Four of the last five newsletters I’ve written have been about fatally flawed studies badly reported on by the media. And in this issue, I could easily have done it yet again (more on that later). Instead, this newsletter is directed to a subset of our subscriber list: the media. Although, I’m never actually quoted by the media — perhaps because I’m not part of the medical fraternity — I am, nevertheless, widely read by them. Our subscriber list includes reporters and health editors from large media organizations around the world including Reuters, ABC, NBC, CBS, Fox News, Bloomberg News, the NY Times, the LA Times, The Chicago Sun-Times, and a whole bunch of readers at the India Times. For the media, it would seem my newsletters are the proverbial guilty little pleasure, to be enjoyed but never mentioned.
This newsletter, then, is my gift to all our media subscribers. By the end of this newsletter, I want you to walk away newly outfitted with two fundamental questions that you will henceforth be able to call upon when reporting on future studies.
- Are the studies evaluating the form of the nutrient/hormone/biochemical actually used by the body in its natural environment, or are they evaluating a synthesized form found only in a laboratory?
- Have the studies accounted for the interrelatedness of nutrients/hormones/biochemicals when making conclusions based on the study data, or are they treating each “supplement” like an isolated magic bullet — like, dare I say, a drug?
As you will see, by asking these questions, you will be better serving your readers/viewers, and you will look a whole lot smarter in the process. And you still won’t have to mention me. That’s what we call a win/win scenario.
Let’s begin by taking a look at the latest silly study in the news.
Vitamin D, again
Here is a sampling of the headlines that began appearing in December:
- Benefits of Vitamin D May Be Overblown1 RTTNews.com. “Benefits Of Vitamin D May Be Overblown.” NASDAQ. 21 Dec 2011. (Accessed 21 Dec 2011.) http://www.nasdaq.com/aspx/stock-market-news-story.aspx?storyid=201112211331rttraderusequity_0695&title=benefits-of-vitamin-d-may-be-overblown
- Are you taking too much vitamin D?2 Deborah Kotz. “Are you taking too much vitamin D?” 21 Dec 2011. The Boston Globe. (Accessed 21 Dec 2011.) http://www.bostonglobe.com/lifestyle/health-wellness/2011/12/21/are-you-taking-too-much-vitamin/wPDvUurKc6ZWnFBvKlCpJM/story.html
- Are the benefits of vitamin D overhyped? 3 Healthwatch. “Are the benefits of vitamin D overhyped?” 20 Dec 2012. CBS News. (Accessed) 22 Dec 2012. http://www.cbsnews.com/8301-500368_162-57345349/are-the-benefits-of-vitamin-d-overhyped/
You don’t even have to read the articles to realize that vitamin D is being trashed. How can this be? Hasn’t vitamin D been getting favorable press for a number of months — billed in the news as the next wonder nutrient? It feels a bit like the Republican primary, where a nutrient rises up in the polls only to be subsequently cut down to size.
What these headlines, and numerous other ones like it, are referring to is a recent study published in the Annals of Internal Medicine that challenged the idea that vitamin D had any benefit beyond mild bone building.4 Mei Chung, PhD, MPH; Jounghee Lee, PhD; Teruhiko Terasawa, MD, PhD; Joseph Lau, MD; and Thomas A. Trikalinos, MD, PhD. “Vitamin D With or Without Calcium Supplementation for Prevention of Cancer and Fractures: An Updated Meta-analysis for the U.S. Preventive Services Task Force.” Ann Intern Med. December 20, 2011 vol. 155 no. 12 827-838. http://www.annals.org/content/155/12/827.full.pdf+html In truth, there’s actually a lot of scientific data that connects vitamin D to a host of health benefits, including a lower risk of bone fractures, reduction of heart disease, prevention of flu, elimination of cognitive problems in older adults, elimination of asthma, lowering the risk of diabetes and MS, and even protection against cancer.
But this new review of 19 clinical trials and 28 observational studies conducted by the U.S. Preventive Services Task Force (USPSTF) suggests that most of these “benefits” amount to little more than hype. The one benefit the review granted was that, in combination with calcium, vitamin D can indeed help reduce bone fractures. But as far as cancer is concerned, the data actually suggests that vitamin D supplements are useless — or at best unproven. In addition, a separate study, published in the same issue of Annals of Internal Medicine found little benefit for vitamin D in terms of heart disease risk.5 Cora McGreevy and David Williams. “New Insights About Vitamin D and Cardiovascular Disease: A Narrative Review.” Ann Intern Med December 20, 2011 155:820-826. <http://www.annals.org/content/155/12/820.abstract>
So what’s my problem with these vitamin D studies?
As I stated at the top of the newsletter, it’s actually twofold.
- The studies make no differentiation between vitamin D2 and D3 in their evaluations.
- And they do not account for the interrelatedness of vitamin D with other nutrients, with the exception of calcium.
Let me explain.
Although the study makes mention of the two forms of vitamin D, it does not actually differentiate between them in its analysis of the data. By not differentiating between vitamin D2 and D3, the study’s conclusions assume a de facto bias that the two forms of vitamin D are interchangeable. They are not. Vitamin D, also known as calciferol, comprises a group of fat-soluble secosterols. The two major forms are vitamin D2 and vitamin D3. Vitamin D2 (ergocalciferol) is largely human-made and added to foods, whereas vitamin D3 (cholecalciferol) is synthesized in the skin of humans after exposure to sunlight from 7-dehydrocholesterol and is also consumed in the diet via the intake of animal-based foods. Although both forms are metabolized and, at least at first glance, appear to exhibit identical responses in the body, they actually behave quite differently. In fact, the metabolic pathways for D2 and D3 in the human body are anything but identical. The net result is that vitamin D2’s potency is less than one third that of vitamin D3.6 Laura A. G. Armas, Bruce W. Hollis, and Robert P. Heaney. “Vitamin D2 Is Much Less Effective than Vitamin D3 in Humans.” The Journal of Clinical Endocrinology & Metabolism November 1, 2004 vol. 89 no. 11 5387-5391. <http://jcem.endojournals.org/content/89/11/5387.full.pdf+html>
But that’s not all. In addition to having markedly lower potency, D2 also has a significantly shorter duration of action relative to vitamin D3, which shows up in 25OHD levels. Specifically, both forms of vitamin D produce similar initial rises in serum 25OHD over the first 3 days (a primary reason that most researchers consider them equivalent). But 25OHD continues to rise with D3 supplementation, peaking at 14 days, whereas serum 25OHD falls rapidly in D2 treated subjects. In fact, levels fall so far with D2 supplementation that they are no different from baseline at 14 days. 7 Ibid The bottom line, as clearly stated in the American Journal of Clinical Nutrition, is that “vitamin D2 should not be regarded as a nutrient suitable for supplementation or fortification”.8 Lisa A Houghton and Reinhold Vieth. “The case against ergocalciferol (vitamin D2) as a vitamin supplement.” Am J Clin Nutr October 2006 vol. 84 no. 4 694-697. <http://www.ajcn.org/content/84/4/694.full.pdf+html>
This is proof-positive that even a reporter can understand that D2 and D3 are not metabolically identical in the human body. Thus, any study that does not differentiate between the two cannot claim that its conclusions apply to both forms. Thusly, any review of previous studies that failed in this regard would be equally flawed and, likewise, cannot speak for vitamin D as a whole.
Now, this addresses the first question that I said you need to ask of the current studies: is the study in question actually evaluating the form of vitamin D used by the body in its natural environment? And the answer in this case is: clearly not. And, as we also learned, it matters. But that’s only half the story. We still have the second question to address: has the study accounted for the interrelatedness of vitamin D with other nutrients? Well, certainly it addressed the relationship of vitamin D with calcium. But what about other nutrients, and does that interrelatedness matter?
Health is a whole body thing
In nature, natural substances do not exist in isolation. For example, you will not find a plant that contains only beta carotene. Instead, you will find plants that contain a number of carotenoids — one of which is beta carotene. Carrots, for example, contain upwards of 400 carotenoids — a number of which work together synergistically. For example, both alpha-carotene and beta-carotene (almost always paired together in nature) are forms of provitamin A (i.e. they are converted into vitamin A inside your digestive tract), but their benefits are not interchangeable. Higher levels of alpha-carotene in the blood are associated with a reduced risk of death…from all causes.9 Chaoyang Li, MD, PhD; Earl S. Ford, MD, MPH; Guixiang Zhao, MD, et al. “Serum -Carotene Concentrations and Risk of Death Among US Adults.” Arch Intern Med. Published online November 22, 2010. doi:10.1001/archinternmed.2010.440. <http://archinte.ama-assn.org/cgi/content/full/archinternmed.2010.440v1> Supplement with a naturally sourced, full-complex beta-carotene supplement (which will come paired with alpha-carotene) and you get that benefit. Supplement with synthetic beta-carotene made from acetylene gas and you don’t. But what does that mean “scientifically?” Run a study using synthetic beta-carotene and write up the results as representing all forms of beta-carotene, and you’ve significantly misled people. And what does it mean to you as a reporter? If you run a story on the study without challenging its basic assumptions, you’ve not only misled people, but you’ve also ultimately contributed to the premature deaths of thousands of people who read your story and acted on its advice. That’s heavy karma.
The bottom line is that you should be leery of any studies that isolate single nutrients. Oftentimes, an isolated nutrient will not work well without the presence of another key component. For example: boron deficiency affects your body’s ability to utilize calcium and affects the composition, structure, and strength of bone, leading to changes similar to those seen in osteoporosis. That doesn’t mean that boron is more important than calcium — just that you need boron to utilize the calcium. One doesn’t work without the other. But what it also means is that any study done on calcium supplements that doesn’t allow for the presence of sufficient boron will produce misleading results. And speaking of the interconnectedness of things, it should probably also be mentioned that boron is also a necessary cofactor for the utilization of vitamin D so that any study on vitamin D and calcium that doesn’t account for boron levels is fatally flawed from the start.
At this point, I’m going to make a minor detour and expand on the concept of interrelatedness, as this represents a fundamental dividing line between conventional medicine and alternative medicine. And understanding this difference is fundamental to understanding why alternative medicine rarely “tests” well when analyzed by “conventional” researchers.
As I explain in Lessons from the Miracle Doctors, although modern medicine likes to claim Hippocrates and the ancient Greeks as its founding fathers, it is probably Isaac Newton and the seventeenth-century philosophers and scientists — who defined the universe as a giant machine ruled by the laws of mechanical physics and math — who are probably much better candidates for the title.10 Culbert, Michael. Medical Armageddon. San Diego: C and C Communications, 1994. Physicians of that era likewise began to define the human body as a machine that ran smoothly until acted upon by some outside agent. Accordingly, the human body could be studied, documented, medicated, and tweaked as required. This viewpoint became more and more dominant as time went by, until by the nineteenth century:
- The human body was no longer viewed as a holistic entity but rather as a grouping of separate parts and pieces.
- Disease was no longer viewed as an imbalance in the body but rather as a set of symptoms.
- Medical research was defined as the observation and classification of both the body’s parts and its various sets of symptoms.
Based on the above, the physician’s job was now defined as eliminating (or at least managing) those symptoms. In other words, disease or injury manifests as symptoms entirely separate from the body as a whole. Eliminate the symptoms, and you eliminate the problem. Also based on the above, all drugs, nutrients, hormones, and supplements, etc. needed to be tested in isolation. Interrelatedness, synergy, and holistic approaches were considered, if they were considered at all, as meaningless concepts. Thusly, all testing procedures were designed to analyze and favor isolation. If two nutrients each tested separately as 10% beneficial, for example, they would be summarily dismissed — and reported in the media as ineffective. But if used in combination they turned out to be 70% effective, that would never be known. They would never be tested in combination, and any benefits of that combination would be purely anecdotal and exist only in the world of alternative medicine.
Speaking of which, the world of alternative medicine has its own form of isolation in that there are many terms used to describe what is essentially the same healing art — and yet those terms have caused people to rally round their “preferred” term in an attempt to isolate themselves from the rest of the pack. Let’s take a look at some of those terms.
Alternative medicine is usually defined as any healing practice that does not fall within the purview of conventional medicine. The medical establishment often derisively defines it as “based on folk traditions and anecdotal evidence as opposed to scientific evidence.” In truth, alternative medicine is often supported by science, although such proofs are usually ignored by the medical establishment. As for anecdotal VS scientific evidence, conventional medicine relies far more on anecdotal evidence than you might believe — with some estimates indicating that as much as 85% of medical treatments are untested and based purely on anecdotal evidence.11 Richard Smith. “The ethics of ignorance.”Journal of medical ethics.” 1992, 18, 117-118, 134 <http://jme.bmj.com/content/18/3/117.full.pdf> As one example, radical mastectomies were the accepted norm for almost 100 years when it came to treating breast cancer, with thousands upon thousands of women being subjected to ever more radical and disfiguring surgeries. But this procedure was never tested; it continued as the preferred surgery for breast cancer for decades based entirely on anecdotal evidence. When finally, scientifically studied, radical mastectomy proved no more effective than lumpectomy (a derisive term created by the medical establishment to undermine “renegade” doctors they disagreed with) — certainly a disappointment to the multitude of women cruelly disfigured by an unnecessary, and finally, invalidated surgery.
In any case, alternative medicine is still the most widely used term and the one I tend to use the most…by force of habit.
Complementary medicine is the term used to describe a branch of healing that is really no different than alternative medicine. It is, rather, a highly nuanced refinement. The idea is that alternative medicine is used “instead” of conventional medicine, but complementary medicine is used “in combination” with conventional medicine. This nuanced terminology is really designed to make the practices more acceptable to conventional doctors. And in fact, it has worked — to some degree — as many hospitals have now incorporated some aspects of complementary medicine as part of the services they offer. In truth, I think this has less to do with any acknowledgement of the efficacy of complementary medicine as it does with doctors following Sun Tzu’s dictum from the Art of War: “Keep your friends close, and your enemies closer.”
More importantly, any distinction between alternative and complementary medicine were rendered moot when the National Institutes of Health conjoined them as CAM (complementary and alternative medicine) and created the National Center of Complementary and Alternative Medicine.12 NCAM. National Center for Complementary and Alternative Medicine. <http://nccam.nih.gov/health/whatiscam/>
Another term used to describe alternative medicine is “naturopathic medicine.” As defined by the American Association of Naturopathic Physicians, “Naturopathic medicine is based on the belief that the human body has an innate healing ability. Naturopathic doctors (NDs) teach their patients to use diet, exercise, lifestyle changes and cutting edge natural therapies to enhance their bodies’ ability to ward off and combat disease. NDs view the patient as a complex, interrelated system (a whole person), not as a clogged artery or a tumor. Naturopathic physicians craft comprehensive treatment plans that blend the best of modern medical science and traditional natural medical approaches to not only treat disease, but to also restore health.”13 “What is Naturopathic Medicine?” American Association of Naturopathic Physicians. <http://www.naturopathic.org/content.asp?contentid=59>
Naturopathy can be thought of as CAM with certification. To become a naturopathic doctor (ND), you have to go to an accredited school and be licensed.14 “What is a Naturopathic Doctor?” American Association of Naturopathic Physicians. <http://aanp.membershipsoftware.org/content.asp?pl=16&sl=60&contentid=60> This weeds out some, but hardly all, of the more “unusual” practices of alternative medicine. Natural healing, by the way, is a generic term that encompasses naturopathy, but is not specific to the practice of naturopathic physicians. When most people use the terms “natural healing” and “naturopathy,” they are usually referring to physical healing techniques only.
Holistic medicine, also known as “integrative holistic medicine,” is yet another term that seeks to “clarify” the definition of alternative medicine. Physicians who practice holistic medicine, for the most part, define it as emphasizing the need to look at the whole person, including analysis of physical, nutritional, environmental, emotional, social, spiritual, and lifestyle values. Holistic medicine encompasses all stated modalities of diagnosis and treatment including drugs and surgery if no safe alternative exists. Holistic medicine focuses on education and responsibility for personal efforts to achieve balance and well being.15 “Promoting Holistic Healing & Practices.” American Board of Integrative Holistic Medicine. <http://www.abihm.org/>
What is the point
Despite any differences between the subgroups of alternative health, they share certain commonalities that differentiate them from conventional medicine, and two of them are the points that I asked you to consider today:
- Natural is preferable to synthetic or pharmaceutical
- Nutrients are holistic, not magic bullet isolates
Concluding message to the media
Natural and synthetic versions, in most cases, are not the same thing. Further, bioidentical and pharmaceutical versions, in most cases, are not the same thing. In some cases they may be “chemically” identical, but even then, they are almost always structurally different. But in fact, they are usually chemically different as well — to make them patentable. In the future, when reporting on studies of natural substances (nutrients, hormones, etc.), please take note of which version was studied and if that information was incorporated as part of the data — and note it in your articles. Also, if the negative results came from the study of a synthetic or non-bioidentical substance, you might want to note that in your article as well and mention that, despite the researchers’ claims to the contrary, the results do not necessarily apply to natural versions of the same substance.
From my experience, the only value in testing synthetic nutrients is to prove that they don’t work as well as their natural counterparts.
The second key point to take from this newsletter is that in nature, natural substances do not exist in isolation. Testing an isolate is fine for pharmaceutical drugs since they were designed in a laboratory to be isolated magic bullets. But testing a natural substance in isolation excludes all of the benefits of interrelatedness that actually make those substances work. It provides a false picture. It is a lie.
The bottom line is that I realize that you’re overworked and under-budgeted, but in the future, can’t you just filter all studies of nutrients that you report on through the following two questions:
- Are the studies evaluating the form of the nutrient/hormone/biochemical actually used by the body in its natural environment, or are they evaluating a synthesized form found only in a laboratory?
- Have they accounted for the interrelatedness of nutrients/hormones/biochemicals when making conclusions based on the study data, or are they treating it like an isolated magic bullet — like a drug?
If not, then can you please qualify the study’s conclusions and not lead with your usual silly, scare mongering headlines talking about how some nutrient has been proven useless…or even dangerous.
Now that you know better, that would be shameful!
PS: for more on vitamin D nonsense, check out /natural-health/nl110110/vitamin-d-calcium-dietary-supplements.
PPS: Amusingly, at the same time the media was trumpeting the “vitamin D is hype” study, two new studies were more quietly being released that added to its list of potential benefits.
- A study scheduled to be published in the January 2012 issue of the Journal of Clinical Endocrinology & Metabolism suggests that low levels of vitamin D are associated with diabetes.16 News Briefs from The Endocrine Society – December 5, 2011 (Accessed 22 Dec 2011.) <http://www.endo-society.org/media/press/2011/News-Briefs-from-The-Endocrine-Society-December-5-2011.cfm>
- According to a just published Oxford University study, reduced levels of vitamin D associated with a rare genetic defect appear to be directly linked to multiple sclerosis.17 Sreeram V. Ramagopalan, David A. Dyment MD, M. Zameel Cader MD, Katie M. Morrison MSc, et al. “Rare variants in the CYP27B1 gene are associated with multiple sclerosis.” ANN NEUROL 2011;70:881–886 <http://onlinelibrary.wiley.com/doi/10.1002/ana.22678/abstract>
|↑1||RTTNews.com. “Benefits Of Vitamin D May Be Overblown.” NASDAQ. 21 Dec 2011. (Accessed 21 Dec 2011.) http://www.nasdaq.com/aspx/stock-market-news-story.aspx?storyid=201112211331rttraderusequity_0695&title=benefits-of-vitamin-d-may-be-overblown|
|↑2||Deborah Kotz. “Are you taking too much vitamin D?” 21 Dec 2011. The Boston Globe. (Accessed 21 Dec 2011.) http://www.bostonglobe.com/lifestyle/health-wellness/2011/12/21/are-you-taking-too-much-vitamin/wPDvUurKc6ZWnFBvKlCpJM/story.html|
|↑3||Healthwatch. “Are the benefits of vitamin D overhyped?” 20 Dec 2012. CBS News. (Accessed) 22 Dec 2012. http://www.cbsnews.com/8301-500368_162-57345349/are-the-benefits-of-vitamin-d-overhyped/|
|↑4||Mei Chung, PhD, MPH; Jounghee Lee, PhD; Teruhiko Terasawa, MD, PhD; Joseph Lau, MD; and Thomas A. Trikalinos, MD, PhD. “Vitamin D With or Without Calcium Supplementation for Prevention of Cancer and Fractures: An Updated Meta-analysis for the U.S. Preventive Services Task Force.” Ann Intern Med. December 20, 2011 vol. 155 no. 12 827-838. http://www.annals.org/content/155/12/827.full.pdf+html|
|↑5||Cora McGreevy and David Williams. “New Insights About Vitamin D and Cardiovascular Disease: A Narrative Review.” Ann Intern Med December 20, 2011 155:820-826. <http://www.annals.org/content/155/12/820.abstract>|
|↑6||Laura A. G. Armas, Bruce W. Hollis, and Robert P. Heaney. “Vitamin D2 Is Much Less Effective than Vitamin D3 in Humans.” The Journal of Clinical Endocrinology & Metabolism November 1, 2004 vol. 89 no. 11 5387-5391. <http://jcem.endojournals.org/content/89/11/5387.full.pdf+html>|
|↑8||Lisa A Houghton and Reinhold Vieth. “The case against ergocalciferol (vitamin D2) as a vitamin supplement.” Am J Clin Nutr October 2006 vol. 84 no. 4 694-697. <http://www.ajcn.org/content/84/4/694.full.pdf+html>|
|↑9||Chaoyang Li, MD, PhD; Earl S. Ford, MD, MPH; Guixiang Zhao, MD, et al. “Serum -Carotene Concentrations and Risk of Death Among US Adults.” Arch Intern Med. Published online November 22, 2010. doi:10.1001/archinternmed.2010.440. <http://archinte.ama-assn.org/cgi/content/full/archinternmed.2010.440v1>|
|↑10||Culbert, Michael. Medical Armageddon. San Diego: C and C Communications, 1994.|
|↑11||Richard Smith. “The ethics of ignorance.”Journal of medical ethics.” 1992, 18, 117-118, 134 <http://jme.bmj.com/content/18/3/117.full.pdf>|
|↑12||NCAM. National Center for Complementary and Alternative Medicine. <http://nccam.nih.gov/health/whatiscam/>|
|↑13||“What is Naturopathic Medicine?” American Association of Naturopathic Physicians. <http://www.naturopathic.org/content.asp?contentid=59>|
|↑14||“What is a Naturopathic Doctor?” American Association of Naturopathic Physicians. <http://aanp.membershipsoftware.org/content.asp?pl=16&sl=60&contentid=60>|
|↑15||“Promoting Holistic Healing & Practices.” American Board of Integrative Holistic Medicine. <http://www.abihm.org/>|
|↑16||News Briefs from The Endocrine Society – December 5, 2011 (Accessed 22 Dec 2011.) <http://www.endo-society.org/media/press/2011/News-Briefs-from-The-Endocrine-Society-December-5-2011.cfm>|
|↑17||Sreeram V. Ramagopalan, David A. Dyment MD, M. Zameel Cader MD, Katie M. Morrison MSc, et al. “Rare variants in the CYP27B1 gene are associated with multiple sclerosis.” ANN NEUROL 2011;70:881–886 <http://onlinelibrary.wiley.com/doi/10.1002/ana.22678/abstract>|