Monday, 30 June 2014

UK doctors stand up for truth and integrity

Dr Malcolm Kendrick wrote an interesting blog post about UK doctors challenging NICE on its guidelines on drugs and the undisclosed financial interests of those making the decisions.

Kendrick and colleagues also wrote to NICE about their guidelines (specifically in relation to cardiovascular risk), the poor scientific basis for drug recommendations and the lack of transparency with regard to conflicts of interest on the panel.

This is good news for the medical profession and the population of the UK.  Journalists don't investigate or challenge poor science or corruption in government and individual patients cannot achieve much alone.  I've reproduced the introduction and main headings plus part of one section.  It's worth reading the whole blog post:

Letter sent to NICE:
Concerns about the latest NICE draft guidance on statins
We are concerned about your draft guidance on CV risk for discussion and debate. We would ask for a delay until our concerns are addressed. Whilst we agree with much of the guidance, our concerns focus on six key areas:medicalization of healthy individualstrue levels of adverse events, hidden data, industry bias, loss of professional confidence, and conflicts of interest
The draft guidance recommends offering statin treatment for the primary prevention of CVD to people who have a 10% or greater 10-year risk of developing CVD.
1. Medicalisation of five million healthy individuals.
2. Conflicting levels of adverse events
Furthermore, the rate of adverse effects in the statin and placebo arms of all the trials has been almost identical. Exact comparison between trials is not possible, due to lack of complete data, and various measures of adverse effects are used, in different ways. However, here is a short selection of major statins studies.
AFCAPS/TEXCAPS: Total adverse effects losartan 13.6%: Placebo 13.8%
4S: Total adverse effect simvastatin 6%: Placebo 6%
CARDS: Total adverse effects atorvastatin 25%: Placebo 24%
HPS: Discontinuation rates simvastatin 4.5%: Placebo 5.1%
METEOR: Total adverse effects rosuvastatin 83.3%: Placebo 80.4%
LIPID: Total adverse effects 3.2% Pravastatin: Placebo 2.7%
JUPITER: Discontinuation rate of drug 25% Rosuvastatin 25% placebo. Serious Adverse events 15.% Rosuvastatin 15.5% placebo
WOSCOPS: Total adverse effects. Pravastatin 7.8%: Placebo 7.0%
Curiously, the adverse effect rate of the statin, it is always very similar to that of placebo. However, placebo adverse effect rates range from 2.7% to 80.4%, a thirty fold difference.
3. Hidden data
4. Industry bias

Important findings from some other non-industry sponsored studies

5. Loss of professional confidence
6. Conflicts of Interest (real and perceived)

Yours Sincerely
Sir Richard Thompson, President of the Royal College of Physicians
Professor Clare Gerada, Past Chair of the Royal College of General Practitioners and Chair of NHS Clinical Transformation Board
Professor David Haslam, General Practitioner and Chair of the National Obesity Forum
Dr J S Bamrah, Consultant Psychiatrist and Medical Director of Manchester Mental Health and Social Care Trust
Dr Malcolm Kendrick, General Practitioner and Member of the British Medical Association’s General Practitioners sub- Committee
Dr Aseem Malhotra, London Cardiologist.
Dr Simon Poole, General Practitioner
David Newman, Assistant Professor of Emergency Medicine and Director of Clinical Research, Mount Sinai School of Medicine, New York
Professor Simon Capewell, Professor of Clinical Epidemiology, University of Liverpool

Playing the ball and not the man

I've written before about my frustration when discussing research evidence with people, some who treat this as interesting opinion rather than demonstrable fact.

One recent conversation was about vegetable oils and the potential carcinogenic effects of oil made from foodstuffs that are difficult to turn into oil (and require a lengthy industrial process to do so.)  The response from the sceptic, when presented with information from various cardiologists such as Dr Steven Gundry was to the effect that these people are only interested in selling their books.  I find it curious that the work of Einstein and Stephen Hawking are not dismissed for the same reason, though they both wrote books.

I overheard a heated discussion amongst a group of young men about diet and fitness.  There was some dispute about carb loading and exercise performance.  I suggested that some elite athletes follow a low carb/high fat diet.

One of the group started challenging me and the conversation quickly shifted to a debate about cholesterol and statins.  I pointed out how the NICE guidelines incentivise doctors to prescribe these drugs to groups of people that have not been shown to benefit in research studies.  I also commented on how the link between high cholesterol and heart disease had not been proven.  The young man disclosed that he is a medical student and demanded details of published research papers to back up my claims.  I quoted the work of Dr Malcolm Kendrick, Uffe Ravnskov, Duane Graveline and others.  The young man dismissed their work commenting that they probably didn't get on with their team or had other personality differences and conflicts at work.  At no point did the medical student present solid evidence to refute my statements.  He merely made derogatory remarks about the doctors I'd quoted.

The person next to me leaned over and quietly introduced himself as a cardiac lipidologist working in the medical school of a University of London college.  He told the medical student that I was absolutely right and that GPs lose money if they DON'T prescribe enough statins.  He confirmed that medical publishing subscribes to dominant paradigms and blocks publication of research that contradicts them, because the field is manipulated by big pharma.  The medical student looked confused and deflated.  The lipidologist encouraged him to keep an open mind in his work and not believe everything he is told.

I couldn't have asked for a better coincidence.  It wasn't about winning an argument, but finding a way to get through to someone who would not listen to the scientific evidence, but preferred to trash the people involved.

I was reminded of this when listening to Jimmy Moore interviewing Dr James E Carlson.  Carlson has faced his own challenges from medical students and Google AdSense, who claimed he posed a risk to readers.  He has now produced an online lecture series.  Here's number 7 of the series.  Number 8 is worth watching here:

Back to the title:  in football players are encouraged to play the ball and not the man, or risk a card for a foul.  The knee jerk response to a challenging concept seems to be to attack the author rather than present contradictory evidence.  Maybe I should carry a whistle and a red card for future conversations.

Saturday, 28 June 2014

Science and Seth Roberts

I wrote about the death of Seth Roberts in April.  He was an interesting character, who challenged shoddy statistical analysis and scientific generalisations.  His selection of interesting articles posted regularly on the blog prompted much discussion and further investigation by those interested in improving their own health.

I sometimes felt uncomfortable about his self experiments when he took interesting results from a brief trial and generalised from them.  He'd been experimenting with eating honey or sweet things before bedtime to aid sleep.  This led to some curious conclusions from Seth and his readers about the way sugar had been 'erroneously demonised'.  I wondered about his dental health as well as the impact on those with diabetes who followed his advice.

Paul Jaminet has written a nice appreciation of Seth Roberts, which looks at the strengths and weaknesses of his approach to science.  It's well worth reading.

The post starts with an announcement:  'The cause of death was occlusive coronary artery disease and cardiomegaly.'  This is based on a blog post by Seth's mother, which gives the general cause and states that more detail are expected later in the year.

Paul Jaminet makes a curious statement about Seth's approach to diet (highlighted in bold):

'But Seth was wedded to experimentation as a scientific methodology. This worked well as long as he was using sleep quality as a biomarker, since sleep quality is close to 100% correlated with health. He entered riskier ground, I think, when he selected reaction time as a biomarker to optimize. I doubt this has a simple relationship to health; I suspect one can improve reaction time while damaging health. And when optimizing this biomarker led him to consume large amounts of butter on top of large amounts of flaxseed oil, I think he should have recalled the arguments of our book, and been more persuaded by them than he was.'

I've read a lot of Seth's posts and his own diet book.  I'd understood that Seth started with sugar water and then light, flavourless olive oil as a weight loss aid.  He'd switched to butter and added flaxseed oil to improve balance and gum health.  I'm not sure how Paul defines 'large amounts' as I did not gain this impression from my reading.  My biggest concern is that Paul Jaminet is focussing on the fat intake and ignoring the rest of Seth's diet.  It is not clear to me that Seth stuck rigorously to a low carb or paleo diet.  

I'd be very concerned if people concluded that there was a cause-effect relationship between his fat intake and the blocked arteries and enlarged heart, without considering other dietary components and lifestyle aspects.  We don't have conclusive proof about what caused the heart disease.  Correlations are not causes.  Just because people carry umbrellas when it rains does not mean that umbrellas cause rain.

Monday, 26 May 2014

Euro election 2014: handsome is as handsome does

On Thursday we voted in the EU election for MEPs.  After a long internet search, I discovered the candidates, but not how they'd appear on the ballot paper (more of that later).

I'm cynical about election manifestos and party commitments, having seen promises broken every year, including the pledge to hold a referendum on the revised EU constitution.

I'm more interested in how individual MEPs behave when in post.

There are 8 MEPs for the London region:  Charles Tannock (Conservative), Claude Moraes (Labour), Baroness Sarah Ludford (Liberal Democrat), Dr Syed Kamall (Conservative), Jean Lambert (Green), Gerard Batten (UK Independence Party), Mary Honeyball (Labour), Marina Yannakoudakis (Conservative).

I wrote to my MEPs for London on 21 January this year, expressing concerns about Georgia's interest in joining the EU.  In Georgia homosexuality is legal, yet the head of the church's followers advocate killing gays and a young gay man was recently murdered in the capital Tbilisi.

Syed Kamall (Con) responded asking if I'd like him to submit a Parliamentary question to the European Commission about this issue.  I agreed and he sent me a copy of the letter of to the Commission.

Marina Yannakoudakis (Con) twisted my question and answered about the right to gay marriage (which I did not even mention.)  She dismissed the idea that gays are threatened or murdered in Georgia.  I responded with a list of links to articles (gleaned from a cursory Google search), but answer came their none.

['The recognition of gay-marriages is not a pre-condition of EU Membership. If it were, then current EU Members may face problems since some do not recognise such marriages'.  'As for your words on "persecution and killings" of LGBT people in Georgia, I have found no similar reports of such incidents, so I would be grateful if you could provide me with further information so that I can investigate this alleged matter.'

'I'm sorry that you are unaware of the situation in Georgia for gays and lesbians and have been unable to find evidence for my claims.  As for examples of death threats an injury to gays in Georgia, here is a small selection via  cursory Google search:

Crowd led by Priests attacks gay rights marchers in Georgia

Antigay protesters disrupt Georgian rights rally

What was behind Georgia's anti-gay rally?

Terrifying video of rioters attacking gay pride participants in Tbilisi

In Georgia, a grisly murder highlights vulnerability of gay people

Georgia:  time for homsexuality to come out of the closet?

This is the oldest report:

Pride and Prejudice ]

Jean Lambert (Green) responded with a clear and concise account of her position and upcoming vote on the 'Lunacek report', a roadmap against homophobia and discrimination on ground of sexual orientationa nd gender identify for the EU.

Charles Tannock's (Con) response was brief, but asserted his position as a longstanding friend of Georgia who shares my concerns about human rights and civil liberties in Georgia.

Claude Moraes (Lab) sent a long reply, but confirmed his (and the Labour party's) position as committed defenders of human rights.

Mary Honeyball (Lab) acknowledged my email and said she'd get back to me.  Nothing more arrived from her.

Sarah Ludford (Lib Dem) sent a long reply with an extensive history of action in the EU on homophobia and human rights.  She concluded with a paragraph on Liberal Democrat policy on the issue.  This was the most detailed response of all.

 Gerard Batten (UKIP) has still not acknowledged my email or replied to it.

On Thursday I went to my polling station with preferred MEP candidates in this order of preference:  Sarah Ludford, Syed Kamall, Jean Lambert, Charles Tannock = Claude Moraes.

I discovered that I had ONE vote and could only pick a political party.  

I could not, in all conscience, vote Conservative with the views of Marina Yannakoudakis, however much I admire Syed Kamall.  Labour, with one non-response and one party political puff, could not get my vote.  Green, with a good response on this issue, could not be trusted on the economy.  UKIP keep the other parties on their toes, but Mr Batten is not doing his job.  Sarah Ludford sent the most comprehensive response, though I'm not too keen on other aspects of her party's work, particularly in relation to sexual abuse and harassment of staff and constituents.  I'd prefer to be able to vote for people I support and exclude those I don't.

I voted.

Update:  Here are the UK results for the European elections.

Lazy Mary Honeyball and Gerard Batten are still in, but hard working Sarah Ludford is out.

Labour: 806,959
Con: 495,639
UKIP: 371,133
Green: 196,419
Lib Dem: 148,013

MEPs: Claude Moraes (Lab)Sayed Kamall (Con)Mary Honeyball (Lab),Gerard Batten (UKIP)Lucy Anderson (Lab)Charles Tannock (Con)Seb Dance (Lab)Jean Lambert (Green).

N = 1 self experimentation

I've written about the late Seth Roberts, who was famous for self experimentation.  Jimmy Moore has also published results of his experiments to reduce and maintain weight and good health.  Paul and Shou Ching Jaminet also advocate self research in finding your way to optimum weight and good health.

The gold standard for scientific research is the randomised controlled trial.  A statistically significant number of people is divided randomly into two, one group is given the variable (drug, food, other intervention) and the other group is not.  The second or control group may be given a placebo pill, food or other intervention.  Those assigned to each group are numbered and recorded.  The aim is to ensure that neither the test subjects or those working with them know who has the intervention and who does not.  This prevents the researchers and test subjects from skewing the results.  It also eliminates confirmation bias, when humans seek and find results that seem to confirm what they believe.

Using yourself as a test subject is open to criticism, because an individual result cannot be generalised out to the whole population.  On the other hand, it can be useful for the tester to help find solutions to their own health problems not provided by health care professionals or over the counter drugs.  There is even greater risk of confirmation bias and other distortions creeping into n=1 experiments.  Humans are notoriously unreliable when remembering the past and liable to make post hoc rationalisations.

I was asked to participate in trials of a sleep device.  The questionnaire was detailed in asking for feedback on what happened AFTER I tried the device.  It was open to criticism, because it stopped there.

In my view, we need to be systematic in experimenting on ourselves.  Here's my list of things to include when trying out something to improve health, weight or fitness:

1  Keep a notebook or file on computer detailing what happened
2  Before starting the experiment, note down your history of this topic (weight loss, insomnia,  low mood or whatever) to get a baseline starting point.   Record previous attempts to improve the situation and interventions used as well as  your views about factors affecting your progress
3  Start the experiment
4  Identify ONE intervention and make every effort to keep the rest of your life as consistent as possible (eg add more fat to diet or wear orange safety goggles).  Avoid adding other NEW changes to diet or lifestyle.  If you make multiple changes, it's impossible to determine what has caused improvement/deterioration/no change in your state.
5  Note the results each day.  Record numbers wherever possible (eg weight loss/gain; amount of time it took to fall asleep, time slept - light/deep/dreaming sleep, amount and quality of dreams, times woke during the night, time taken to sleep again etc)
6  Record other factors that may have affected progress as well as other notable things (eg external events affecting sleep/stress).

I've run experiments on myself and kept note of food intake, body composition, blood glucose, blood pressure and sleep patterns.  I've noticed how difficult it is to draw definite cause effect conclusions, but have made tentative guesses, often with multiple potential contributory factors (particularly to insomnia).  This helps me to avoid over confident generalisations or assertions and focusses my attention on areas for further investigation.

I've encouraged clients to use self experimentation and notebooks, arguing that these are much more persuasive with their doctors than verbal reports, particularly when GPs dismiss weight loss problems as chronic overeating.  This gives them more confidence in dealing with their own health and communicating with their doctor.

You may not find a single solution, but will gain a clearer sense of your own metabolism and what helps and hinders progress.  I still have insomnia sometimes, but recognise the contributory factors and how I can limit them.

Postscript:  It's useful to identify your goal prior to self experimentation.  For example with insomnia you may want to fall asleep sooner or sleep longer, rather than waking up in the early hours of the morning.  You might want to have deeper sleep.  If you know where you want to go explicitly, it's easier to track progress and alter your experiment later on.

David and Goliath world cup football

In 1950 the world cup final was between Brazil and Uruguay in the Maracana stadium.  Brazil needed a draw to win and their victory was thought to be a foregone conclusion on home turf.

Uruguay has a population of less than 5 million and this dwindled to less than 2.5 million after the military dictatorship.  Brazil has more than 200 million people and is one of the BRICs countries, predicted to surge ahead of traditional Western economic power houses.  In 1950 Uruguay's economy was dominated by meat exports.  Fray Bentos is a town that gave its name to a company famous for corned beef.  In a world recovering from World War 2, meat exports from Argentina and Uruguay had little competition and the European Union hadn't yet established itself nor had the United States of America consolidated its protectionist position, so imports were welcome.

The mayor of Rio de Janeiro spoke to the crowd before the match, saluting the Brazilian team as conquerors before the ball was in play.

Uruguay won 2-1 with a decisive goal by Ghiggia.

Denmark won the 1992 European cup final, having only joined the tournament when Yugoslavia could not play because of the war in Bosnia.

Never underestimate smaller nations in football.

Tuesday, 29 April 2014

Seth Roberts RIP

Sad news that Seth Roberts died on Saturday 26 April 2014.

Seth was a psychology lecturer in California and Beijing.  He pioneered work on self experimentation for improving health.  He wrote about his experiments in treating insomnia and depression.

He also wrote a book on weight loss based on the notion that we eat less if our appetite is not stimulated by strong smells and taste of food.  This was the 'Shangri-La Diet'.

I disagreed with lots of what Seth wrote.  I tried several ideas, some helped and others didn't.  I appreciated his view that people could take control of their own health and find solutions, where healthcare failed them.  Seth was also critical of academic bias, cheating and poor research findings.

One of my favourite Seth blog posts was the story of Morex and how he finally lost weight and regained health and confidence by drinking light olive oil, as recommended by Seth.

The best tribute to Seth Roberts would be if more people used themselves as test subjects and worked out ways to better health and fitness through self experimentation and observation.  Having more self confidence and openness to new ideas is the core of his legacy.

UPDATE:  Seth's mother posted a piece about his death on the blog.  There is no definitive cause identified to date (more information will arrive later this year).  However there is some suggestion that heart problems may have been triggered by mercury in fish and air pollution in Beijing.

I hadn't realised how much of a collaborator Seth was.  A number of people have written about his curiosity and generosity in discussing ideas and giving of his time and knowledge to help others.