Falconer Strikes Back: A Veterinary Homeopath Refutes the Skeptics and Reveals the Emperor’s Nakedness

It can be very instructive when proponents of alternative medicine respond to comments or criticism from skeptics. Sometimes, they respond with reasoned, even evidence-based defense of a specific practice. This is a good sign and can lead to productive discussion. More often, they respond with passionate but empty rhetoric simply asserting that they are right and their critics are ignorant, greedy, or simply terrible people. This is not a good sign, but it is still instructive because it often reveals, in their own words, underlying beliefs or attitudes that inform their practices and give the lie to any impression they may try to create that they are offering evience-based therapies.

Such is the response of Dr. Will Falconer to “skeptics,” which I suspect may mean me given his blog post comes a few months after several of mine mentioning him and his dangerous rejection of science-based medicine in favor of homeopathy (here and here). Dr. Falconer’s posts are regularly recommended on the Facebook page of the Academy of Veterinary Homeopathy, so I think it fair to say he is not a lone extremist but a representative of a perspective widely accepted among veterinary homeopaths, and I suspect the larger holistc veterinary medical community.

The core of his response to skeptics is a straightforward rejection of science in favor of personal experience, which is one of the key philosophical underpinnings I have previously identified as a characteristic feature of alternative medicine. He calls this “Common sense vs The Age of Science,” and makes it clear that when science is in conflict with belief and intuition, science is to be rejected. He uses one of the classic examples of quackery to suggest that what science says is untrue is patently obvious to anyone with common sense–the disproven but still widely feared link between vaccines and autism:

The “science” drum is beaten loudly when skeptics enter a conversation. Instead of being open minded and inquiring, these minds have snapped shut like a steel trap, rebuking anyone who doesn’t toe the line they’ve drawn on what’s real.

“Where’s the research, the double blind studies?!” “There’s no scientific proof that homeopathy is anything more than water. Anyone who gets well from it is making it all up! It’s a placebo response!!” “Vaccinations do not cause autism.” Etc. etc.

Meanwhile, mothers are seeing their perfectly normal, well adjusted toddlers lose all vestiges of normal life shortly after getting vaccinated. The rising autism incidence parallels closely the rise in vaccine requirements for children over the last 20-30 years. Any careful medical research could uncover this.

The evidence is overwhelming that vaccines do not cause autism and that the irrational fear of vaccines has sickened and killed many children, but Dr. Falconer believes we are all so infallible that simple, everyday experience outweighs the evidence of hundreds of studies involving millions of children. Except, of course, for the everyday experience of those of us whose common sense tells us vaccines have nothing to do with autism.

Dr. Falconer then goes on to try and show that scientific research is worthless, and that even leading figures in science and evidence-based medicine don’t believe in it. His failure to understand what he reads, and his ability to twist it to fit his ideology despite the fact that the people he discusses are in direct and active opposition to his view, is truly amazing.

He begins by citing John Ioannidis’ work showing that false positive findings and exaggerated effect sizes are common in publishes scientific research. Quacks love to cite this study because they believe it means science is worthless and they are free to ignore it. As others have discussed in detail, this is not at all what this research means or what Dr. Ioannidis believes. Science, unlike “common sense,” intuition, and personal faith is an ongoing, self-correcting process. We are constantly identifying each other’s mistakes and working as a community towards better understanding. Identifying and correcting the sources of error in the conduct and reporting of research is part of this processes. Dr. Ioannidis is not suggesting we give up on science. In fact in his latest paper, which I wrote about last week, he lays out a strategy for using scientific research to do precisely what faith-based practitioners like Dr. Falconer are so unwilling to do: to identify and abandon ineffective therapies using scientific research.

Dr. Falconer also cites one of the founding figures of the evidence-based medicine (EBM) movement, Dr. David Sackett, stating that he has given up on evidence-based practice. However, even the quote Falconer uses shows that the reason Dr. Sackett has quit teaching EBM is precisely because he’s afraid his status as an expert might inappropriately lead others to value his opinion and experience as an individual over objective data.

Sackett is not doing this because he has ceased to believe in evidence based clinical practice but, as the BMJ comments, because he is worried about the power of experts in stifling new ideas…

Dr. Sackett has twice announced he is quitting a specialty in which he has been recognized as an expert, and in a recent interview he explains why. He feels that recognition of expertise too easily leads to the fallacy of appeal to authority, in which the personal experience and opinion of the expert is given too much credence and contrary arguments or evidence is ignored.

Yet this is exactly what Dr. Falconer is arguing for, the rejection of scientific evidence in favor of the opinion and experience of supposed experts. He lauds Andrew Wakefield and Samuel Hahneman for the wisdom of their experience and ignores the fact that extensive scientific research has proven them both to be wrong. Rather than a brave, independent thinker challenging dogma and orthodoxy, Falconer is advocating uncritically accepting and following the word of supposed experts based on their individual experience. And rather than humbly accepting human fallibility and accepting the need for mechanisms to guard against our own errors and misjudgments, he, like Dr. Fallek and so many other alternative practitioners, believes his own experiences and perceptions to be so reliable that no amount of data or evidence to the contrary can cause him to question his beliefs.

And then, without a trace of self-consciousness or irony, he concludes his response to skeptics by asserting his proud refusal to listen to anything that challenges his beliefs and his adherence to two of the most definitively false beliefs of alternative medicine, and he bizarrely tries to turn the world on its head and call this attitude “evidence-based medicine.” Bizarre but instructive:

Just as you’ll never convince mothers of autistic children that vaccinations are harmless, you’ll never convince veterinary homeopaths that animals are getting well by delusion. We’ve got volumes of patients that speak otherwise. Animals don’t live in delusion.

We don’t have time for the skeptic’s blathering. We’ve got work to do. Medical research marches on, pet by pet, horse by horse, tot by tot: real patients, real results.

Homeopathy: Evidence based medicine at its finest.

 

 

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Holistic Veterinary Medicine: A Variety of Faith Healing

Early on in my effort to understand and evaluate alternative veterinary therapies, I had the naïve notion that learning about their mechanisms of action and the research evidence behind them would enable me to tell which were safe and effective and which weren’t. In some cases, there turned out not to be any plausible mechanism and no evidence, or even evidence against these therapies. I was, again naively, surprised to find that not only were most self-described “holistic” veterinarians not disturbed by this, they were offended that I would ask for such evidence or that I would see the lack of it as a reason to distrust their practices.

It was at this point that I came to realize the primary difference between conventional medicine and alternative/holistic/integrative medicine is one of philosophy. Science-based medicine relies on the processes of science to understand how the world works and what is an effective way to protect and restore health in our patients. Being human beings, conventional vets and scientists are not immune to the kinds of thought errors and emotionally driven reasoning that leads us astray, but we have at least the philosophical approach that scientific research methods intended to compensate for these work and should be relied on whenever possible.

Alternative practitioners, on the other hand, have much greater faith in their own experiences and those of others, especially those they trust or those who agree with them. They tend to see scientific research as a nice extra at best, or entirely irrelevant or misleading at worst, but not in any way a necessary part of evaluating the effectiveness and safety of their therapies. Intuition, revelation, tradition, and other subjective and experience-driven methods of evaluating treatments are more meaningful and compelling to them that science.

This creates the appearance of a conflict about facts which is really a conflict about values and beliefs. Most alternative veterinarians pay lip service to the need for a value of science, and yet their actions are inconsistent with their words. They see science as most useful for marketing therapies they already believe in and convincing or battling skeptics, not as a necessary step towards a true understanding. They are, in essence, asserting the primacy of faith over reason in understanding health and disease and our responses to them.

Such a philosophical position is fair enough, though obviously I feel it is mistaken and leads away from a true understanding of the world. However, it is disingenuous or deceptive when it is presented not as a philosophical, essentially a religious, point of view but as the practice of medicine. Pet owners have a right to know that they are being seen by a doctor with a faith-based approach to medicine that essentially rejects the basic foundations of science and modern healthcare.

In an effort to expose this underlying difference in philosophies, so pet owners will have a fair choice of which approach to follow, I occasionally discuss examples of veterinarians openly promoting this perspective. The latest that I have run across comes from Dr. Marcie Fallek, a veterinarian currently promoting a new book, Krishna’s Flute: The Spiritual Journey of a Holistic Veterinarian. The promotional materials begin with a fairly straightforward example of fear mongering:  “Are Vets Killing Pets?” Asks Holistic Veterinarian in New Book….’Trust your intuition for your dog’s survival,’ warns Dr. Marcie Fallek.” No unreasonable appeal to emotion there, eh? Oh, but it gets better. Dr. Fallek goes on to ask a series of inflammatory rhetorical questions with a clear message and little regard for facts:

  • Are prescription drugs killing pets? Are they necessary? Is there a better, safer way? Are yearly or triennial vaccinations really necessary? Are they safe?

  • Why are dogs and cats now ‘old’ at 8 years, when 30 years ago, they lived until their late teens and early twenties?

  • Are the thousands of dollars spent on diagnostic tests worth it? Are the tens of thousands of dollars spent on therapies like chemo and radiation effective? Isn’t there a cheaper and most importantly, safer and more effective way to treat disease?

  • Why do elderly clients say their old family dog lived ‘til 18 and was rarely at the vet’s? With vet bills often more than yearly mortgage payments are pets really better off?

  • Why do many animal companions have the same chronic diseases as people? Why don’t squirrels have allergies? Deer skin infections? Crows asthma? Raccoons ear infections? Why don’t wild animals share human illnesses, while domestic animals do?

  • Do pets really have to die?

There is plenty of recourse to the usual misrepresentation of science-based veterinarians as greedy and unconcerned about the well-being of their patients, and the usual unsupported assertions that conventional medicine is harmful and alternative medicine superior, but the core of this approach is to undermine the very idea that science can be a useful way to approach healthcare.

The notion that there used to be a Golden Age before modern science and medicine in which animals were healthier and lived longer and which has been ruined by money-grubbing doctors sowing disease and poisoning our pets for gain is the rankest sort of ignorant historical revisionism imaginable. There are few reliable data on the historical health and longevity of pets, but all the voluminous data for humans shows our lives to be longer and healthier by far in the last century than ever before in history, and there is no reason to believe this is different from the pattern in our pets.

Similarly, the ridiculous appeal to nature fallacy that suggests wild animals frolic in an Eden of health and well-being and outlive their captive brethren stuck in a toxic artificial environment runs counter to all the data and evidence. Life for wild creatures is, in the classic words of Hobbes, “nasty, brutish, and short,” and it is a deep delusion to envision it as Dr. Fallek apparently does.

So how is such a blithe disregard for fact and reality maintained? Why through faith, of course. The “spirituality” invoked here is simply an ideological a get-out-of-jail-free card employed to excuse substituting wishful thinking and fantasy for reality. Dr. Fallek clearly explains that intuition trumps all other sources of knowledge because it is ultimately the voice of God speaking to us:

Please listen to your inner voice. This inner voice is our God-given intuition, it is our birthright, ingrained in our DNA, installed to protect us and our loved ones….With LOVE and TRUTH as the bottom line, not marketing masquerading as medicine, following the heart leads to a safer truer path of healing.

She goes even farther in the sample chapter of her book offered for free, asserting that this inner voice is infallible:

The most important lesson we can learn in life is to trust our inner voice. It is never wrong.

This sample chapter consists almost entirely of an anecdote. This story purports to describe a dog seen by three conventional veterinarians, including board-certified specialists, and wildly misdiagnosed. After many expensive and useless diagnostic tests and multiple harmful and unnecessary treatments, Dr. Fallek diagnosed an obvious congenital abnormality and relieved his symptoms with a few acupuncture treatments.

My inner voice tells me this is a grossly biased and self-serving misrepresentation of what actually happened. But since I prefer to rely on facts when possible, and there are none available to corroborate or challenge this narrative, I will simply have to refrain from judging the accuracy of the story. However, even if it is true exactly as told in Dr. Fallek’s book, it is merely an example of individual incompetence, not proof that conventional medicine is useless and harmful and the alternatives Dr. Fallek sells are safe and effective. Stories are just stories, not evidence, though of course the whole point here is that alternative medicine prefers compelling narrative to evidence.

So what does Dr. Fallek offer as an alternative to conventional medicine, which she dismisses blithely as “an endless cycle of cortisone and antibiotics?” Apparently, the usual hodgepodge of practices which are, in their own theoretical justifications, incompatible with one another but which share the only important characteristic: a preference for faith, intuition, and personal narrative over controlled research data as the guiding principle. Homeopathy, which is the quintessential faith-based medical practice completely incompatible with reality and already convincingly disproven. Acupuncture, which might have some reasonable basis for scientific study if not practiced, as by Dr. Fallek, according to the mystical nonsense that is mislabeled Traditional Chinese Medicine. The dubious and as yet unproven dogma of raw diets. Hysterical and exaggerated fear mongering about the dangers of vaccination.

In other words, this independent thinker committed to listening to her own inner voice espouses nearly all the core dogma of the alternative veterinary medicine community. While there is, of course, some diversity of opinions among veterinarians promoting alternative medicine, just as there is among proponents of conventional medicine, there are common ideological themes which lead to common practical approaches. These themes include:

  1. The trope of science and technology as      dangerous and “natural” or historical approaches as benign.
  2. Science-based vets as money-driven dupes or      shills of the malign pharmaceutical and pet food industries compared to      the purely caring and spiritually-guided alternative practitioners working      only for the well-being of their patients.
  3. A misty-eyed misreading of history to suggest      the past and the natural world as healthful and benign and the modern,      technological world as toxic and harmful.
  4. A deep suspicion of scientific research and a      blind trust of personal experience.

As I said previously, it is perfectly fine for Dr. Fallek and anyone else to believe whatever they wish to about the nature of the universe and about health and disease. Her approach to medicine is her religion, and everyone is entitled to their religious beliefs. However, our society has generally chosen to expect our doctors to provide care based on science and evidence to the greatest extent possible, largely because these approaches have created the dramatic improvements in our health and longevity that Dr. Fallek denies have happened. Improvements in sanitation, nutrition, public safety, and both preventative and therapeutic healthcare have given us more and better life than any previous human generation, and the evidence of this is voluminous and has led to a societal contract with healthcare providers that emphasizes science-based care.

The days of medical anarchism, where any and all medical approaches were treated as equally legitimate, ended in the early 20th century, and the scientific approach was given precedence. If we choose to retreat from that and emphasize spiritual, faith-based medical approaches above scientific ones, we deserve to at least understand that is what we are doing and make an informed choice to do so. When members of the Academy of Veterinary Homeopathy, such as Dr. Fallek, vociferously deny in public that homeopathy is inconsistent with science and claim it is in fact scientifically proven to work, they are not only factually wrong, but they are being deceptive. Elsewhere, they clearly describe the spiritual nature of this practice and fundamentally treating not the patient’s but their “energy” or “emotions” or “vital force,” in short their soul. If they would honestly admit homeopathy is a spiritual practice, not a scientific medical treatment, then at least pet owners would get an honest and fair choice between medicine and faith healing.

 

 

 

 

 

 

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Evidence-Based Medicine: Separating the Wheat from the Chaff

As I have discussed before, evidence-based medicine is the formal, explicit application of the philosophy and methods of science to generating understanding and making decisions in veterinary medicine. Science shows us how the world works, and in medicine it shows us which of our therapies are effective. But perhaps even more importantly, it shows us which are ineffective or not safe. A key to practicing truly science-based medicine is accepting that our perceptions and appearances can be deceiving, and often we will be wrong in our assessment of which therapies work and which don’t. This means we must have the humility and courage to give up cherished beliefs and practices when science clearly shows us our faith in them is wrong.

This is one of the key differences between science-based and alternative medicine. The very category of complementary and alternative medicine (CAM) exists precisely to protect from scrutiny and criticism those therapies that have either been shown not to work or that haven’t been adequately tested. As I have discussed previously, CAM proponents often have a fundamental philosophical distrust of science and the hierarchy of evidence, and they often believe personal experience, intuition, tradition, and other low-reliability Potential considerations in prioritizing the testing of unproven medical practices.kinds of evidence are as good as or superior to scientific research. There is a general human tendency to resist change and to cling to beliefs and habits even when there is good reason to abandon them, but this is an even greater problem in CAM than in conventional medicine because it is part of the philosophical rationale of alternative medicine.

A recent paper by John Ioannidis, one of the most productive critics of the scientific literature and process, emphasizes the natural and important role of rejecting the disproven and targeting our research efforts to most effectively and efficiently separate the safe and effective from the unsafe and ineffective.

Vinay Prasad and John PA Ioannidis. Evidence-based de-implementation for contradicted, unproven, and aspiring healthcare practices. Implementation Science 2014, 9:1

In this paper, the authors illustrate how identifying ineffective or unsafe practices, and contradicting current practices, is a common and intrinsic part of the process of science-based medicine. There are hundreds examples of such practices being identified and abandoned, just as there are examples of new ideas being treated skeptically and then accepted once adequate supportive evidence is developed. It would be difficult to demonstrate a similar pattern for most alternative disciplines, where new ideas are often accepted on theoretical or anecdotal grounds alone, and where few ideas are rigorously tested or rejected even when negative evidence is available.

The authors also discuss how the natural human resistance to change plays out and affects both the scientific literature and the response to evidence about existing practices. The purpose of the article is specifically to develop and advocate for a strategy to efficiently use scientific research to change medical practices. Such a strategy would not be necessary if people naturally made decisions in a rational, disinterested, and evidence-based way. However, the difference between science-based medicine and alternative medicine lies largely in the fact that compensating for our innate cognitive biases is built into the very fabric of science, whereas following the guidance of these biases is the favored approach in much of the alternative medical community.

The authors also review the issue of how truly evidence-based conventional medical practices are. This is often raised by defenders of alternative medicine with the goal of invoking the tu quoque fallacy, that proponents of science-based medicine cannot legitimately criticize the poor evidence base for alternative medicine while scientific medicine has an imperfect evidentiary foundation. The authors do identify significant deficiencies in the evidence base of conventional medicine, reporting for example that a review of Cochrane systematic reviews found 49% of interventions could not be definitively validated or contradicted based on the evidence, and 48% of recommendations from the American Academy of Cardiology were based only on expert opinion. This is still quite a bit better than the claims made by proponents of alternative medicine, and there is reason to believe that when all forms of scientific evidence are considered, most conventional medicine has a significantly more solid foundation in evidence than the bulk of alternative medicine. Nevertheless, it is clear that there is significant room for improvement in the degree to which conventional medicine is evidence-based.

This paper also addresses the issue of how to prioritize research on unproven therapies. While it doesn’t address alternative medicine directly, and so doesn’t deal with the issue of prior plausibility, it does lay out an interesting approach. While there is room for debate about the specifics, I appreciate the general approach. It is not appropriate to say that before rejecting any therapy we must always have high-quality and high-level evidence. The resources for scientific studies are limited, and we cannot test every approach no matter how unlikely to be useful simply because someone believes in it. And there are ethical problems with subjecting people or animals to studies of therapies that are irrational or not adequately evaluated at the preclinical level, as demonstrated by the awful experience of patients with pancreatic cancer treated with the Gonazalez Regime. Deciding how much effort to put into testing specific unproven therapies is a complex balance of different considerations, and this paper addresses several of these.

           
Potential considerations in prioritizing the testing of    unproven medical practices

Factor    to consider

General principle How to implement this factor

Prior   evidence base

Priority   should be given to practices where the present evidence base is weakest.

For   instance, a tiered system may be utilized: Level 1 (Weak) Randomized trials   of interventions claiming subjective benefits, that are unblinded or fail to   use proper controls. 2 (Weaker) Historically controlled studies of   interventions that purport survival benefits, case series documenting   improvements in subjective endpoints and quasi-experimental studies. 3   (Weakest) Practices based on pathophysiology and expert opinion alone. In   many cases, professional conflicts may also prove problematic; thus, it may   be reasonable to pursue this technique using content-specific experts in   strictly an advisory capacity

Cost/ubiquity

Priority   should be given to interventions with significant net financial burden on   health payers.

For   instance, orthopedic procedures for chronic back and joint pain, including   knee and hip replacement surgeries are widely utilized in the United States,   incur large financial burden on payers, but have little evidence of sustained   long term benefits.

Alternative   options

Priority   should be given to practices for which there are several alternative options,   particularly if alternatives are of completely different mechanisms (thus   unlikely to also be overturned), or of low cost or bolstered by stronger   evidence.

For   instance, consider the market for anti-rheumatologic agents. Maintenance   treatment of rheumatoid arthritis (RA) with disease modifying agents (DMARDS)   has historically relied upon oral anti-immunologic agents such as   methotrexate, azathiaprine, cyclosporin, and hydroxychloroquine. Recent years   have witnessed a boom in novel drugs, typically expensive monoclonal   antibodies against circulating cytokines or cell surface receptors. To date,   this market has been limited by paucity of head to head trials, and, of   trials that have been conducted, the majority are industry-sponsored studies.   Collectively, there remains clinical uncertainty about how best to use these   agents [20].

Documented   harms

Priority   should be given to test practices where the harms are well documented and   confer substantial morbidity.

For   instance, there is growing awareness of strut fracturization, embolism, and   migration of IVC filters. At the same time, the IVC filter has never shown to   improve any patient-centered outcome for any patient population in a   prospective trial, and traces its approval through the FDAs 510 k   mechanism [21].

Testing   the intervention makes financial sense

Priority   should be given to test practices where the cost to test is far less than   ongoing expenditures of the practice.

In   some respects, trialists should think like CEOs, weighing the costs of   conducting a study, which may find a practice ineffective versus the ongoing   expenditures for that practice. At times, such calculations may favor costly   trials where the existing evidence base is weak, observational studies   suggest inefficiencies, and the ongoing costs are large [22]. At   other times, small trials that eliminate boutique practices may be employed [23]. Whose   financial bottom line is being affected is important to consider. For that   reason, nonconflicted bodies should make these determinations, utilizing   investigators without financial conflicts of interest.

Proponents   are open-minded

Priority   should be given to test practices where negative results may truly gain   traction.

Some   specialties (primary care providers) may be more ready to abandon   contradicted medical practices, and it is reasonable to test practices when   there is genuine belief that contradiction can gain traction. Furthermore,   some practices may be cumbersome (tight glycemic control in the ICU),   time-consuming (routine gown and glove precautions) or unpleasant, and their   contradiction may also be palatable. Finally, as payment structures shift   from fee for service towards bundles [24], costly   components may lose faithful disciples. Other fields, those with numerous and   hyperbolic third party advocates, have been notoriously unwilling to trust   results that undermine their worldview, no matter how robust the science.

Value   of information gained

Priority   should be based on the expected value of funding a specific study that may   inform de-implementation, at the size and cost proposed.

Value   of information (VOI) offers a decision-making framework that tries to capture   several of the above issues, at least the ones that can be best quantified [19]. VOI   can be used to prioritize and power clinical trials taking into account the   costs of increasing study sample size, the potential number of persons   affected by changes in that practice, the costs of the practice, including   downstream costs, and the increased knowledge of marginal changes in health   outcomes that may result from testing — converting all to the final common   denominator of cost per favorable outcome gained.

I particularly appreciate the consideration of the impact of the evidence gained from research. If negative results are not going to have any impact, is research really justified? Clearly, we do not need more research on homeopathy for many reasons, for example, but a big reason is that additional research will never dissuade true believers but will simply add to the illusion that there is some scientific legitimacy to the ideas or practices they employ. Likewise, the money spent through the National Center for Complementary and Alternative Medicine has failed to validate most of the therapies studied, yet it has not apparently led to the rejection of any therapies despite the negative evidence generated.

Skeptics like myself are often accused of blind, unthinking defense of conventional practices and closed-mindedness. The exact opposite, however, is the truth about skepticism. It is the process of demanding evidence for all practices, including those I personally rely on. Articles like this illustrate that truly science and evidence-based medicine is as rigorous and critical in approaching its own practices as those under the label of CAM. This kind of critical scrutiny and adherence to the evidence, whatever it reveals, is necessary for progress and improvement in medicine, and is the acceptance of that that distinguishes science-based medicine from alternative approaches to developing and employing medical knowledge.

 

 

Posted in Science-Based Veterinary Medicine | 1 Comment

Dog Food Logic–A Great New Guide to Dog Foods for Dog Owners

I was recently asked to review a new book for dog owners called Dog Food Logic: Making Smart Decisions for Your Dog in an Age of Too Many Choices by Linda Case. I was very impressed, and I encourage anyone interested in a rational, science-based approach to feeding our pet dogs to read this one. Here is the original review I provided for the book.

Dog Food Logic is an indispensable book for any pet owner who wants to make thoughtful, informed decisions about what to feed his or her canine companions. The dog food industry is a bewildering, ever-changing landscape of companies and brands, and dog owners are inundated with marketing masquerading as science, with rigid advice from self-declared experts, and with fads every bit as intense and short-lived as those in the human weight loss business. Dog Food Logic cuts through the noise and chaos and provides pet owners with a rational, science-based approach to evaluating their pets’ dietary needs and their feeding choices.

Rather than simply telling dog owners what food to buy, Dog Food Logic provides a concise and comprehensible guide to the three main subjects we must understand in order to make sound feeding choices: the science of canine nutrition, the nature of the dog food industry, and the pitfalls in our own ways of thinking that make us susceptible to marketing hype and irrational decisions. Rather than trying to tell us what to feed, Ms. Case empowers dog owners to make choices consistent with the needs of our individual pets and our own values.

In Dog Food Logic, the author displays a deep understanding of not only the science of nutrition but of the human-animal bond. Feeding our pets is more than providing them with essential nutrients. It is an expression of love and one of the most enjoyable shared experiences between pet and owner. Ms. Case understands that the emotional nature of feeding our animal companions must be appreciated and nurtured, but that it can also make us vulnerable to manipulation. Advertising and advice about what to feed our pets often plays on our anxieties about their health and happiness and our desire to do everything possible to ensure a long and healthy life for our dogs. Ms. Case is able to help us see through such manipulative marketing and make sound feeding decisions based on science while still respecting the role of feeding in the deep bond between owners and our pets.

As a veterinarian, a scientist, and a dog owner, I have waited a long time for a book like Dog Food Logic, one which I can enthusiastically recommend to my clients and colleagues. After reading Dog Food Logic, you will of course have a deeper understanding of canine nutrition, the pet food industry, and how to make good choices about feeding your pet. But you will also have a greater understanding of yourself as a pet owner and a consumer. Understanding how we make choices, and how those choices can be influenced by the quirks of our own thought processes and by the manipulative power of marketing, enables us to make better decisions about all aspects of our pets’ care. If we apply the same critical thinking and evidence-based approach to behavior and training, veterinary care, and all the other decisions we make as pet owners, we will better caretakers with happier, healthier pets.

Posted in Nutrition | 3 Comments

Nutrition Resources for Pet Owners

There is, as we all know, a tremendous amount of misinformation on the internet concenring virtually any subject. Yet the internet is an unqeustionably powerful information resources, likely indispensible for anyone seeking to be an informed consumer. For pet owners, the quantity of information about pet nutrition is overwhelming. Yet the quality of most of this infomration is poor, with little in the way of scientific evidence backing claims made, and with advertising and other commercial messages often indistinguuishable for legitimate and useful information resources.

So I have put together a brief list of useful informational resources for pet owners concerning dog and cat nutrition. These resources are produced by board-certified veterinary nutritionists and academic institutions or consortia with solid credentials in veterinary nutrition. I may not necessarily agree with every single statement in these resources, but I consider the sources trustworthy and the information reliable.

The objection will inevitably be raised that many of these individuals or organizations have some connection with the commercial pet food industry. This industry does support the majority of the research and education in veterinary nutrition, which raises the legitimate question of potential bias. That said, the claims and statements made by academic veterinary nutritionists are most often backed by research evidence, and this evidence does not become magically irrelevant just because of potential funding bias.

While any industry-funded research must be scrutinized carefully to ensure appropriate methodological techniques are employed to reduce the risk of bias, and while in a perfect world all research would be sponsored by independant government agencies or through funding mechanisms that prohibited any connection between funder and researcher, this is not our current reality.

All individuals have their biases, whether ideological, financial, cognitive, or other, and the purpose of the techniques of science are to minimize the influence of such biases on our understanding. The opinions of individuals promoting and/or selling unconventional diets or disparaging commercial diets are not free of bias, but they are often free of real scientific evidence. It is not the individual nor their affiliations that is ultimately the most salient feature in evaluating the reliability of factual claims, it is the quality of the data.

I invite anyone who is legitimately concerned about the influence of industry on the veterinary profession’s understanding and approach to nutrition to do more than complain. Provide real evidence to support your own claims or those of others you believe have a better approach.  Support the generation of better evidence with less risk of funding bias. Encourage the highest standards of research design and reporting to minimize the risk of bias.

World Small Animal Veterinary Association

Nutrition Toolkit-

Selecting the Best Food for your Pet

The Savvy Cat Owner’s Guide to Nutrition on the Internet 

The Savvy Dog Owner’s Guide to Nutrition on the Internet 

Calorie Needs for Healthy Adult Cats

Calorie Needs for Healthy Adult Dogs 

Pet Nutrition Alliance

Pet Owner Resources-

Frequently Asked Questions

Assessment

Nutritional Guidelines

Preventive Care

Body Condition Score Chart

Muscle Condition Score Chart

Nutrition Calculators & Charts

Food Safety

Food Safety Guidelines

ASPCA and Pet Poison Helpline

Pet Food Recall Alerts

Pet Food Information

Home-Cooked Diets

Ingredients in Pet Food

Nutrition Myths

Pet Health

Feeding Guidelines For Dogs and Cats

How to Evaluate Nutritional Health Claims and Detect Fraud on the Internet

Keeping Your Pet Healthy

Nutritional Consultation Services

Nutritional Needs for Specific Diseases

Nutritional Supplements

Weight Management and Obesity

Tufts Veterinary School Nutrition Service

Frequently Asked Questions

Home-cooked Diets

Raw Diets

The Ohio State University Veterinary Nutrition Support Service

Pet Owner Resources

 

 

 

Posted in Nutrition | 4 Comments

WVC Presentations and Bibliography- Evidence-Based Veterinary Medicine

I presented four hours of lecture at the Western States Veterinary Conference in Las Vegas February, 2014. Here is the bibliography for those talks, which contains a lot of good resources on critical thinking, evidence-based veterinary medicine, and alternative veterinary medicine.

bibliogrpahy

And here are the PowerPoint presentations I used for these lectures. I will be posting narrated videos of these presentations as soon as I am able to get them together.

What is Evidence-Based Veterinary Medicine and Why Do We Need It?

Myths and Misconceptions About Evidence-Based Veterinary Medicine

The Future of Evidence-Based Veterinary Medicine: Challenges and Opportunities

Are Complementary and Alternative Veterinary Medicine and Evidence-Based Veterinary Medicine Compatible?

 

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VancouverFeline and Evidence-Based Medicine

Stumbled across this blog post from VancouverFeline recently. Warms my skeptical heart!!

In medicine, we have many habits and quirks handed down through the generations. Often, we think nothing of these, and even believe that these well-accepted practices are grounded in rational evidence-based thinking. Surprisingly many are not, and even today, medicine is heavily influenced by fashion and eminence.

The word “believe” and all its derivatives has no place in sound medical practice. I cringe every time that word used by specialists in a peer-reviewed journal, article or lecture. If we want medicine to be a religious experience, then there are faith-healers happy to be consulted. Use of the word “believe” implies “I have not thought about this and am accepting faithfully this concept”. Granted no doctor has time to individually explore every medical concept that we use, but a collective level of skepticism is absolutely necessary.

We often think we are being healthily skeptic when, in questioning medicine, we head off in a New Age direction, feeding ourselves and our pets with naturopathic, homeopathic and expensive wonder products. Words that should stop you in your tracks, prompting some deep questions and caution, are “traditional”, “cure”, and “natural”. Just because the ancestors used something, when nothing else was around, and they believed it helped, remember that placebo effect, desperation and faith all come into play (as it does in all medical fields) – before popping something into my body, I would rather see the evidence.

 

 

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Benefits & Risks of Neutering, an Evidence Update–Cancer and Behavioral Problems in Vizslas

As part of my ongoing coverage of the risks and benefits associated with neutering, I wanted to review a recent article on the subject, this one looking specifically at cancer risk and behavioral problems in Vizslas.

Zink, MC. Farhoodly, P. Elser, SE. Ruffini, LD. Gibbons, TA. Riegr, RH. Evaluation of the risk and age of onset of cancer and behavioral disorders in gonadectomized Vizslas. J. Amer Vet Med Assoc. 2014;244(3):309-319.

The Study
This study involved  an analysis of data collected in 2008 through an online survey of owners of Vizslas in the U.S. and other countries (U.S. owners made up about 87% of the responses, with almost all the others coming from the UK, Australia, and Canada). Information was collected on about 2,500 dogs, and both cancer and behavioral problems were reported in about 25% of these.

The authors looked at the cancers and behavioral problems reported by owners as well as the age when individuals were neutered, if they were, the sex, and the age at which the medical problems examined were reported (though this last figure often had to be guessed at). The authors specifically excluded many conditions from the analysis, including some previously reported to be associated with neuter status. They did not, for example, consider orthopedic diseases because these were uncommon (~9% of the dogs). Oddly, they did not consider skin conditions either, though these were reported in about 20% of the dogs.

The reported results cover several cancers that are especially common in Vizslas, including Mast Cell Tumors (MCT), Hemangiosarcoma (HAS), and Lymphoma (LSA), as well as behavioral problems (noise phobias, separation anxiety, and various forms of aggression). The general results, broken down by age of neutering, are reported in the tables below.

Table 1 Zink et al

Table 2 Zink et al

The odds of MCT and LSA were higher for neutered than intact animals. The odds of HSA was higher for neutered females than for intact females, but there was no relationship between neutering and HSA risk for males. The odds of cancers other than these three were also higher for neutered than for intact animals. For all of these cancers, the odds were higher in those neutered after 12 months of age than in those neutered earlier.

For behavioral problems evaluated, the odds of having such a problem were higher in dogs neutered before 6 months of age than in intact dogs. There were no differences in the odds of behavior problems between intact dogs and those neutered after 6 months of age with the exception of storm phobia which was more common in neutered animals overall than in intact animals.

There was no difference in the age at death or the longevity of neutered dogs compared with intact dogs.

Limitations of the Study
The first potential limitation of this study is that the population of dogs included are potentially not representative of the general pet dog population. Only one breed was included, and only 60% were reportedly kept as “primarily a family pet,” with most of the others being used for show or hunting activities. About 23% were reported to have had offspring and almost half (43%) of the dogs were intact, whereas surveys suggest over 80% of the overall owned dog population is neutered. The average age at death was also reported to be 9 years, which seems quite young compared to many other breeds and mixed-breed dogs of similar size. Since there are genetic factors involved in many health conditions, and potentially developmental and environmental factors associated with how dogs are kept, caution must be used in extrapolating results from one population to another.

Another significant limitation of this study is the method of data collection. All data was collected by anonymous online questionnaire, with no attempt to verify the accuracy or validity of these data. Diagnoses of cancer and behavioral problems and assessment of age at neutering were based entirely on reports of owners, sometimes many years after the fact.

This raises a host of concerns. Owners may have reported diagnoses incorrectly, such as misidentifying cancers or reporting benign tumors as “cancer.” Owners may have been more likely to report cancer and/or neutering information if they believed there to be a relationship between the two or if they knew one purpose of the study was to examine such a relationship. Owners also identified cancer and skin conditions as top health concerns, suggesting a population of respondents particularly interested in these conditions, which might have affected their rate of reporting them.

There is also no way to identify what if any differences there were between people who participated in the survey and people who did not, or between the dogs owned by these different groups. It is likely that people who were aware of the survey and motivated to complete it differed in numerous ways from other Vizsla owners and owners of other kinds of dogs, and this again could affect the health conditions reported and the risk factors affecting them.

Another issue is that this study looked at potential risks posed by neutering, but it did not include assessment of most of the potential benefits of this procedure in this population. For females, for ecample, neutering is believed to be protective against mammary cancer (though the evidence is not as strong as commonly supposed), which in some populations is a very common and frequently malignant type of cancer. In this population, mammary cancer was reported in less than 1% of the females in the study, a rate dramatically less than in other populations studied. This suggests either that this population is a much lower risk of mammary cancer than others, in which case the protective effect of neutering might not be meaningful, or that the incidence of this disease was underreported.

Similarly, uterine infections (pyometra) are a common and serious disease in intact females, and these can be completely prevented by neutering. Yet the rate reported in this study was quite low. 22 cases were reported, which would be a rate of about 4% of the ~535 intact females included. Other studies have reported rates of 10-50% depending on age, so either this population has an unusually low rate of this disease, or the incidence was not accurately reported.

Health problems and cost or disruption for owners associated with estrus, reproductive behaviors, or actual reproduction were also not evaluated in this study.

Overall, the study found no difference in the longevity or overall mortality of neutered versus intact dogs. This is in contrast to other studies which suggest neutered animals may live longer on average than intact animals. More importantly, it calls into question the significance of the reported increase in cancer risk in neutered dogs. If neutered dogs are truly at significantly higher risk of often fatal diseases like HAS and LSA, one might expect intact animals to live longer as a results of being less likely to experience these diseases. And if the two groups have roughly the same life expectancy, perhaps there are benefits to neutering not reported here that counterbalance the risks discussed?

Bottom Line
This study contributes useful new information to the ongoing process of evaluating the risks and benefits of neutering. It supports information from other studies, in Rottweilers and Golden Retrievers, that suggest neutering may increase the risk of some cancers, such as hemangiosarcoma and lymphosarcoma, in breeds predisposed to develop these diseases.

The study also has a number of significant limitations. The dogs in the study were all of one breed, and they differed in a number of ways from the general pet dog population, so findings in this group may not be applicable to other populations.  The data was collected though anonymous questionnaires completed by owners, often years after the events being asked about, and there was no way to confirm the accuracy or validity of these reports. There is also a high risk that the people who chose to participate in the survey, and the dogs they own, are quite different from the general pet owning population and their pets, in their concerns, knowledge, and pet care practices.

The study did not examine many of the risks posed by being intact, which have to be considered in weighing the overall risks and benefits of neutering. Rates of pyometra and mammary cancer, common and serious medical problems prevented by neutering females, were far lower in this study than generally reported elsewhere, suggesting either that the study population was quite different from other dog populations or that the rates of these diseases were not accurately reported.

And it is unclear how significant the reported increase in the risk of cancers in neutered animals really is since there was no overall difference in the longevity of neutered and intact animals. If neutered animals are much more likely to get cancer, it is surprising that they tended on average to live just as long as intact dogs.

Overall, this study supports the current trend towards questioning the dogma of routine neutering for all dogs. The risks and benefits are likely to vary according to breed, age, and many other variables, and a one-size-fits-all approach is not ideal. Unfortunately, a great deal of additional research will need to be done for dog owners and veterinarians to have confidence in specific recommendations for individual dogs.

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Academy of Veterinary Homeopathy Doesn’t Like Criticism–Except Their Own

During the discussion about the AVMA resolution identifying homeopathy as ineffective, defenders of homeopathy were adament that it would be unfair of the AVMA to single out their methods for criticism. I wonder if the House of Delegates was aware of the sort of criticism of conventional medicine, and the AVMA, that routinely appears on the Facebook page of the Academy of Veterinary Homeopathy (AVH), the official organization representing veterinarians offering homeopathy. The AVH is very comfortable blaming conventional veterinarians and treatments for all kinds of terrible health problems and denying fundamental scientific principles behind conventional medicine. Are these really the sorts of comments it is unfair to challenge?

“What things make your pet more vulnerable to cancer? Anything that impairs immune system function.  The following are, in order of importance, those things your animal receives that cause immune system breakdown:  Vaccination  Heartworm pills  Flea pesticides  Antibiotics”

“There is a big push underway to get pet owners to return to conventional veterinarians… and guess who is paying for it. Yup big pharma and the commercial food companies like Hills… what a surprise!!! Don’t be fooled. Holistic vets actually keep your pets healthy and happy at a fraction of the cost. To find one visit www.theavh.org

“Are germs really the problem???

Why homeopathy is your BEST option for treating your beloved animal friends…

Only homeopathy actually corrects the predisposition to illness or disease – making your pet (the soil) less vulnerable – and healing quickly and completely when their resistance drops due to stress or other factors.”

“As I look time and again at when my patients started their decline into poor health, I repeatedly see the timing being “about a month” after a round of vaccinations. Not in every case, but in a large percentage of my patient population, this is true.”

“Did you know that when it comes to feline leukemia, EVERY SINGLE vaccine is unnecessary. Why? FeLV is a chronic disease, and vaccines by definition don’t prevent chronic disease. And FeLV is very much an opportunist virus, attacking and setting up housekeeping in only 10% of those exposed. You can imagine these are the weaker, poorly nourished animals, likely eating an unnatural kibble diet.”

“Dr. WhiteCoat and the monstrously huge pet food industry (sales of $20+ billion per year) would like you to believe you can’t possibly make a raw diet for your pets. They are invested in selling you bags of kibble, cans of mucky meaty glop, and the best marketing of all, “prescription diets” for those health challenges your animals may confront.”

“We interrupt our normal posts for an important announcement.  The CDC is reporting sharp increases in the number of patients with swine flu. Homeopathic physicians have long used the homeopathic remedy Influenzinum to safely protect their patients from the flu with great success. The normal protocol – Influenzinum 200C – one pellet dissolved in the mouth once a month. In cases where flu is widespread – a dose every two weeks during a period of widespread flu is often advised. There are also an array of wonderful remedies one can take for flu symptoms – again that are safe, quick acting and effective.”

“Treatment with allopathic drugs (antibiotics, steroids, hormones, etc.) should be avoided unless absolutely necessary. The need for drug treatment is actually quite unusual, and should be considered a last resort.”

“Corticosteroids (cortisone-type anti-inflammatory drugs) are the most abused and dangerous class of drugs. Not only do they not cure the underlying cause of the problem, they usually make the underlying problem, that is, the real problem, worse.”

“Allopathic (conventional Western) medical thinking generally seeks immediate gratification: just make the symptom go away. So the patient may be better in the short term, but is usually worse in the longer term. Homeopathy is just the opposite: sometimes the symptoms are worse in the short term (such as with aggravation or the reversal of a previous suppression), but the real benefit is in the longer term.”

“Sadly, did you know that your dog has a 50% chance of dying of cancer? Want to know the five steps that can significantly reduce your pet’s chances of getting cancer? Here they are:

* Reduce or eliminate the use of commercial flea and tick products. They are poison.

* Stay away from using pesticides, herbicides and fungicides on your lawn and garden.

* Use non-toxic cleaning products for your home.

* If you must alter your dog or cat – don’t do it too early in their lives.

* Eliminate or greatly minimize their exposure to vaccinations.”

And the AVH actually promoted one of the most misleading and dishonest news stories of the last year concerning veterinary medicine: ”

“Is your vet being honest with you???  Well, on a recent episode of ABC’s 20/20, common veterinarian practices were examined in a piece entitled ‘Is Your Veterinarian Being Honest With You?

Worth watching.”

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On CAVM Research and Plausibility

I have been participating in a discussion on the Veterinary Information Network (VIN) about the AVMA’s failure to take a scientific and principled position on homeopathy, and it prompted me to outline a few thoughts on the subject of whether more research on some CAVM therapies is always worthwhile, and what the role of plausibility plays in evaluating such therapies. I’m reposting these thoughts here since these subjects come up often on this blog.

I once thought the answer to separating useful CAVM from nonsense lay in more research. Having spent several years investigating CAVM and the claims and rationales made for it, I realize this is not actually that likely to be helpful, for many reasons. One is that much of CAVM is based on philosophical and ideological foundations completely incompatible with science, and the promotes of these “metaphors” don’t have any interest in applying science to their practices other than its potential value as a marketing tool for creating broader acceptance and legitimacy. (I have written about this before.)
For scientific research to be useful in separating true from false, we must be willing to accept negative results and abandon therapies even if they seem effective in our uncontrolled personal observations. There is rarely any serious will to do so among proponents of CAVM, as illustrated by the homeopathy debate and the comments you and Craig have made about the views of some acupuncture proponents.

It is also the case that the vast majority of the CAVM research done, in human as well as veterinary medicine, is of poor methodological quality and very high risk of bias. It is possible to find many positive studies on almost any practice, yet systematic reviews that base conclusions on well conducted studies with limited bias risk almost always conclude there is no effect beyond placebo. All these poor studies suck up scarce resources and create a misleading impression of the state of the evidence. Again, to help us distinguish true from false, scientific methods have  to be employed in ways that generate reliable evidence that leads to meaningful conclusion which can be applied in practice, and this is seldom the case in CAM research.

So if the research done will not dissuade true believers and is generally unreliable and misleading, how is it going to clarify our understanding or inform our practices? I’m not saying no CAVM should be researched, of course, only that in many cases (such as homeopathy, energy medicine and other forms of vitalism, etc.) the answer is already as clear as it can reasonably ever be, or the fundamental premises of the methods are not amenable to science and rigorous scientific research is not welcomed or heeded by proponents. In these cases, the resources used to conduct such research are wasted and the waters only further muddied.

Which brings me to the second response evoked by your comments. Of course, plausibility is not the definitive standard for judging the efficacy of a therapy. However, the fact that plausible ideas are sometimes false and implausible ones sometimes true doesn’t mean we should jettison plausibility entirely as a tool in evaluating therapies. The pioneering epidemiologist Sir Austin Bradford Hill discussed the multiple interacting criteria for establishing a causal relationship and both the weaknesses and the utility of plausibility in a classic paper I think every clinician should read many times, and which I have also written about before.

Plausibility is a bit like our clinical index of suspicion–it doesn’t give us a definitive diagnosis, but it helps us start moving in the direction most likely to be productive. In the case of veterinary medicine, where resources for research are so scarce, do we really want to spend them on studies of ideas which can only be true if multiple well-established principles of basic science are false? Should we indefinately call for more research on homeopathy and methods for balancing Yin and Yang, or should we put most of our energies and talent towards ideas with a bit higher probability of being true? Plausibility is one of many factors to consider in weighing botht he mertis of a therapy and the value of further research.

Finally, of course all the same principles we are talking about apply equally to conventional therapies. Much of what we do in conventional medicine lacks high-quality supporting evidence, and some of it is even implausible. I challenge the pharmaceutical reps I talk to as vigorously as the herbalists, and I haven’t made any more friends in the world of stem cell therapies or hyperbaric medicine than I have among TCVM practitioners.

However, it is fallacious to suggest, as is sometimes done, that the criticism some of us are making of unconventional medicine are somehow weakened or inappropriate just because conventional medicine is imperfect. Trimming the dross from our repertoire and strengthening the quality of science and care we provide should reasonably start with the least defensible practices. And while I may respect the intelligence and genuine commitment to patient welfare of colleagues who support such therapies, their good perosnal qualities are not really evidence for the therapies they promote any more than the often venal and malicious behavior of some in the pharmaceutical industry is evidence that their products don’t work. As you say, our interventions need to stand on the merits of the evidence concerning them, and opinion is not evidence regardless of the strengths or weaknesses of the source.

 

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