD.”

  1. The American Academy of Pediatrics has clearly stated that the extensive research shows no connection between MMR or specific ingredients in vaccines, including thimerosol, and ASD. The AAP has listed many of the original studies here so parents can investigate them for themselves:

https://www2.aap.org/immunization/families/faq/vaccinestudies.pdf

  1. The Centers for Disease Control has also stated directly that “studies have shown that there is no link between receiving vaccines and developing ASD.” Here is the CDC page addressing the issue, again with links to relevant evidence:

http://www.cdc.gov/vaccinesafety/concerns/autism/

  1. Autism Speaks, a parent and child advocacy group for families affected by ASD has also officially accepted the evidence that vaccines are not linked to the disorder and provides summary of some of the most compelling studies:

https://www.autismspeaks.org/science/science-news/new-meta-analysis-confirms-no-association-between-vaccines-and-autism

“Over the last two decades, extensive research has asked whether there is any link between childhood vaccinations and autism.  The results of this research are clear: Vaccines do not cause autism.  We urge that all children be fully vaccinated.”

  1. For those not into reading research studies, PBS has put together a clear and comprehensible presentation on the vaccine/ASD question and the general issue of childhood vaccinations which is fact-based and informative:

http://www.pbs.org/wgbh/nova/body/autism-vaccine-myth.html
http://www.pbs.org/wgbh/nova/body/vaccines-calling-shots.html

Toxins in Vaccines

In addition to having accurate information about the ingredients in vaccines, it is important to have accurate information about the health effects, if any, of those ingredients. No substance is absolutely safe (it is possible, after all, to die from too much oxygen or water despite the fact that both are necessary for life). Likewise, many substances can be safe or even beneficial at some level or in one form even when they are harmful at a higher level or in a different form.

As an example, people are often familiar with the use of formaldehyde in embalming and with the fact that, under the right circumstances, it can increase the risk of cancer and cause other adverse effects. So it is natural to be surprised to see it listed as an ingredient in vaccines. What people often do not know is:

1. Formaldehyde is produced naturally in the body and is essential in the production and metabolism of certain amino acids needed to make proteins.

2. The amount of formaldehyde in vaccine sis far, far less than what is normally present in our bodies and naturally produced in many foods. The highest possible exposure to this chemical in normal vaccination practice is less than 1% of the amount already present in the body naturally, and the extra is typically metabolized completely within 30 minutes after vaccination.

3. The formaldehyde present in vaccines makes them safer by reducing the risk of vaccines becoming contaminated with viruses and causing infections or other illness.

Here are some further sources of information about formaldehyde and other vaccine ingredients people may have concerns about:

http://www.fda.gov/BiologicsBloodVaccines/ScienceResearch/ucm349473.htm
http://www.harpocratesspeaks.com/2012/04/demystifying-vaccine-ingredients.html
http://www.cdc.gov/vaccines/vac-gen/additives.htm
http://www2.aap.org/immunization/families/faq/vaccineingredients.pdf
http://www.fda.gov/BiologicsBloodVaccines/SafetyAvailability/VaccineSafety/ucm187810.htm

So when considering vaccine ingredients when making decisions about vaccination, it is necessary to find detailed and accurate information about them to determine whether or not we should be concerned about individual compounds.

 

My letter to my representative: 

I write to urge you to vote for SB277, which will make our state’s schools safer.  

I appreciate the critical importance to public health of vaccination both as a veterinarian and as the parent of a student in the California public schools. While our generation has been fortunate enough not to see the epidemics of polio, measles, and other vaccine-preventable disease our parents can still remember, many of these disease can and will return to harm our own children if we are not vigilant. Parents certainly have the right to decline vaccination for their children, even if their decision may be based on misinformation and fear. However, they do not have the right to endanger my daughter or others by sending their children to public schools unvaccinated.

The measles outbreak and the pertussis epidemic are stark reminders of how fragile we are as a community.  SB277 will protect our children and communities by raising the vaccination rates.  SB277 is the best way to ensure that the weakest among us – the young, the ill, the old, and those for whom vaccines don’t work – are safe from vaccine-preventable disease. 

We are relying on you to help protect our communities.  This legislation is the right thing to do.  Please vote for it.

 

 

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John Maddox Prize for Promoting Science & Evidence in the Public Interest

A great science advocacy group from the UK called Sense About Science offers annual prize to recognize individuals who are publically promoting the importance and use of science and evidence. Here is how they describe the award:

2015 John Maddox Prize

The John Maddox Prize rewards an individual who has promoted sound science and evidence on a matter of public interest. Its emphasis is on those who have faced difficulty or hostility in doing so. Nominations of active researchers who have yet to receive recognition for their public-interest work are particularly welcomed.

The prize is open to nominations for any kind of public activity, including all forms of writing, speaking and public engagement, in any of the following areas:

Addressing misleading information about scientific or medical issues.

Bringing sound evidence to bear in a public or policy debate.

Helping people to make sense of a complex scientific issue.

Nominations can be made here. There are MANY great individuals out there working in this area, so pick your favorite and nominate them (even if it’s not a certain awesome veterinary blogger!) 😉

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Publications

In addition to my work on this blog, I do write for the professional veterinary literature and lay press as well, so I thought I’d list some of those publications for anyone who is interested.

Professional Literature

McKenzie, BA. Evidence-based veterinary medicine: What is it and why does it matter? Equine Vet Edu. 2014;26(9):451-452.

McKenzie, BA. Veterinary clinical decision-making: cognitive biases, external constraints, and strategies for improvement. J Amer Vet Med Assoc. 2014;244(3):271-276.

McKenzie, BA. Is complementary and alternative medicine compatible with evidence-based medicine? J Amer Vet Med Assoc. 2012;241(4):421-6.

McKenzie, BA. Evaluating the benefits and risks of neutering dogs and cats. CAB Reviews: Persp in Agricul, Vet Sci, Nutr, Nat Res. 2010;5(45).

McKenzie, BA. What’s the Evidence? Glucosamine and chondroitin for canine osteoarthritis. J Amer Vet Med Assoc. 2010;237(12):1382-3.

General Media

Evidence, Communication Key to Evaluating Veterinarian
SF Gate online: January, 2014

How Much Rawhide is too Much for Dogs?
SF Gate online: February, 2012

McKenzie, BA. (2012). Protecting public health is the responsibility of the government. In: Engdahl, S. (Ed.), Alternative Therapies (Current Controversies) (pp.130-7). Farmington Hills: Greenhaven Press. Adapted from “CAM and the Law, Part I: Introduction to the Issues,” ScienceBasedMedicine.org, November 9, 2010.

McKenzie, BA. (2012). The popularity of alternative medicine is exaggerated. In: Zott, LM. (Ed.), Alternative Medicine (Opposing Viewpoints) (pp.90-7). Detroit: Greenhaven Press. Adapted from “How Popular is Acupuncture?” ScienceBasedMedicine.org, March 25, 2011.

How to Help Elderly Dogs with Degenerative Conditions
San Jose Mercury News online: June, 2011

Why is my Cat Sneezing?
San Jose Mercury News online: April, 2011

Can Dry Cat Food Cause Kidney Problems?
San Jose Mercury News online: April, 2011

Don’t Pamper Pets with Halloween Candy
San Jose Mercury News online: November, 2010

 

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Science Through the Looking Glass- The Integrative Veterinary Care Journal

While much of so-called complementary and alternative medicine (CAM), also referred to by the latest marketing buzzword “integrative medicine,” is clearly inconsistent in theory and practice with science and science-based medicine, nevertheless practitioners of CAM like to assume the trappings of legitimate medical science. From copying the title of Doctor for professions like chiropractic, naturopathy, and “Oriental Medicine” which have little to do with science-based healthcare, to holding “scientific” conferences and conducting research studies (sometimes legitimate, often pure propaganda), proponents of CAM try to look as much like practitioners of science-based healthcare as possible even while simultaneously denigrating it and claiming to have entirely different and superior methods. Another element to this effort is the publication of CAM-centered journals.

Legitimate research into plausible therapies, such as dietary supplements and herbal remedies, is often published in mainstream medical journals. But much of CAM research is so clearly ridiculous or so methodologically sloppy that it cannot be accepted into scientific journals. This has led to the creation of a parallel system of journals with all the trappings of real medical journals but willing to publish almost anything that makes CAM therapies look like they work.

In the past, I have written about articles appearing in some of these publications, including the Journal of the American Holistic Veterinary Medical Association journal of the Academy of Veterinary Homeopathy. I recently had an opportunity to look at the current issue of another example of this genre, the Integrative Veterinary Care Journal (IVC).

Despite the title, this is really more of a magazine than a journal, publishing opinion pieces and anecdotes primarily rather than formal research studies. It is also dense with advertising, some of which is cleverly formatted to look like articles rather than ads, apart from the small label of “Advertorial” or “Product Profile” in the header. Legitimate journals, of course, also employ sometimes excessive or ethically questionable use of advertising, but there is an added layer of hypocrisy in the blatant commercialism of the IVC given the tendency of CAM advocates to attack science-based medicine for financial ties to healthcare product industries. This reminds us that practitioners of alternative therapies have every bit as much financial interest in their products and services, and in the industries that support them, as conventional practitioners.

The Advisory Board for the IVC includes many familiar individuals associated with the AHVMA and other pro-CAVM organization. I have previously discussed statements made by Dr. Richard Palmquist (1, 2, 3, 4, 5) Dr. Jean Dodds (1, 2), Dr. Barbara Fougere (1), Dr. Joyce Harman (1) and Dr. Christina Chambreau (1), and all have staked out positions incompatible with a science-based approach to veterinary medicine. Dr. Steve Marsden is a well-known practitioner of so-called Traditional Chinese Veterinary Medicine (TCVM), which is a soundly mystical, pseudoscientific practice, and he is a driving force behind the Cured Cases database and forum, a project for collecting anecdotes to generate the impression of evidence in favor of alternative therapies and for providing a forum in which talking about disease being caused and treated by alterations of Heat, Wind, Ying, Yang, Chi and so on is taken seriously. So it is not surprising to find that the contents of the IVC reflect the disdain for the scientific approach to medicine these folks often express.

While there are certainly reports and ads for mainstream medical practices in the IVC, these are “integrated” with some pretty egregious pseudoscience and nonsense. No effort is made to distinguish legitimate science from outright magic. This illustrates a serious problem with the whole concept of integrative medicine. It gives the appearance of legitimacy to nonsense while degrading the overall quality of veterinary medicine. Or as Mark Crislip colorfully puts it, “If you integrate fantasy with reality, you do not instantiate reality. If you mix cow pie with apple pie, it does not make the cow pie taste better; it makes the apple pie worse.”

Essential Oils and Chinese Medicine
The first example of nonsense in this issue of IVC is an article discussing the use of essential oils according to the principles of Chinese Medicine. The article is written by Dr. Cynthia Lakenau, a “holistic” veterinarian, and Jeffrey Yuen, a Chinese Medicine practitioner. Dr. Lakenau practices the usual hodgepodge of mutually inconsistent methods which are unified only by their opposition to science-based medicine. She also has some of the usual uncharitable views of conventional veterinary medicine:

I am very encouraged by the acceptance in some corners of the conventional world, enough to truly hope and believe that every veterinary college in the future will offer training in all alternative modalities, minimize drug use, and truly practice wellness maintenance medicine.  But I see two problems both created from greed.  I am nervous that when the conventional world realizes the loss of income from animals being truly healthy, they might wage an aggressive smear campaign. [I imagine that is how she’ll categorize this article if she sees it]

Mr. Yuen has no conventional medical training but describes his credentials this way:

Jeffrey C. Yuen comes from two Daoist lineages. He is an 88th generation Daoist master of the Yu Qing Huang Lao Pai (Jade Purity Yellow Emperor Lao Zi School) and a 26th generation Daoist Master of the Quan Zhen Long men Pai (Complete Reality Dragon Gate School)… Having a strong resonance with Daoist teachings ever since childhood, Jeffrey studied extensively under Master Yu Wen and was allowed to openly practice and serve the community when he was 16 years old… Mr. Jeffrey C. Yuen also studied Chinese herbal medicine with Master Gong Song-Liu, a eunuch for the last two emperors of the Qing Dynasty who apprenticed with the imperial medical physicians. As a friend of Master Yu Wen, Gong was persuaded to teach Jeffrey, imparting his deep knowledge of Chinese medicine over a period of 8 years. ..Today Jeffrey Yuen is recognized internationally as a master scholar, teacher and practitioner of Classical Chinese Medicine. This includes Acupuncture, Herbal Medicine, Nutrition/Dietetics, the therapeutic use of Stones and Essential Oils, Tai Qi, Qi Gong and Daoism. Indeed, as a Daoist priest, Jeffrey is at the forefront of the restoration of the spiritual roots of Chinese Medicine. His teachings rooted in the spiritual tradition of Daoist mysticism bring a clarity, wisdom and depth to Chinese Medicine rarely found today.

This resume illustrates the explicitly religious nature of TCM and TCVM. The health practices employed in TCM are fundamentally spiritual practices based in a faith-based ideology, not medical practices aimed at curing physical ills or based on modern scientific principles. Despite the use of herbal remedies and the recent adoption of acupuncture among mainstream medical professionals, at its core TCM has more in common with Christian Science, Voudou, and other forms of faith healing than it has with scientific medicine. Sadly, it is often presented to patients and veterinary clients as a medical rather than a religious practice.

The mystical nature of this approach is evidence in the IVC article concerning essential oils.

Essential oils represent the genetic unfolding of the plant, the Jing, the essence of the plant. They therefore have potential effects on physical developmental problems as well as the mental and spiritual…The plant’s Jing will resonate with the body’s Jing. As a result, a vast degree of possible healing can occur when essential oils are applied to acupuncture meridians..

The article goes on to suggest that if children and animals fear needles or do not willingly ingest Chinese herbal concoctions, one can achieve similar effects by applying essential oils to magic locations on the body (despite the problem that acupuncture points cannot be shown to exist or be consistently identified and agreed upon by acupuncturists).

And while it is claimed that scientific sounding rationales for the use of such oils can be found (what the authors call “the chemotype theory”), this is not considered essential to evaluating the safety or efficacy of such products. Instead, TCM categorizes these agents in term of the mystical system it employs for other interventions, “law of signatures, five elemental associations, nature or temperature, taste, aroma, relationship to neighboring plants and channel (or meridian) affiliation.” This collection of mystical theoretical constructs, and the associated diagnostic practices employed in TCM, renders even potentially plausible interventions like herbal medicine unreliable when they are employed according to what is essentially a system of magic.

Additionally, according to Lakenau and Yuen, essential oils are categorized and employed according to their “notes.”

High Notes- Oils that evaporate rapidly, influence the Wei Qi (defensive immune system or external) level, Primarily used for acute conditions. “They awaken the senses, serving as the first invitation for a patient to change.”

Middle Notes- “used for more sub-acute problems that tend to be in the Ying level, which affects plasma in the blood…useful for circulatory issues (movement of Qi moving blood), to regulate digestion…and for cognitive function (digesting and assimilating the information around us and eliminating that which is not needed” [which, presumably, includes biochemistry, physiology, and clinical trials]

Base Notes- “for chronic, constitutional issues at eh Yuan level (which can influence genetic tendencies)”

While the theory here is fanciful, the fact that it is suggested employing these remedies in this manner is actually a responsible way to treat serious disease is outrageous.

…if you have a dog with an autoimmune joint disease such a rheumatoid arthritis, you could use a top note…to help with his ability to rest during any acute situations; a middle note…to help clear the heat of the latent infection; and a base note…to help treat the fascial pain

Since rheumatoid arthritis is a serious, painful disease which is not due to the “heat of a latent infection” and does not involve the fascia, following this advice would be gross malpractice.

Finally, the authors suggest topical application of essential oils for “bodywork and cranial-sacral work,” thus merging the theoretical nonsense of certain manipulative therapies with the nonsense of TCM. They also suggest deciding where to apply the oils based on acupuncture points (which are, of course, as objectively real as constellations in the night sky) or which “humors” you want to affect. Apparently, the ears affect the nervous system whereas the paws effect circulation. At this point, I suspect no one will be shocked to learn that no scientific research is cited to support any of the claims or recommendations in this article.

Treating Canine Lipomas
Another article in this issue addresses the treatment of a common benign tumor called a lipoma. These are aggregations of fat which typically occur in middle-aged and older dogs. The exact cause is not known. They are more common in certain breeds and possibly in overweight dogs. Research in humans suggests possible genetic risk factors, but the definitive cause is not known. This, of course, provides an open field for rampant speculation of how to treat and prevent these benign tumors.

Conventional medicine recommends no treatment unless they cause clinically important problems, based on size and location, and then surgical removal. However, the author of this article, Dr. Christina Chambreau, who is predominantly a homeopath (meaning, she believes in magic) has a different perspective.

The holistic perspective looks at all symptoms as clues to an underlying vibrational imbalance (Qi, vital force, etc.). Most integrative practitioners see lipomas as the body’s way of exteriorizing toxins…TCVM lists lipomas as stagnation of body fluids.

This paragraph manages, completely without irony, to lump together a variety of mutually incompatible theories that share only the feature of being nonsense incompatible with actual science. Qi, vital force, etc. (by which she means other alternative medicine constructs such as chiropractic’s “innate intelligence,” Ayurveda’s “prana,” and so on) are mystical forces that are fundamentally spiritual in nature. These are undetectable, unmeasurable, magical energies that apparent cause all disease and can be manipulated to cure disease, but only if you are willing to believe in them with no actual evidence. Once again, this illustrates the fundamentally religious nature of much alternative medicine.

The notion that disease is caused by mysterious, unidentified “toxins” is another popular alternative medicine trope. It is theoretically inconsistent with the notion of spiritual imbalances causing disease, but this never seems to bother alternative practitioners. In any case, it shares at least the quality of being arrant nonsense.

Stagnation of body fluids is a reference to the humoral theory of health and disease. This is a popular concept in pre-scientific folk medicine. It was the basis for all the bloodletting and purging that European and early North American physicians used to practice, but these ideas and associated practices were abandoned by conventional medicine when science proved them to be untrue an ineffective. TCVM and other holdovers from pre-scientific medical practice retain such notions despite the evidence against them and the dramatic improvement in health that accompanies abandoning these ideas.

Of course, the fantastical theories are merely a way of introducing equally fantastical treatments that are equally lacking in any evidence of efficacy other than the testimony of the faithful. Though Dr. Chambreau admits that most integrative practitioners report being able to predictably cure lipomas with their therapies, she nevertheless uses anecdotes of responses to treatment as the basis for recommending specific therapies. Of course, she recommends minimizing the use of “chemicals and drugs in medical treatment” and of flea and tick preventatives. There is no evidence that these are risk factors for lipomas, of course, but Dr. Chambreau is willing to overlook this lack of evidence of causality, as well as the evidence of beneficial effects from medicines and parasite prevention, in order to imply that avoiding these substances will somehow reduce the risk of lipomas. Why work to prove something you can simply imply without evidence?

She also suggests looking out for her Early Warning Signs of Internal Imbalances, a dog’s breakfast of random clinical findings that she suggests, again without evidence, are somehow related to mysterious “imbalances” that might lead to actual disease. To this she adds the suggestion that some alternative vets believe lipoma risk can be reduced by “natural rearing,” a philosophy I’ve discussed before which is consists of an irrational hodgepodge of unproven or quack practices. And, not surprisingly, raw foods are mentioned as possibly preventing lipomas, just one among the many miraculous, and as yet unproven, claims for raw diets.

Speaking of miracles, Dr. Chambreau discussed one treatment for lipomas that really can’t be characterized in any other way. She reports the case of a dog who somehow managed to get lipomas despite “being raised naturally with few to no vaccines, a great diet, and no chemical exposure.” (Not that this casts any doubt, of course, on the value of these preventative strategies). He was treated with “Tui Na…Chinese massage to enhance Qi and lymph flow…[using] acupressure points on the meridians above and below each lump.” And as we all know, “Pericardium 8 is a spot in the center of a person’s hand that emits a significant amount of chi, so [the acupressure practitioners] held their palms on the lipoma. The lumps would resolve within a few days…” So by literally laying on of hands, we can supposedly make lipomas go away using the chi we project from a point in our palms named after the sack around the heart? Amazing!

Apparently, as the dog aged, this magic ritual didn’t entirely make the lumps go away anymore, but Dr. Chambreau confidently reports that “they were much less problematic than they would have been if not treated.”

The article goes on to suggest that some lipomas have been shrunk or cured using acupuncture, Chinese herbs, “a high fiber macrobiotic diet,” homeopathy, colostrum, flower bud therapy, probiotics, and chiropractic. No evidence other than anecdotes is provided for any of these claims. She does also mention liposuction, steroid injections, and surgery, all of which actually do have scientific research evaluating their effects.

With regard to surgery, however, Dr. Chambreau suggests that the most common and clearly effective treatment for lipomas is actually a bad idea, and buttresses this claim with a mishmash of sloppy reasoning and mystical ideology:

Several surgeons stated that removing one lump resulted in multiple lumps appearing later in the dog’s life. [And we know the surgery is the cause of the subsequent tumors how?]

This is because surgery removes only the tip of the iceberg. Surgery will do nothing to address the toxins causing the fatty tumor, and will leave scar tissue behind; this blocks the point of discharge the body needs to release those toxins. Once scar tissue is created, the toxins feeding the tumor are forced deeper into the patient’s body, causing damage to deeper organ systems. [A frightening prospect made less disturbing by the fact that it’s completely made up and that these “toxins” have not been shown to actually exist or cause any of the terrible consequences Dr. Chambreau proposes]

Reiki for Shelter Animals
Reiki is another form of spiritual healing in which a healer directs a mysterious form of spiritual “energy” to heal physical disease. It has the advantage over some alternative therapies of being benign in itself since it relies on magic rather than plant chemicals or needles. Nevertheless, no reliable scientific evidence has demonstrated any actual healing effects. If magic is real, then perhaps someday we will be able to demonstrate such effects, but as Tim Minchin has pointed out, “Throughout history, every mystery ever solved has turned out to be—not magic.”

The process of performing Reiki, however, might have some actual behavioral and physical effects on animals. It does, after all, involve quiet, gentle interaction and sometimes touch from a human. Anyone who has ever shared a bed or petted a dog or cat will be unsurprised by the idea that animals might enjoy this sort of interaction and find it comforting. It seems gratuitous to take ordinary kind and comforting interaction that might help shelter animals and load it down with a pile of mystical baggage and then claim that is why the animals benefit.

In this issue of IVC, however, Ms. Kathleen Prasad makes some pretty dramatic claims for Reiki in shelter animals, some of which may be actual effects of the interaction (though claiming this would require controlled research) and others are farfetched at best.

Despondent cats and dogs become more social and seem happier

I wouldn’t be at all surprised if this is true. I just would like to see some evidence it has anything to do with “spiritual energy” instead of loving human contact.

Sick animals are aided in their recovery

This kind of claim needs to be proved to be taken seriously

…Animals who have been here for a long time often get adopted shortly after treatments…One of the amazing benefits of Reiki is the inner transformation it creates in these animals..[who] can release their stress and get back in touch with their true essence. Once they remember who they are, their sweet spirits can shine through so potential adopters can see…

Clearly, these folks haven’t heard of confirmation bias or any of the other ways we fool ourselves into thinking our actions have effects they really don’t. While gentle human interaction may indeed relieve stress, all of this spiritual and psychological language is merely the projection of humans’ feelings and beliefs onto animals. And the idea that there is a direct relationship between being treated with Reiki and getting adopted is an empirical claim which needs to be demonstrated before being made.

[Some Reiki believers] often speak of how Reiki transforms the hospice experience…Since learning Reiki and using it to help with animal care during hospice, [they] report that all the deaths they have witnessed are extremely peaceful.

The use of spiritual practices in animal hospice care is something I have written about before, and it does come with significant risks. While the humans involved may find such practices comforting, and that is a good thing, there is no reason to think our animals share any of our many specific and often incompatible spiritual beliefs. I have personally seen animals who are suffering be denied appropriate pain control and human euthanasia by owners whose spiritual beliefs precluded the use of these therapies. While animal owners are entitled to these beliefs, veterinarians have a duty to advocate for the welfare and interests of our patients. It is all too easy for psychologically comforting rituals like Reiki, acupuncture, homeopathy, and so on to fool us into thinking we have done something real to reduce an animal’s suffering when we actually have not. We must rely on objective scientific evidence to help us determine if what we are doing is truly comforting our patients and not just us.

The article also claims that Reiki can help people working with shelter animals cope with stress. Again, I suspect this is true. People are often surprised to learn that I meditate and find it helpful personally. That is quite a different thing, however, from claiming that one can channel a spiritual energy force to improve physical health and the chances of a pet being adopted!

Evidence-based Chinese Herbs for Horses?
Dr. Kendra Pope contributed an article to this issue of IVC which makes use of a popular buzzword in both conventional and alternative veterinary medicine, “evidence-based.” I have been deeply involved in the promotion of evidence-based veterinary medicine (EBVM) for years, and unfortunately I often find that when people use the term I am reminded of the movie the words of Inigo Montoya in the move The Princess Bride, “You keep using that word. I do not think it means what you think it means.”

Evidence-based medicine is a set of principles and practices that extend the basic epistemological principles and methods of science to the development and use of scientific knowledge in medicine. It involves explicit and structured incorporation of scientific research evidence into clinical practice. Merely citing case reports or methodologically weak and biased studies in support of your claims and announcing “QED!” is not evidence-based medicine.

In this article, a number of citations are made in support of specific claims. These include the claims that acupuncture can effectively treat lameness and that a variety of Chinese herbal remedies, presumably applied according to the mystical system of TCM, can effectively treat tendonitis, acute and chronic respiratory disease, chronic sinusitis, colic, seizures, infertility, hepatitis, fibrous osteodystrophy, and other maladies. Since published literature is cited to support these claims, it is tempting to simply assume they have been proven and accept them at face value.

This ignores, however, the critical element of known as critical appraisal, the explicit evaluation of published research to determine the degree of confidence it is appropriate to have in the conclusions of research studies and their applicability to particular patients. A closer look at the citations in this article revealed some interesting facts. For one thing, of the 27 publications cited, 24 were in journals or textbooks devoted exclusively to TCM or alternative therapies. Of the remaining 3 articles, two were narrative reviews (essentially individual opinion pieces), and only one was a report of a clinical research study. And guess what this one study found? “Treatment with the composite did not result in statistically significant changes in any of the parameters evaluated.” That’s right! The only study cited that wasn’t from an alternative medicine journal found the remedy didn’t work! Yet it was cited in support of this practice. How’s that for evidence-based medicine?

The bulk of the studies come from the American Journal of Traditional Chinese Veterinary Medicine, and when reviewed most of these are either narrative reviews and opinion pieces, case reports and case series, or uncontrolled trials at high risk of bias. This is typical of the reports in journals dedicated to alternative veterinary therapies. They create the impression of real science by borrowing the terminology and some methodological features of scientific research but ignore the fundamental principles and key controls for bias and error that make science and science-based medicine work. This is part of the reason why a recent systematic review of veterinary homeopathy written by full-time advocates for the method was unable to find convincing evidence of real clinical effects despite many hundreds of published reports. The quality is nearly always so poor as to render the results unreliable.

Bottom Line
The IVC journal is a classic example of the effort of alternative medicine advocates to have their cake and eat it too. They want to have the legitimacy and the marketing value of being seen as scientific without giving up those beliefs and practices which are fundamentally incompatible with science. They want scientific evidence to support their beliefs but never see it as an adequate reason to abandon any therapy. And they want to be seen as open-minded doctors “integrating” alternative therapies into accepted conventional medical practice while at the same time portraying conventional medicine as frequently misguided, ineffective, dangerous, and subordinate to malign financial interests.

If CAVM proponents want scientific legitimacy, they should earn it through real, rigorous research published in real veterinary journals, and through a willingness to treat their methods as scientific hypotheses open to testing and even rejection rather than tents of an essentially religious faith that can be justly accepted without evidence on the basis of belief alone. Products like IVC are merely marketing masquerading as science, and this is fundamentally deceptive.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

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FDA Reviews Its Regulation of Homeopathy-Now is Your Chance to Comment!

The FDA is reviewing its regulation of homeopathic products, both prescription and over-the-counter. The current regulatory structure essentially no evidence of safety or efficacy since the products were grandfathered into the legislation in 1938 by its author, a Senator who had practiced homeopathy . The FDA considers homeopathic remedies for animals to be unapproved drugs but has generally declined to enforce regulations concerning their veterinary use.

Despite this regulatory loophole, the FDA does not recognize homeopathic drugs as effective, and states on its website, “FDA is not aware of scientific evidence to support homeopathy as effective.” The evidence, which I have reviewed here many times, is overwhelmingly clear that homeopathy is nothing more than a placebo. (1, 2, 3, 4)

The FDA is asking for input from the public concerning this regulatory system. It will be holding a public hearing April 20 and 21 in Silver Spring, MD and also accepting written comments electronically and by post. I encourage anyone interested in seeing the regulation of these products rely on evidence rather than history and politics to consider attending or offering a comment.

I have submitted a comment, along with a document of supporting information. Anyone who wishes to post a similar comment is welcome to use any or all of this text for that purpose:

The Food and Drug Administration (FDA) Proposed Rule: Homeopathic Product Regulation: Evaluating the Food and Drug Administration’s Regulatory Framework After a Quarter-Century; Public Hearing

ID: FDA-2015-N-0540-0001

I wish to offer my perspective on the regulation of homeopathic remedies by the FDA. As both a healthcare consumer and as a practicing veterinarian, I see the marketing and use of homeopathic products without legitimate scientific evidence of safety and efficacy as a danger to human and animal health. These products should be held to the same standards of evidence as any other drug if they are to be marketed with claims that they can treat or prevent disease in humans or animals.

The current regulatory structure effectively allows most homeopathic products to be marketed and used in humans and animals, with or without the guidance of a physician or veterinarian, without any of the scientific evidence of safety and efficacy required of most drugs regulated by the agency. This is a result of historical and political factors, but it leaves the public without the scientific information and guidance needed to make effective and informed decisions about the use of these products. The FDA itself acknowledges that “FDA is not aware of scientific evidence to support homeopathy as effective.” (http://labels.fda.gov/)

Even National Center for Complementary and Alternative Medicine (NCCAM) of the National Institutes of Health, which is specifically charged with investigating alternative therapies, acknowledges the lack of scientific evidence for efficacy:

“Most rigorous clinical trials and systematic analyses of the research on homeopathy have concluded that there is little evidence to support homeopathy as an effective treatment for any specific condition.”

The scientific evidence is overwhelming and unequivocal that homeopathy provides no therapeutic benefit beyond the placebo effect of the consultation with a homeopath. Despite over 150 years of use and extensive research, no convincing evidence of a specific treatment effect has been produced. And there is also evidence that despite containing no active ingredients, homeopathic remedies can be harmful. When such products are mislabeled as homeopathic when they actual contain biologically active chemicals, or when they are used to treat serious illness in lieu of effective medical care, they can cause injury and death. Attached I have provided a brief overview of this robust scientific evidence concerning homeopathy.

The evidence that homeopathic remedies are ineffective is an internationally accepted scientific consensus rejected only by dedicated practitioners of homeopathy and those they have misled. Given this consensus, it is an abrogation of the FDA’s responsibility to protect human and animal health to allow therapeutic and prevention claims to be made for these products. I recommend the agency take the following steps.

  1. Draft and submit to Congress a report identifying homeopathy as ineffective and recommending changes in the agency’s authorizing legislation to prohibit the marketing and use of homeopathy without fulfillment of the same new drug licensing requirements applied conventional drugs.
  2. Produce educational materials for healthcare providers and patients in both human and animal health fields identifying the ineffective nature of homeopathy for the treatment or prevention of human and animal disease.
  3. Require all OTC homeopathic products to carry a label similar to that required for dietary supplements under DSHEA, “This/these statement(s) have not been evaluated by the Food and Drug Administration. This product is not intended to diagnose, treat, cure or prevent any disease.”
  4. Vigorously enforce regulations in both human and animal health fields prohibiting treatment and prevention claims for homeopathic remedies without fulfillment of the requirements of a NDA.

Regulation of Homeopathy [Docket No. FDA–2015–N–0540] Supporting Evidence Document

 

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