Veterinary Orthopedic Manipulation (VOM)-A Familiar Tale of Quackery

Posted on April 23, 2012 by skeptvet

The hallmark of classic medical quackery is the lone genius proclaiming the discovery of a radical new approach to healing that is simple, perfectly effective, and perfectly safe. This magical new therapy, described in impressive scientific terminology invented from scratch for the purpose, would revolutionize medicine if not for the sinister individuals and institutions of conventional medicine suppressing the good news about it. Fortunately, published research demonstrating the safety and efficacy of such innovations isn’t necessary anyway, because the proof is in all the happy stories the inventor can tell about his own successes.

While I’ve posted several lists of warning signs of quackery (1, 2, 3), and discussed a number of individuals and companies whose marketing activities exemplify some of the specific signs on these lists (such as Eric Weisman, Gloria Dodd, Nzymes.com, and others), seldom have I seen such a paragon of quack medical self-promotion as Dr. William Inman’s Veterinary Orthopedic Manipulation and Laser Therapy Roadshow.

I became aware of this operation through a direct mail solicitation to attend a training workshop in Dr. Inman’s special style of cold laser therapy. I’ve written about cold laser before, and the bottom line is that while there is some plausibility to the idea that low-frequency lasers might have beneficial effects, based in preclinical research, the clinical trial evidence is mixed and inconclusive in humans and non-existent in veterinary medicine. So no firm conclusion about the efficacy of this treatment is justified by anything more than speculation and anecdote. Despite Dr. Inman’s revolutionary new “Chaos Conversion Therapy” (a term he apparently invented, since I can find no other use of it) that has apparently made lasers even more effective for allergies, endocrine disease, and cancer, I was not tempted to attend. I was also not tempted to write a post about it, until I checked out his website.

Apart from having apparently devised a whole new theory to dramatically improve the effectiveness of the questionable practice of cold laser therapy, Dr. Inman has made great strides (and a good deal of money) reinventing the even more questionable chiropractic theory of subluxations and devising an entirely way to waste your time and money banging on your pet to cure every imaginable ill caused by this imaginary abnormality.

According to his web site:

Veterinary Orthopedic Manipulation (VOM) is a healing technology that locates areas of the animal’s nervous system that has fallen out of communication, and re-establishes neuronal communication and thus induces healing. VOM is singularly the most simple, effective and safe healing modality in veterinary care to date.

Wow, sounds cool! So what can it fix? Well, apparently almost any musculoskeletal, gastrointestinal, glandular, or behavioral problems, ear infections, allergies, and just about anything else.

And how does it work? This is the fun part. Some proponents describe it as simply a variation of veterinary chiropractic, in which the imaginary vertebral subluxation complex interferes with either nerve conduction or the mysterious spiritual force known as innate intelligence, thus causing disease in almost any body system. This disease is supposedly treated by “adjusting” the spine to fix the undetectable subluxation and restore the body’s natural state of health. Apart from some evidence that chiropractic is about as useful for back pain as other kinds of physical therapy, over a century of research has failed to document the subluxation or any other benefits to this therapy.

This lack of evidence hasn’t much hampered the work of chiropractors in human or veterinary medicine. However, selling just another variant of chiropractic apparently isn’t good enough for Dr. Inman. He even went so far as to found his own organization, the International Association of Veterinary Chiropractitioners, and  according to his web site:

Is Veterinary Orthopedic Manipulation (VOM) chiropractic care?

No! VOM exists in between veterinary medicine and chiropractic care. It has similarities to some of the chiropractic modalities and functions by restoring function by reducing “subluxations” as is done in chiropractic care. It uses a hand-held device that is used in a popular human chiropractic technique called “Activator Methods” but it is not to be confused with that technique. The differences between VOM and Chiropractic care are significant and distinct.

VOM exists in a gray area between both professions (Veterinary and Chiropractic) and benefits from the positive aspects of both, a hybrid, and thus more effective than either by themselves.

Ah, so it is neither chiropractic nor veterinary medicine, and naturally this means it’s better than either one. (?!) In an article on the subject Dr. Inman published in the Journal of the American Holistic Veterinary Medical Association, he expands on his notion of the subluxation.

The location of the subluxation phenomenon is not the nerve or the bone, but it is the neuronal interference that exists at the interneuron of the dorsal horn of the facilitated spinal segment. 

It cannot be seen on x-ray, cannot be imaged by ultrasound or MRI, but can be readily demonstrated with the application of a simple diagnostic protocol using a hand-held device….

Subluxation is only a switch that can potentially be turned back on. This is simply done by providing adequate force to the interneuron through the mechano-receptor inputs into the dorsal horn. (Please see diagram). Note: this is mechano-receptor force, not motion, thus the process is inherently safe and amazingly effective.

…Thus 100% of all subluxations can easily and objectively be located and evaluated using the VOM Diagnostic Technology and neurological subluxation signs.

…The VOM Diagnostic Technology is amazingly accurate. Diagnostic reading patterns are demonstrable weeks to years before radiographic and other diagnostic technique will verify.

Now any medical approach which fixes a problem that cannot be detected except by the special methods of that approach and that does so with perfect accuracy, absolute safety, and “amazing” effectiveness is by definition either a miracle or bullshit. It would seem likely that if this one was in the miracle category, it would have succeeded in replacing the rest of veterinary medicine in the 30-odd years since Dr. Inman claims to have begun developing the technique in 1982. Certainly, many revolutionary new medical practices have gone from ridicule to dominance in that amount of time. But Dr. Inman has some thoughts on both the fact that VOM sounds too good to be true and why it hasn’t achieved the recognition it deserves.

How can VOM be that easy?

Why not? Who says that a healing modality has to be complicated, difficult and expensive? Who says it should take hundreds of hours to learn and perfect? A technology that goes to the root of the problem, a simple technology that relies on the animal’s innate ability to heal itself, one that re-establishes communication with the pet’s ability to heal itself, will be easy, powerful and effective. 

Why haven’t I heard of the VOM Technology before?

Because it works! That may not make sense at first, but consider this: if the VOM Technology does what it appears to do, it makes a lot of techniques, surgeries and medications obsolete. The professionals that provide those techniques, surgeries and medications will be placed in academic and financial jeopardy. These are the people that control publications in the field and control licensure and applications. AKA politics.

Ah, of course, the Dan Brown Gambit, in which a vast conspiracy suppresses the miraculous truth out of fear and greed. Sure.

So what sort of evidence is offered for the quite grandiose claims made for VOM? As usual, pseudoscientific ramblings based on bogus theories and piles of anecdotes, which (as Dr. Mark Crislip has pointed out in a different context) don’t become evidence by force of numbers any more than piles of cow dung become gold when enough is collected. VOM is apparently a one-man vision with no need for input from science or any formal clinical research.

VOM was developed in a vacuum, meaning it was developed with a trial and error approach in a clinical setting without input from other sources. Dr. William Inman has been the sole source of the VOM Technology.

Over the past 18 years and represented by over 45,000 clinical cases (on file and available on computer) the patterns for over 250 disease conditions have been recognized and tested for reliability.

Wow! One doctor, 45,000 clinical cases, and not a single published clinical trial. Why is that again? Oh yeah, the obstinate oppression of the medical establishment. Uh huh.

Well, at least VOM is an efficient form of quackery and easy to learn. As Dr. Inman points out,

Unlike AVCA certification and instruction that takes 150 hours and five modules to complete, a veterinary Chiropractitioner (VCP) can adequately apply VOM after a “VOM Small Animal Module One” seminar attended in their home town in a weekend.

Apparently, Dr. Inman no longer practices so he can devote himself to teaching:

In 1996 he began teaching the VOM, VMR, Somato-Visceral, and Myofascial Release fulltime in lieu of clinical practice. Currently he is not licensed in any jurisdiction and limits his efforts to teaching only. He does not consult on specific cases as that infers clinical practice.

Of course, this might have something to do with his history of legal troubles:

The license of Dr. William Inman, Seattle veterinarian, has been suspended for a minimum of five years and he has been fined $10,000 by the state Department of Health’s Veterinary Board of Governors…The board found Inman displayed “incompetence, negligence or malpractice”….The action is believed by longtime veterinarians to be the harshest ever taken in this state.

Dr. Inman has maintained that the Board identified his technique as safe and effective even while disciplining him for other reasons. However, news reports claim, “The board in its report, however, made “no conclusion” whether the technique was improper conduct.”

And the record of his appeal of the veterinary medical board case indicates:

The Board found twelve violations, four of which are not at issue on appeal: the failure to keep adequate records; unprofessional conduct in failing to perform a proper work-up on a cat named Mickey; surgery that did not conform to the appropriate standard of care; and misrepresentation to Mickey’s owners that veterinary orthopedic manipulations were effective when Dr. Inman should have known they were not.

The appeals court affirmed the veterinary medical board’s findings and after a review of the procedures found the judgment and punishment appropriate. These findings include gross misconduct including deliberately encouraging staff to falsely identify parasites patients did not actually have and giving medications and vaccinations in clearly inappropriate circumstances. Apparently, unable to practice conventional medicine appropriately, Dr. Inman chose to invent his own alternative approach to healthcare and sell that instead.

Of course, Dr. Inman and his supporters will undoubtedly dismiss my criticism and his legal troubles as mere vindictive attacks by those threated personally and financially by his revolutionary invention. And undoubtedly many anecdotes will be presented from satisfied pet owners and veterinarians convinced that VOM works wonders and that Dr. Inman is unjustly accused.

But the pattern seen in this case is strikingly similar to that seen in the other examples of snake oil salespeople I have discussed here. Lone misunderstood genius offers revolutionary therapy supported by theories inconsistent with established science and anecdotes. This therapy makes money and converts but is either not tested in any formal scientific way or fails such testing. Lone genius is undeterred and continues practicing. Said genius then persecuted by the establishment and accused of gross misconduct or incompetence unrelated to revolutionary invention and switches from clinical practice to full-time promoter of said revolutionary practice. Supporters claim genius is misunderstood martyr and critic are frightened, greedy, or just plain mean.

One has to wonder whether this pattern can be said to indicate the seemingly obvious: Each of these people is either deluded or deliberately deceiving the public, and the reason their therapies are not accepted with adulation by the mainstream is because there is not good reason to think they work. Isn’t this more likely than the alternative the each and every one of them has discovered something original and miraculous that should be accepted widely without any proof beyond their say so and the testimonials of their clients?

Posted in Chiropractic, General, Law, Regulation, and Politics | 18 Comments

What’s in Chinese Medicine? New DNA Study Finds Some Unpleasant Answers.

Posted on April 15, 2012 by skeptvet

The lack of effective regulation covering herbal remedies and dietary supplements is well-known. The General Accounting Office has warned Congress about the widespread deceptive and illegal marketing of such remedies. And there are numerous studies which illustrate the potential dangers of unregulated and inadequately tested herbal products. Apart from the issues that such remedies are often put together on the basis of unscientific mythological understandings of health and disease, or that they are marketed on the basis of the naturalistic fallacy, the notion that such remedies can be viewed as “natural” and so are automatically safe, and that they are seldom rigorously evaluated through adequate pre-clinical and clinical trial testing, one big problem with herbal and other Chinese Medicine products is that practitioners and patients often don’t even know what they contain.

For example, I’ve written previously about Yunnan Paiyao, which is supposed to control bleeding, both topically and systemically. Many preparations of this product don’t even list an active ingredient. I cannot imagine most people being willing to take a medicine when the manufacturer refused to disclose the ingredients, but the same sensible caution doesn’t always seem to be applied to herbal products.

Of course, many Traditional Chinese Medicine products do list their ingredients, but given the problems with label accuracy for other unregulated alternative remedies, such as probiotics, some skepticism about the accuracy of these labels seems warranted. An objective method for determining what such remedies actually contain would be a good start in evaluating their quality control and the potential for harm from undisclosed ingredients.

Some studies have looked at chemical components, including undisclosed pharmaceuticals and heavy metals. A recent pilot study has taken a different approach, trying to identify the plant and animal ingredients through identification of DNA found in the products.

Coghlan ML. Deep sequencing of plant and animal DNA within traditional Chinese medicines reveals legality issues and health safety concerns. PLOS Genetics. 2012;8(4):e1002675.

The authors looked at 28 samples of TCM products seized by the Australian customs service and were able to identify plant and animal components of 15 products. One of the methodological problems with this approach is that databases of DNA sequences, particularly for plants, are not yet sufficiently extensive to allow precise species-level identification of many plants. However, these databases are growing rapidly, and the precision of this technique is likely to be excellent as the reference resources improve.

Examples of the usual sorts of concerns did surface in the study. Plants with known toxic properties were identified in 4/15 samples, including Ephedra, and Asarum, a potential source of aristolochic acid, which is a TCM ingredient known to cause kidney failure and   urinary tract cancer. The authors did not evaluate the samples to determine if these toxins were actually present, though they indicated that combining such standard chemical analysis with their DNA sequencing approach would be the optimal way to evaluate such products.

The study also identified DNA from known endangered species of both plants and animals, including bears and Saiga antelope. TCM remedies made from parts of endangered species are a significant environmental problem which is particularly infuriating since there is no reasonable evidence to suggest the inclusion of these ingredients has any actual health benefit. Sympathetic magic and other mythological foundations for such practices are not legitimate reasons to contribute to the threats to endangered animal and plant species.

Finally, the study identified significant mislabeling. 78% of the samples contained DNA for species of animals not listed on the label. Sheep, goats, water buffalo, and cows were found, among other species, and these likely represent adulteration with cheaper, easier to acquire ingredients replacing traditional ingredients such as those from bear and Saiga antelope. While this may reduce the risk to such endangered species, one can hardly approve of substituting animal products with no demonstrated health effects for other animal products with no evidence of health benefits and then not even honestly labeling the products.

Though this particular study looked at a very limited selection of remedies and only identified a relatively small set of ingredients, it demonstrates both that such methods can be useful in identifying the true constituents of TCM products and also that these products can contain ingredients that are toxic, that come from endangered species, or that aren’t listed on the labels. Such problems aren’t likely to improve without meaningful regulations requiring thorough and accurate labeling, independent monitoring of compliance with label regulations, and ideally requirements for reasonable evidence of safety and efficacy before the products can be marketed at all. Unfortunately, none of these sensible requirements seem likely to be put in place any time soon.

 

Posted in Herbs and Supplements | 4 Comments

Choosing Wisely: Physicians Take a Stand Against unecessary Tests and Treatments

Posted on April 9, 2012 by skeptvet

The subject of unnecessary diagnostic testing is a contentious one that I’ve addressed here before (Overdiagnosis, Screening Tests). In human medicine, the government provides evidence-based guidelines for preventative healthcare interventions, including screening tests, through the U.S. Preventative Services Task Force (USPSTF). While being mostly ignored, this agency occasionally draws great controversy when challenging the classic American myths that More is Better and Statistics Don’t Matter. For example, after concluding that the evidence didn’t support routine screening mammography for as many women as had previously been told to have it done, the USPTF revised the screening guidelines. This generated a media conflagration on the scale of the Culture Wars, and led to a bunch of lawyers and politicians with remedial science knowledge passing legislation directing the government to ignore the evidence. Fortunately, other recommendations for less widespread screening for prostate cancer and cervical cancer have been greeted with less hysteria.

Still, the idea that unnecessary screening tests hurt more people than they help is a tough sell to those who don’t understand the complexities of reliability, validity, predictive value, and other factors involved in evaluating the risks and benefits of disease screening. Anecdotes about individuals who had a potentially serious disease detected by screening and believe that the subsequent treatment saved their lives are very compelling. They seem to get more coverage and have more impact than stories about people harmed by unnecessary treatment after detection of lesions that likely would never have caused them any problem. Nevertheless, unnecessary diagnostic tests not only cost a lot of money, reducing the resources available for providing necessary healthcare, but they also do harm many individual patients who are forced to go through unneeded secondary testing or treatment for diseases that either don’t exist or would never have made them ill.

A new organization of physicians has been formed to try and educate both clients and doctors about this problem and to make sound, evidence-based recommendations about diagnostic testing. Choosing Wisely has gotten a fair bit of media coverage lately for promoting lists of specific procedures that are often done unnecessarily, and for suggesting that these only be done when certain criteria are met. The lists also address some therapies which may be unnecessary, including the ever-popular excessive and inappropriate use of antibiotics.

These lists have generally avoided particularly controversial subjects, and so far haven’t been greeted with the panic that some of the USPSTF recommendations have. Hopefully, the effort will have some impact on physician behavior and consumer expectations. And once the organization and its approach is familiar and gains some credibility, perhaps they will be able to take on more controversial subjects, such as the lack of evidence to support annual physical examinations in adults without symptoms of illness (or even CAM therapies and tests not supported by evidence?).

 

 

Posted in General | 13 Comments

New Review Finds Little Evidence that Nutraceuticals Help Animals with Arthritis

Posted on March 27, 2012 by skeptvet

I have written extensively about various supplements and herbal treatments for arthritis. For the most part the evidence seems weak for all of these products, though there are a couple of suggestive studies that might lead to demonstrably effective treatments someday. I have also talked about the need for application of rigorous, explicit evidence-based medicine techniques (EBM) in veterinary medicine. A recent paper in the Journal of Veterinary Internal Medicine does an excellent job of illustrating EBM methods, and its subject is the use of nutraceutical for treatment of osteoarthritis in animals.

J.-M. Vandeweerd, C. Coisnon, P. Clegg, C. Cambier, A. Pierson, F. Hontoir, C. Saegerman, P. Gustin, S. Buczinski. Systematic Review of Efficacy of Nutraceuticals to Alleviate Clinical Signs of Osteoarthritis. Journal of Veterinary Internal Medicine. 2012. Epub ahead of Print.

The authors adapted the CONSORT statement and recommendations from the Centre for Evidence-Based Medicine at Oxford to design an explicit and detailed scoring sheet for research trials involving nutraceuticals for osteoarthritis. This sort of transparency, and establishing criteria for grading evidence in advance, are important aspects to an evidence-based review, which help to minimize the potential impact of personal bias on the results.

The authors then conducted a thorough literature search for articles in English and French that concerned the use of common nutraceuticals in arthritis treatment. A total of 67 articles were found, of which 22 met the inclusion criteria of the review (controlled clinical trials evaluating clinical signs of pain or locomotion). The literature search terms are presented in the report in a way that makes replicating the search straightforward.

An exhaustive evaluation of these 22 studies was then conducted, with a grading of the quality of evidence for the following nutraceuticals:

Glucosamine
Chondroitin Sulfate (various forms)
Undenatured Type II Collagen
Avocado and Soybean
Gelatine Hydrolysate
Omega-3 Fatty Acids (aka fish oil)
Hydroxycitric Acid
Green-Lipped Mussel Powder
Special Milk Protein Concentrate
Indian and Javanese Turmeric
Various combinations of these ingredients and such as manganese, vitamins, amino acids, chromium, and more

The conclusions were quite straightforward:

The strength of evidence was low for all nutraceuticals except for omega-3 fatty acid in dogs…The evidence of efficacy of nutraceuticals is poor, with the exception of diets supplemented with omega-3 fatty acids in dogs.

The authors also touched on many of the limitations of the available literature, not only the small numbers of studies and subjects, but the lack of replication, the tendency for all the research on a single subject to come from one researcher or research group, the lack of motivation for studies given the lack of effective regulation of dietary supplements and many others.

This is an excellent example of the application of EBM methods to veterinary questions. While the available evidence is often limited in quantity and quality, we need to critically appraise what there is in order to make the best clinical decisions. I think the methodology used in this paper is a model for how such reviews can be conducted and how they can be useful to general practitioners.

My only quibble was with the conclusion the authors reached concerning fish oils. I have previously reviewed three of the four studies they evaluated (here and here), and while I agree that they are generally good quality studies, I think the results are less convincing than the authors claim or than this review suggests. It can be difficult to balance an objective, checklist-based evaluation of the evidence, which reduces the influence of reviewer bias, with the need for a judicious assessment of the details of the evidence, and I think the authors of this review generally do a good job. But I think they reach the wrong conclusion with regard to the fish oil question.

Below is a detailed evaluation of the findings of each study, which I think illustrates why the few positive data reported provide only weak evidence of a benefit for fish oils in treatment of arthritis.  

A.    Dose-titration effects of fish oil in osteoarthritis dogs.  

1.     Semi-objective measure (veterinarian clinical assessment)

Of five measures assessed at four time points, all measures improved for all groups. Without a no-treatment arm, it is impossible to know how much of this apparent improvement is an artifact of study participation.

Only two measures improved significantly more for highest dose diet compared with the lowest dose diet (with no differences between the medium and lowest dose diets). These improvements were small and of dubious clinical significance: from 1.68 to 1.40 (~17% improvement) and from 2.00 to 1.64 (~18% improvement) on a scale where 1-no signs, 2-mild signs, 3-moderate signs, 4-severe signs). 

2.     Subjective measure (veterinarian estimate of overall change based on exam and owner input)

Veterinarians were asked, based on their own assessment and owner input, how much over the 90 days of the study they thought the diets had slowed or accelerated the dogs’ arthritis, or if they had no effect. All diets were believed to have slowed the progression of the disease, with the highest dose diet scoring 2.32 and the lowest dose diet 1.99 on a scale of 1-significantly slowed, 2-slightly slowed, 3-no effect.

Veterinarians were then asked, based on their own assessment and owner input, how much over the 90 days of the study they thought the dogs’ arthritis had changed. All dogs were believed to have improved, with those on the highest dose diet scoring 2.55 and those on the lowest dose diet scoring 3.15 on a scale of 1-extreme improvement, 2-moderate improvement, 3-slight improvement, 4-no effect. 

  1. A multicenter study of the effects of dietary supplementation with fish oil omega-3 fatty acids on carprofen dosage in dogs with osteoarthritis.

Reduction of the carprofen dose was the stated goal of the study, and the dose decreased for both groups. The control diet group dose decreased over 12 weeks by an average of 0.59mg/kg/day (from 4.14 to 3.58mg/kg/day, ~14%). The test diet group dose decreased by an average 1.13mg/kg/day (from 4.39m to 3.26 mg/kg/day, ~26%). The final dose differed between the two groups by 0.32mg/kg/day.

C.    Multicenter veterinary practice assessment of the effects of omega-3 fatty acids on osteoarthritis in dogs 

1.     Semi-objective measure (veterinarian clinical evaluation)

Out of five clinical measures over three time periods, there were no significant differences between control and test diet groups.

2.     Subjective measure (owner survey)

Out of thirteen measures over three time periods, there were two measures that differed significantly between groups at the first evaluation and one other measure that differed significantly at the second and third time period. No express statistical controls for making multiple comparisons were described despite p-values being reported for fifty-four different comparisons.  

D.    Evaluation of the effects of dietary supplementation with fish oil omega-3 fatty acids on weight bearing in dogs with osteoarthritis. 

1.     Objective Measure (force plate analysis)

Two measurements for each group were compared at two points in time and then a comparison was made of the percentage change in these measurements for both groups over the intervening period. Of the total of eight comparisons, one was significantly different between groups. 

2.     Semi-objective measure (veterinarian clinical evaluation)

Of five measures compared between groups at two points in time and in terms of change over time, the test group improved more than the control group in terms of two measures. This was the same measure of effect as used in Study 10, in which no such difference was seen. 

3.     Subjective measure (owner survey)

Of thirteen measures evaluated at two points in time, there were no significant differences between groups. This was the same measure of effect used in Study 10, in which three of the measures did differ at some of the time points.

References
1.     Fritsch D, Allen TA, Dodd CE, et al. Dose-titration effects of fish oil in osteoarthritis dogs. J Vet Intern Med 2010;24:1020–1026.

 2.     Fritsch DA, Allen TA, Dodd CE, et al. A multicenter study of the effects of dietary supplementation with fish oil omega-3 fatty acids on carprofen dosage in dogs with osteoarthritis. J Am Vet Med Assoc 2010;236:535–539.

3.     Roush JK, Dodd CE, Fritsch DA, et al. Multicenter veterinary practice assessment of the effects of omega-3 fatty acids on osteoarthritis in dogs. J Am Vet Med Assoc 2010;236:59–66. 

4.     Roush JK, Cross AR, Renberg WC, et al. Evaluation of the effects of dietary supplementation with fish oil omega-3 fatty acids on weight bearing in dogs with osteoarthritis. J Am Vet Med Assoc 2010;236:67–73.

 

Posted in Herbs and Supplements, Science-Based Veterinary Medicine | 6 Comments

Crananidin: Cranberry Extract for Urinary Tract Infections in Dogs and Cats?

Posted on March 16, 2012 by skeptvet

The question of whether cranberries, in some form, have value in treating or preventing urinary tract infections (UTIs) is a pretty old one. Mark Crislip at Science-Based Medicine has written a nice summary of the topic, and he has found over 100 references dating back to 1962. Like most herbal remedies, it has traditionally been thought helpful for a wide variety of unrelated disorders, but it is now pretty firmly established in most people’s minds as useful for UTIs.

Unfortunately, as usual the subject is more complicated than is generally realized. The theoretical justification for using cranberry to treat UTIs used to be that it acidified urine and made it less hospitable for bacteria, however that is no longer believed to be true. The current theory is that chemicals called proanthocyanidins interfere with the attachment of bacteria to the bladder wall, making it easier for the body to eliminate these bacteria and harder for infections to get started.

This is certainly a plausible mechanism established  by in vitro studies. The trouble is that the proanthocyanidins inhibit attachment only for E.coli with little hairs called fimbriae on them. There are many other bacteria that can cause UTIs, and there isn’t yet any evidence that proanthocyanidins affect these. And in humans fewer than 20% of E.coli in bladder infections have fimbriae, so theoretically, these chemicals should be only be useful in preventing recurrent infection in a small minority of cases. (Interestingly, the vast majority of E.coli from kidney infections are fimbriated, so cranberry could possibly be more useful in these cases). There is also the problem that no one has actually proven that oral cranberry leads to proanthocyanidins getting into the urine, or being biologically active when they get there.

As Dr. Crislip points out, though, the theoretical mechanisms are not so important if the remedy doesn’t actually work in clinical trials. So does it? Well, there is still no consensus, since some trials show and effect and others don’t. The best that can be said as of now is that cranberry probably isn’t useful for treating UTIS and it may or may not be useful for preventing them.

Despite this uncertainty, the popular belief that cranberry products are useful for urinary tract infections in humans makes it inevitable that such products will be marketed to pet owners for UTIs in dogs and cats. As in humans, many UTIs are caused by bacteria other than E.coli, and I am not aware of any research on the proportion of fimbriated E.coli in canine and feline UTIs, so the theoretical rationale for this remedy is even weaker than in humans. But a quick Google search shows plenty of veterinary versions on the market anyway, often with pretty confident claims.

I recently came across some marketing materials for one of these, Crananidin from Nutramax. They are careful to avoid any treatment or prevention claims, since that would violate the Dietary Supplement Health and Education Act (DSHEA). However, they try pretty hard to suggest a benefit and even superiority over their competitors despite the absence of any clinical trial evidence.

The Nutramax literature has a nifty little graph of bioactivity in the dog purporting to show that “by 7 days the average bioactivity is over 78% at inhibiting E.coli.” They cite two articles to support this statement. One is an NMR study of the molecular structure of proanthocyanidin, and the only bioactivity data is from mixing fimbriated E.coli with human red blood cells and some cell-surface-receptor coated plastic beads in vitro (interestingly, this study was funded by Ocean Spray). There is no testing or discussion of clinical effects, and no data concerning dog urine. There really seems no way to interpret this citation other than being deliberately misleading.

The other reference is “Data on file, Nutramax Laboratories,” so I presume it is an unpublished in-house experiment. Unpublished data from a company selling a product that “proves” the product works, and is better than the competition, ought to be viewed somewhat skeptically, needless to say.

The marketing literature also has a little chart showing their product “passing” a test of bioactivity and all the competing products failing it. The references for this are the same, and since the published article has nothing to do with this issue, apparently the only evidence for this claim is unpublished in-house data from Nutramax. I’m not aware of any published clinical trials investigating this or any other cranberry product for use in UTIs in dogs or cats.

There also isn’t any evidence concerning the safety of cranberry products in dogs and cats. In humans, one concern is that cranberry juice has a lot of salicylic acid, so people with aspirin allergies or on anti-coagulant medications aren’t supposed to take a lot of it. But those are pretty rare issues in veterinary medicine. And some studies have shown it increases oxalate in the urine by up to 43%, so I wouldn’t recommend it for patients with a history of oxalate urinary tract stones (even though, again, this data is for people, and there are no studies I can find in dogs or cats).

Bottom Line
There is weak theoretical justification for using cranberry products for UTIs, though none of the supporting preclinical evidence involves dogs or cats. There is conflicting clinical trial evidence in humans, and no clinical studies in dogs and cats. There are weak theoretical safety concerns. And, of course, there is abundant marketing making bold statements unsupported by the little evidence that exists. You pays your money and you takes your chances. Fortunately (for Nutramax, if not for our pets), anecdotes claiming a benefit are easy to find, so there should be little trouble selling the products even without convincing evidence of safety or efficacy.

 

 

Posted in Herbs and Supplements | 8 Comments

Protandim: An Update from Science-Based Medicine

Posted on March 13, 2012 by skeptvet

Last year I wrote a review of a dubious herbal combination product called Protandim. At that time, my bottom line conclusion was:

Bottom Line
The underlying theory used to promote this product, that anti-inflammatory and anti-oxidant effects are always safe and beneficial, is highly doubtful. There is only weak in vitro and animal model research to indicate that the ingredients in Protandim, or the combination product, have potentially useful effects on cells or biochemical markers. There is absolutely no clinical trial evidence to indicate Protandim has any of the claimed benefits in humans or animals. While the absence of evidence is not proof the product is unsafe or ineffective, it is absolutely a reason to be skeptical of wild claims of miraculous benefits. At best, using this product is simply rolling the dice and hoping for the best. That seldom works out for gamblers in Vegas, and it is not an appropriate approach to healthcare except in the most dire of circumstances.

Dr. Harriett Hall at the Science-Based Medicine Blog has recently provided an update on this product and a recent clinical study investigating it. The study was bizarre and it is amazing any ethics committee would approve it. It is also not prominently featured on the Protanidim web site, no doubt because no effect was seen. Here are a couple of highlights from Dr. Hall’s summary:

To recap their chain of reasoning: alcoholics might develop lung disease, that lung disease might be correlated with abnormal epithelial permeability, protein levels measured by bronchoalveolar lavage (BAL) might be a valid measure of permeability, permeability might be affected by underlying oxidative stress, and Protandim might reduce oxidative stress by stimulating the body to produce its own antioxidants. Do they perhaps think that lots of “mights” add up to a “mighty” argument?

The second listed author, Joe McCord, has a vested interest: he is an officer of the LifeVantage company, the manufacturer of Protandim. They explain that Protandim is “a nutraceutical with a lengthy history of use in homeopathic, Ayurvedic, and traditional Chinese medicine.” An interesting statement, since Protandim was invented only a few years ago by a person with no medical background and it was patented in 2007. Doubly interesting since it belies the common myth that natural medicines are not profitable because they can’t be patented.

They assessed alveolar epithelial permeability by measuring the total protein in bronchoalveolar washings. Total protein levels did not change in either experimental group. They also found no change in oxidative stress indices, epithelial growth factor, fibroblast growth factor, interleukin-1?, interleukin-10, liver function tests, or other blood chemistry tests. The one finding that was statistically significant was a significant decrease in plasma thiobarbituric acid reactive substances (TBARS), a marker of lipid peroxidation — but that was only in the placebo group!

In short, Protandim was significantly (p<0.01) worse than placebo. No wonder they’re not bragging about this study!

Big Pharma gets a lot of criticism, but aren’t Big Supplement and Big Multi-Level Marketing every bit as guilty of self-interest, distortions, and profit motives? At least Big Pharma can’t make its big bucks without first demonstrating effectiveness and safety to the FDA with clinical trials.

Does Protandim provide any real benefit to its customers? I don’t know, and they can’t hope to know unless they do proper clinical studies.

 

Posted in Herbs and Supplements | 51 Comments

Raw, Cooked, and Dry Cat Diets–A New Study Examined

Posted on March 13, 2012 by skeptvet

The debate about raw diets for pets is an ongoing “hot button” topic in veterinary circles. There is also a less heated but still vigorous debate about cat nutrition in particular and what form and composition constitutes the optimal diet for our pet cats. I have previously written about raw diets extensively, and I still hold the opinion that there is little reason to believe they are superior to cooked diets, including commercial pet foods (1, 2, 3, 4, 5, 6, 7).

The theoretical arguments advanced for using these diets are weak and often simply a form of the appeal to nature fallacy. “Natural” is not synonymous with “optimal,” so even for cats, which are obligate carnivores and often still actively predatory, actual experimental evidence is needed to justify the claim that the natural diet of raw, live small prey, or other raw diets promoted as equivalent, is better than the alternatives.  This is even more true for dogs, who have been so deeply altered by breeding and association with humans from their wild ancestors that it is a stretch even to claim there is a “natural” diet that domestic dogs should be eating.

While the benefits of raw diets remain unproven, there are legitimate concerns about risks, including infectious disease, parasites, and potential dangerous from specific components of some diets, such as bones. These risks do not yet appear dramatic, but they need to be weighed against benefits which can be substantiated by real research, which does not yet exist.

One recent study has compared a commercial kibble with both cooked and raw alternatives in a few cats, and some raw diet advocates are suggesting this is evidence in favor of the benefits of raw diets. Having looked at the study, I think it is an interesting beginning in terms of comparing different feeding options, but I am not convinced it provides significant evidence to support most of the claims made for raw pet diets.

K.R. Kerr, B.M. Vester Boler, C.L. Morris, K.J. Liu, and K.S. Swanson. 2012. Apparent total tract energy and macronutrient digestibility and fecal fermentative end-product concentrations of domestic cats fed extruded, raw beef-based, and cooked beef-based diets. Journal of Animal Science: 90: 515-522.

The study was nicely designed, though this also meant labor intensive, which likely contributed to the small sample size. Nine cats were each fed three different diets in rotation; a beef-based raw diet, the same diet cooked in a microwave to the standards for food safety recommended by the USDA, and a high-protein commercial dry diet. The cats ate each diet for 21 days. The last 4 days of each period, all feces and urine was collected for analysis, and on the last day a blood sample was taken.

The nutritional composition of the three diets was complete and roughly equivalent, though the ingredients of the commercial kibble were significantly different from the ingredients of the other two diets.  And of course the moisture content of the dry diet was significantly less than that of the others.

The only difference among the diets in terms of the bloodwork was a higher creatinine (a measure of kidney function, hydration, and protein metabolism) and triglyceride (a fat) in cats eating the cooked and raw fresh diets than in those eating the commercial dry diet. Though these values differed between the diets, they were within the normal range for all cats. 

Interestingly, there were no differences in the urinalysis values between any of the diets, and all the cats had very high urine specific gravity measurements (>1.064). One of the arguments for feeding fresh or canned diets is that the increased fluid content should improve hydration and reduce urine specific gravity, which is hypothesized to be useful in preventing and managing kidney disease. However, despite having water available at all times, the urine specific gravity was extremely high in all of these cats, and there was no difference between the kibble and the fresh diets.

Any interpretation of these numbers is speculative given the small size of the study, but one would expect the fresh diets to lead to lower renal bloodwork values and lower urine specific gravity than the kibble, particularly if they are to have any protective benefits against kidney disease. This data seems to undermine this hypothesis.

The amount the cats were fed was adjusted regularly to maintain an ideal body condition, so no differences in the effect of diet on body condition could be evaluated. Cats on the dry diet did eat more, in terms of volume and calories, than cats on the other two diets (which were not different from each other). This agrees with the finding that the dry diet appeared to be less digestible than the other two diets (which again did not differ from each other). 

The various measures of digestibility showed the dry diet to be between 4.2% and 11.7% less digestible than the cooked and raw fresh diets. However, as the authors state, “All diets tested in this experiment were highly digestible,” so the real-world significance of this isn’t clear. Presumably, a cat would have to eat a greater quantity of a less digestible diet and would produce more stool, but it is unclear how great a difference this might be or whether it would have any health implications.

Stool quality is often a marketing point for raw diet advocates. In this study, stool quality was evaluated on a 5-point scale:

1 = hard, dry pellets
2 = dry, well-formed stools
3 = soft, moist, formed stool
4 = soft, unformed stool
5 = watery liquid that can be poured

Cats on the dry diet had a higher score (average =3.3) compared to the other diets (which did not differ significantly at averages of 2.8 and 2.9). The ideal score is 3.0, so all of the diets generated a normal fecal consistency. Oddly, the dry diet appeared to lead to moister stools than the higher moisture content diets, which is the opposite of what one might expect.

A number of fecal compounds were measured, but the only conclusion drawn from the differences seemed to be again that the dry diet was less digestible and so led to greater colonic bacterial metabolism than the other two diets. However, the measurements were consistent with normal values seen in healthy cats. The health implications of this are unclear.

So what conclusions did the authors draw from these data?

Although the raw and cooked beef-based diets were more digestible than [the dry diet], all diets were highly digestible in this experiment.

Few differences in serum metabolites were detected

Urine variables did not differ among diets.

All scores of fecal consistency were within a desirable range, but cats fed [the dry diet] had greater scores

Carbohydrate fermentation was similar for all diets.

Fecal putrefactive compounds…were increased in cats fed [the dry diet] but were similar to values reported in the literature for healthy cats.

Because cooking may minimize risk of microbial contamination, and the results from the cooked beef-based diet tested herein were not different than the raw diet, cooking may be an appropriate modification to this feeding strategy

And, finally, the authors argued that more research is needed, which is certainly the case.

Overall, this study is interesting but doesn’t seem to offer much support to the claims made for raw, or even fresh high-moisture diets. No difference of any kind was reported between the raw and the cooked diet, and the vast majority of the measurements made did not differ between these and the dry kibble. And even the high moisture diets led to a high urine specific gravity, which would suggest less than optimal fluid intake.

The dry was slightly less digestible than the fresh diets, but all were easily and thoroughly digested. But as the authors state, “Because the ingredient composition of [the dry diet] was different than that of [the other diets], we acknowledge that the influence of the dietary composition and extrusion cannot be separated.” So it is not even clear if the difference found has to do with the form of the diet or simply the particular ingredients used. Even less clear is whether these differences have any implications for health or disease.

I certainly support further research into different pet feeding methods. My personal guess is that raw will not prove to have any benefits sufficient to outweigh the risks, though I do think feeding moist diets may turn out to be better for cats than feeding dry diets. Homemade diets may have some advantages, but these are probably outweighed by the persistent problems with nutritional adequacy and quality control unless a nutritionist is involved in formulating and supervising them.

I look forward to studies which either confirm these guesses or prove me completely wrong. However, until there is adequate research, these are simply guesses, not facts. The biggest concern I have about raw diet advocates is that they tend to make grand health claims far beyond anything supported by evidence. I wouldn’t be surprised if this paper is held up as evidence for those claims, but a close reading of it does not support that interpretation.

Posted in Nutrition | 18 Comments

Nzymes.com: Same Snake Oil, Different Day

Posted on March 12, 2012 by skeptvet

Knowing that I have an interest in investigating the evidence behind claims for veterinary healthcare products, clients and colleagues sometimes pass along materials concerning veterinary supplements, herbal remedies, and other similar products and ask my opinion. Since there are hundreds, if not thousands of products marketed to pet owners to preserve or restore their pets’ health, I can only look into a few. However, the more of these I investigate, the more clearly I see the patterns of disregard for science and manipulation of the consumer that they have in common.

The latest in this category is a collection of products from a company called Nzymes.com. The website and pamphlet for this company exhibits nearly all of the warning signs of quackery. The company systematically tries to frighten the consumer by suggesting that pets cannot be healthy without their product and that the food and healthcare they are currently getting is inadequate.

Give Your Pet a Fighting Chance

If you are feeding your pet one of today’s popular processed pet foods, then chances are, your pet’s body is depleted of the primary enzyme precursors nature provides abundantly in all living foods.

The fact that we continue to feed our pets such enzyme-less food over an entire lifetime may contribute to the growing list of animal health problems we witness today including; osteoarthritis, inflammation, joint pain, hip dysplasia, pano, OCD, HOD, shedding, hair loss, dry skin, itchy skin, digestive disorders, gastritis, pet food allergies, epilepsy, fatigue, hot spots, and many other stress related symptoms contributed to by a weakened immune system.

The whole “living enzyme” argument is complete nonsense, and there is no evidence for the suggestion that commercial diets are nutritionally deficient or responsible for this long, redundant list of random symptoms and disorders. Some of these problems may be related to nutrition, but that has nothing to do with the claim made here, which is baseless.

But the pseudoscientific nonsense doesn’t stop there. The web site also blames pet food, vaccines, and medications for a variety of ailments, again without paying any attention to the real, and complicated, risks and benefits of these interventions. Classic quack nonsense like claims about the Pottenger cat “study,” about boosting the immune system, about mysterious “toxins” as a cause of unrelated diseases,  and about Candida yeast infections as a common cause of many health problems are all over the company web site.

So, what are they selling with all this fear? Apparently, miraculous panaceas with uncounted benefits and absolutely no risks! Since they aren’t allowed to claim they can actually prevent or treat any disease without having evidence to support it (though they effectively do, despite the Quack Miranda Warning here and there), they promise to “support”

Healthy Joint function, Healthy Muscle Function, Healthy Skin and Coat, Healthy Nervous System, Healthy Immune System, Healthy Circulatory System, Healthy Endocrine System, Healthy Lymphatic System, Healthy Digestive System, Healthy Urinary Function, Healthy reproductive Function, Healthy respiratory System, Healthy organ Function, General Overall Wellbeing

I like how they throw in “Healthy Organ Function” and “General Overall Wellbeing” just to cover any possible body part they might not have thought of. So if you’re afraid the imaginary causes of illness they mention have caused your pets’ problem, or might cause something bad someday, you can take comfort from knowing they this product can treat or prevent absolutely everything (except when it can’t, in which case it’s because of the food, the water, the medications, or anything else except the lack of benefit of their product). 

What, exactly, are the miracle elixirs offered by Nzymes.com?

Ox-E drops
This consists of 5% sodium chlorite, a chemical related to bleach. Properly diluted, this chemical is a safe disinfectant, killing infectious organisms through oxidation. With a pH of 13, if not diluted the chemical can cause burns, especially to the eyes and mucous membranes. Accidental overdose can be fatal.

The company advertises this as helping in “the removal of potentially dangerous free radicals and toxins,” and claims that is boosts the immune system, supports digestion, and enhances “performance.”  Impressive claims for a potentially toxic disinfectant that is actually an oxidant rather than an anti-oxidant.

As the accompanying quack Miranda warning attests, and a simple literature search confirms, there is absolutely no evidence for any of these claims. Plenty of testimonials are offered, of course, which is always the evidence of choice for products that are based on pseudoscience and have never been tested in any reliable way.

Antioxidant Treats
The antioxidant hype is a common marketing ploy for supplements because it’s vague, and there is enough suggestive preclinical research to suggest the general idea is plausible. Unfortunately, there are few clinical trials which show significant real benefits from particular anti-oxidants in particular conditions, and the evidence is growing that some such agents, such as Vitamin E, can actually increase the risk of disease.

The specific ingredients include Vitamin A, Vitamin C, Vitamin E, and a proprietary freeze-dried sprouted soybean meal claimed to contain:

The amount of the vitamins in the supplement are far in excess of what is recommended to prevent deficiency.

Vitamin A- 1000IU (recommended daily dose 50IU/kg, safe upper limit 2,099IU)
Vitamin C- 30mg (recommended daily dose 0, dogs and cats make their own)
Vitamin E- 5IU (recommended daily dose 1mg/kg)

These amounts are probably not high enough to cause harm, but given that most pets are fed diets already supplemented with more than enough of each, the amounts in this product are unnecessary as nutrients. The use of excess amounts of these vitamins as medicines to prevent or treat disease, is not proven, and has often turned out to do more harm than good when tried in humans.

As for the sprouted soybean meal, there is no scientific evidence to suggest health benefits from this either. The company sites a variety of epidemiological studies in humans indicating an association between eating tofu or other soybean food products and lower cholesterol levels, rates of some cancers, and a few other health problems. (They do not, of course, refer to any of the research in humans showing lack of benefit or potential risks from soy supplement products). All of this, unfortunately, is entirely irrelevant to whether or not this particular soy-based product has any benefits for dogs and cats.

The amino acids, vitamins, and minerals listed are all provided in adequate amounts in good quality commercial pet foods. The enzymes are of no benefit, particularly when taken orally since they themselves are destroyed by normal digestion. And none of the phytochemicals have yet been demonstrated to have any health benefits in dogs and cats. So while it is unlikely to be harmful, to is an expensive way to get a few nutrients your pet probably already has enough of and some chemicals that may or may not have any health effects, positive or negative. 

Black Leaf Tincture
This is an herbal product containing black walnut extract, olive leaf extract, and cayenne in 75% alcohol(!). The usual vague and unscientific claims are offered about supporting the immune system, the circulatory system, the digestive system, and so on.

Black Walnut- There is insufficient evidence to support any of the claimed health benefits despite traditional use for a wide range of unrelated problems. There is some concern about possible toxicity, from the walnut itself and from possible fungal contaminates.

Olive Leaf- The evidence in humans suggests some possible beneficial effects on blood pressure and cholesterol levels, but it is weak and not conclusive. There is no eveidence on the possible effects in dogs and cats.

Cayenne- There is a fairly large amount of preclinical research suggesting possible benefits in humans, but little in the way of clinical trial evidence, and nothing in dogs and cats. 

Probiotic
I’ve written extensively about probiotics, and this is an area in which I think some real benefits are possible. Unfortunately, we have yet to develop an adequate understanding of the normal gut ecology to be able to influence it in significant ways, and the evidence for real clinical benefits from specific products varies from weak to non-existent. Nzymes.com does nothing to change this. Their product contains a variety of typical probiotic bugs, and there have been no clinical trials to show that the specific combination has any value. The product was tested, however, in a study looking at quality and label accuracy for veterinary probiotics. It was found to contain only 2.7% of the number of bacteria claimed on the label, suggesting even the ingredient claims made for this product may be questionable, much less the claims of health benefits. 

“A Veterinary Study”
The company does claim to have one rather large veterinary clinical study from 1989 showing that dogs with musculoskeletal pain benefit from its sprouted soybean product. The study was never apparently published, and the information provided on the web site does not make it possible to evaluate it extensively. Six unnamed veterinarians apparently diagnosed dogs with “musculoskeletal inflammation” based on their own exams and the opinions of owners. They gave the supplement to 387 dogs, and 340 of them were reported as improved in one of more of these measures: energy, alertness, stamina, appetite, and accelerated healing. Most cases improved within the first week.

This is almost a cartoon caricature of what a scientific study shouldn’t be. No randomization, no placebo control group, no standardized diagnostic evaluation, no objective diagnostic evaluation (all subjective), no clearly defined diagnosis, no blinding, no record of other conditions or treatments used, and no predetermined or even halfway consistent criteria for response. Any high school science class ought to be able to put together a better “study.” If this is the best the company has been able to do in over 20 years, there is absolutely no reason to believe they have any interest in the scientific validity of their marketing claims. 

Bottom Line
These products are being marketed with an impressive number of the myths and warning signs of snake oil and pseudoscience. The theories offered for why these remedies should help your pet range from complete nonsense to vague unproven hypotheses. There is no scientific evidence to indicate any specific benefit from any of these products for any particular condition in dogs and cats. All the testimonials in the world can’t prove any of the company’s claims to be true, nor can they guarantee that the products cannot hurt your pets. Just as there is little evidence regarding the claimed benefits of these products, there is little to demonstrate that they are safe.

 

Posted in Herbs and Supplements | 250 Comments

Buyer Beware: How to Evaluate Pet Healthcare Products

Posted on March 8, 2012 by skeptvet

This is a great time to be a pet owner. Advances in nutrition and veterinary medicine in the last few decades have led to tremendous improvement in the length and quality of our pets’ lives. We have more and better options for preventing and treating illness in our animal companions than ever before. And apart from professional medical care, there is a staggering variety of healthcare products available for our pets.

But there is a downside to this abundance of choices. We are stuck trying to figure out which products might help our pets, which might do nothing for them, and which might even be dangerous. The government does little to monitor the veterinary market or to require that individuals or companies selling products demonstrate they are safe and effective or that the marketing claims they make are true. And while veterinarians are often the best resource for information about how to care for our pets, they can’t know everything about all of the thousands of products pitched to pet owners. The primary responsibility for making smart choices for our pets lies with us.

Having investigated many of the nutritional supplements, herbal remedies, and other products claimed to benefit our pets’ health, I have developed a checklist that simplifies the process of evaluating unfamiliar pet care products. While this can’t replace a thorough, detailed investigation of a product and the evidence for claims made about it, this checklist can give you an idea of whether something is promising enough to be worth looking into in more detail 

  1. What is it?
  2. Does it make sense?
  3. What’s the evidence?
  4. Is it safe?
  5. Any Warning Signs?

What Is It?
The first question to ask when you hear about a healthcare product for your pet is, “What is it?” This means, what are the ingredients, how is it made, where does it come from, who discovered or invented it, how is it supposed to be used, and anything else that will help you understand what it is you are being asked to give or do to your pet. Certainly, the manufacturer of a pet health product should be eager to give you as much information as you want about what they are selling. If your questions are not answered, if the ingredients or processes are a secret, if you are offered a snowstorm of technical language and no one is willing to explain in plain English what the product is, that’s a reason to consider walking away right at the start.

Of course, you aren’t likely to get a balanced or complete picture about a product from someone selling it. It is important to look for other sources of information. While the information one finds on the Internet should always be taken with lots of grains of salt, it is copious and easy to find. A Google search can turn up lots of information. And when evaluating this information, consider the source. Veterinary medical schools, other scientific research institutions, organizations of medical specialists, and others not actively trying to make money from these products are likely to have more objective and balanced information about them 

Does It Make Sense?
This question is a bit more complicated than it seems, since lots of bad ideas seem reasonable, and a few good ones can sound crazy. This question is a way of getting at what scientists call plausibility and coherence. Basically, if the idea behind a product is a reasonable extension of what science already knows about health and consistent with established principles, then it is more likely to work than something which is based on some mysterious or magical process unknown to science and discovered by a lone genius with no medical training working in their garage. As Thomas Edison said, genius is 1% inspiration and 99% perspiration. Once in a while, a new idea springs up out of the blue and actually works. But most advances in medicine are hard won through careful, laborious building on what we already know.

It’s true, science can’t explain everything. But there are some things we can be pretty sure about. Did you know, for example, that scientists don’t really know exactly how gravity works? There are a couple of theories, and the details still aren’t totally worked out. But if someone offered you a magic collar that would let your dog fly, would you buy it? We may not know all there is to know about gravity, but we can be pretty darned sure it’s going to be there every time we jump out a second story window.

So when you read about a product for your pets that is based on a “revolutionary” new idea that scientists only doubt because they can’t understand it, or that works by some vague “energy” or “quantum” process that is exempt from the ordinary rules that govern the medicines or procedures your vet uses to help your pet, it is worth being a little skeptical and looking particularly closely at the answer to the next question, “What’s the evidence? 

What’s the Evidence?
A concept which has come to dominate human medicine, and which is gradually making progress in the veterinary field, is the idea of evidence-based medicine. People have long known that our individual experiences don’t give us a very reliable idea of what works and what doesn’t in protecting our own health. For thousands of years, basing our medical care on personal experience, tradition, and the words of respected and experienced doctors led to an amazing variety of useless, even dangerous treatments. Bloodletting, leeches, toxic “medicines” that poisoned rather than helped us, even ritual animal sacrifice were widespread therapies that patients and doctors believed worked based on their own experience. And yet most babies died before they could reach adulthood, and those that made it were lucky to reach their forties.

In the last couple of centuries, we’ve shifted the basis of our judgments about healthcare practices from experience to scientific research. The result has been an unprecedented level of success. From wiping out polio to dramatically reducing infant mortality to doubling average life expectancy, science has made our health better by relying on the best available research evidence rather than intuition, experience, history, or the wisdom of respected individuals.

Unfortunately, lots of products for our pets base their claims of success on nothing more than the reputations of inventors and celebrities or veterinarians who endorse the products, and the personal stories of satisfied customers. Unsatisfied customers are rarely heard from. And good quality scientific research is rare, especially when companies can make healthy profits selling their remedies without investing in efforts to prove they actually work. Likewise, it is easier to claim “thousands of years of success” than to carry out a good scientific study that actually proves the product works.

So when looking at the evidence for a product you’re considering giving to your pet, you have to look past the testimonials the manufacturer gives you. As emotionally compelling as stories of miraculous recoveries are, they are not a reliable guide to what works and what doesn’t. A trustworthy company interested in really helping your pet will be able to provide references t scientific studies published in reputable journals. Ideally, these will be studies of their actual product in the same species you are thinking about giving it to. Even evidence for some benefit from one of a dozen ingredients given to laboratory rats isn’t a very useful bit of evidence that the combination of all the components will help your dog or cat.

And as always, consider the source. The company can’t be expected to give you information against their own product, or to provide feedback from unhappy customers. So look for independent sources of information, ideally from medical professionals or otherwise with a scientific background able to access and evaluate the scientific evidence. 

Is it Safe?
There is no free lunch in medicine. If something has benefits, it has risks. If it has no possible risks, that means it doesn’t do anything at all. We cannot expect to tinker with as complex and interconnected a system as the physiology of a living organism and only generate the good effects we want. So any choice to give our pets a medicine or other product to protect or restore their health is always a choice that requires balancing potential benefits against potential risks. The more we know about the risks, the better we are able to make sound, informed decisions.

While companies can be expected to downplay the risks and hype the benefits of their products, a good one will admit that there are possible side effects and tell you what they are and about how often they happen. And again, this information is far more reliable if it comes from objective, scientific research rather than just the impressions of people who have tried the product. A list of possible side effects may be scary, but it doesn’t mean we shouldn’t use a treatment if we need to. At least if we know what side effects are possible, we can watch out for them. If we are told something is perfectly safe, we are being reassured at the cost of being totally in the dark about whether the product is safe for our pets. 

Are There Any Warning Signs?
There are a number of sources listing warning signs that should alert us to products which are likely scams or snake oils rather than real medicine for our pets. One of  my favorites is Dr. Walt’s Warning Signs of Quackery and Fraud. These cover some of the subjects I’ve already mentioned, and plenty of others. My own quick summary of the most important is this:

  1. If it sounds too good to be true, it probably is.
    I’ve already mentioned that anything with no possible side effects is probably too good to be true. The same goes for anything which promises nearly 100% success. Sure, maybe the company offers a “money back guarantee,” but realistically hardly anyone who doesn’t like the product is likely to go to the trouble to return it if it’s not extremely expensive, and when it comes to your pets’ health, getting your money back does little to make up for something that doesn’t work or hurts your companion.

This warning also applies to claims that a product can treat or prevent a wide range of unrelated disease or works to support or strengthen every system in the body. There is no single, simple cause for every illness, and there is no single, simple cure either. Anyone who tells you something, especially when they are selling something, is not giving you an honest or realistic picture.

  1. Mysteries, Miracles, and Magic
    We live in an imperfect world where we don’t know everything and we can’t fix or control everything. This leads to anxiety and a search for ways to make ourselves, and our pets, safer. Unfortunately, this also creates an opportunity for marketers to manipulate us by feeding us scary stories about potential health hazards and then offering to sell us something to protect our pets. When the advertising for a product makes claims about such hazards, or about something they offer to protect or restore your pets’ health, there are some red flags to watch out for.

If the claimed threat is dramatic, overly broad, or something your vet and mainstream science supposedly doesn’t know about or is trying to hide, this is a tipoff that it may be an exaggerated or even totally artificial threat, and that someone is playing on your fears to get to your wallet. And if the protection or remedy offered is a “revolutionary” new discovery (especially without any real scientific research behind it), or if it is claimed to be able to save almost any patient even when all other methods have failed, there is reason to be cautious.

Lots of complicated technical jargon isn’t necessarily a signs that there is real science behind the product. Good doctors will want you to be able to understand the disease they believe your pet has and the remedies they offer. Marketers often want to impress you without actually explaining anything. Advertising that clearly plays to your emotions but is short on facts and evidence is advertising to be wary of. The bottom line is that if you’re told something works miracles, that no one understands why, and that evidence beyond testimonials isn’t needed, you’re being given fairy tales, not evidence.

  1. Galileo and Dan Brown
    Galileo is best known today for being right about the earth orbiting the sun, and for being made to shut up about it by the religious authorities of the time who didn’t like the idea. He was undoubtedly an exceptional man in many ways, not the least of which is being right when most people thought he was wrong. While sometimes wild ideas that turn our understanding of the world upside down turn out to be true, the vast majority of the time they really are crazy and disappear into history without a trace.

Today, anyone with an implausible or radical idea is likely to answer criticism by comparing themselves to Galileo or the other exceptions in history, not the far more numerous misunderstood geniuses who were actually wrong. Claiming that the only reason an idea or product someone is selling you hasn’t been proven scientifically is because it’s too far ahead of its time and science can’t handle it is more likely to be a sign that you’re dealing with a great ego than with great genius.

Similarly, while I find the intricate conspiracies invented by Dan Brown in his novels, such as The DaVinci Code, very entertaining, I don’t find them very believable. When someone says that they don’t have science to back up their claims because veterinarians, pharmaceutical companies, pet food companies, the government, or a combination of these groups is actively suppressing the truth, they are telling stories more suited to fiction than reality. In particular, the suggestion that veterinarians would rather your pets be sick than healthy, so they can get paid to treat them, is absurd and offensive.

All of the steps on this checklist have to be considered together. An idea that makes sense and is consistent with well-established science can still be wrong, so considering the evidence is still necessary. And if an idea seems crazy but has lots of strong scientific research to back it up, it could very well be true (and it stands a good chance of winning a Nobel Prize, since the highest honors in science are given to those who reveal the errors of the past or break truly new ground).

It is always a good idea to consult your veterinarian if you have questions about a product or service affecting your pets’ health. Hopefully, they will be able to give you solid information to help evaluate the product, or at least to direct you to a reliable source where you could find this information. Veterinarians can’t be experts on everything, but the years they spend studying and working with pets are a resource you should take advantage of.

The frustrating reality is that the vast majority of products out there that claim to preserve or restore our pets’ health are based on guesses or unproven theories and have little in the way of hard evidence to tell us if they are safe or if they can do what they claim. One important rule in medicine is Primum Non Nocere, “First, Do No Harm.” There is ample evidence that unproven or unscientific remedies can be harmful, even if they claim to be safe. When the situation is desperate, and there is a great need to intervene and no well-established treatment available, it may be necessary to reach for something plausible even without strong evidence. But when the need isn’t so great, or when we are treating our own fears as much as our pets, we may be better off not gambling on a product that makes wild claims without hard facts behind them. And when there are well-studied and well-understood options with known risks and benefits, we are better off using these first, and saving the roll of the dice for later, or passing over it entirely.

In any case, as pet owners we are responsible for trying to make the most careful, rational, and best-informed choices possible when it comes to our pets’ health. Following this checklist will give you another tool to help you do this, and hopefully to keep your pets happy and well!

Posted in General | 5 Comments

Homemade Diets for Cats and Dogs with Kidney Disease–Most Recipes are Wrong

Posted on March 4, 2012 by skeptvet

A new study has been published adding to the evidence, which I have discussed before(see articles listed below), that homemade diets are frequently nutritionally inappropriate and less consistent or reliable than commercial diets.

Larsen, JA. Parks, EM. Heinze, CR. Fascetti, AJ. Evaluation of recipes for home-prepared diets for dogs and cats with chronic kidney disease. Journal of the American Veterinary Medical Association. 2012;240(5):532-8.

The authors looked at 39 recipes from websites and published books for both veterinarians and pet owners (most written by veterinarians) and identified as intended for dogs with kidney disease and 28 such recipes intended for cats. Though the optimal amount and proportion of every possible nutrient is certainly not known for pets with kidney disease, there are some nutrients for which it is fairly clear that animals with kidney disease have different requirements from healthy animals. And the minimal amount of most nutrients needed to avoid deficiency (though not necessarily the optimal amount) is known for most nutrients. The authors systematically compared the nutrient profile of the recipes they examined with known minimal nutrient requirements and with the established special needs of cats and dogs with kidney disease.

Almost all recipes were vague about key ingredients, requiring the owner to guess about exactly what ingredient to use. Similarly, almost all recipes recommended some sort of nutritional supplement but did not offer specific guidance as to type, quantity, or nutrients. Some recipes offered clearly incorrect information, such as suggesting baking soda as a calcium source even though it contains no calcium.

The authors conclusions were:

None of the recipes assessed in the study reported here provided adequate concentrations of all essential nutrients…Furthermore, many recipes did not accommodate currently accepted nutritional strategies for managing [chronic kidney disease].

There is no doubt that homemade diets can be healthy and appropriate for dogs and cats, both those that are well and those with diseases requiring special nutrition. However, the case has not been made that home-prepared diets are superior to commercial diets, as is often claimed. And while commercial diets may not be optimal nutritionally for many individuals, they are at least consistent and monitored for minimal nutritional adequacy. Any benefits home-prepared diets might have won’t matter if they are grossly deficient or inappropriate in terms of essential nutrients.

For my own clients who wish to feed home-prepared diets, I always recommend consulting with a board-certified veterinary nutritionist (try the local veterinary medical school, or PetDiets.com) to ensure the diet is nutritionally appropriate for the individual pet. Recipes have been repeatedly shown not to be reliable, even when created by veterinarians, and relying on them is likely to lead to feeding a nutritionally inappropriate diet.

  1.     Freeman L, Michel K. Nutritional analysis of 5 types of “Raw Food Diets.” Journal of the American Veterinary Medical Association. 2001;218(5):705.
  2.     Lauten SD, Smith TM, Kirk CA, Bartges JW, Adams A, Wynn SG. Computer Analysis of Nutrient Sufficiency of Published Home-Cooked Diets for Dogs and Cats. Proceedings of the American College of Veterinary Internal Medicine Forum 2005.
  3.     Roudebush P, Cowell CS. Results of a hypoallergenic diet survey of veterinarians in North America with a nutritional evaluation of homemade diet prescriptions. Veterinary Dermatology 1992;3:23-28.
  4.     Taylor MB, Geiger DA, Saker KE, Larson MM. Diffuse osteopenia and myelopathy in a puppy fed a diet composed of an organic premix and raw ground beef. Journal of the American Veterinary Medical Association 2009;234(8):1041-8.

 

Posted in Nutrition | 31 Comments