Quacks

[masterofmonkeys]

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Diet quality

Milk

Omega 3
http://grande.nal.usda.gov/ibids/index.php?mode2=detail&origin=ibids_references&therow=120658

CLA
http://jds.fass.org/cgi/reprint/82/10/2146.pdf



Beef

CLA
A RESEARCH NOTE CONJUGATED LINOLEIC ACID CONCENTRATION IN SEMIMEMBRANOSUS MUSCLE OF GRASS-AND GRAIN- …
NC SHANTHA, WG MOODY, Z TABEIDI - Journal of Muscle Foods, 1997

Omega 3
http://jas.fass.org/cgi/content/abstract/78/11/2849

Both
http://www.csuchico.edu/agr/grassfedbeef/research/lipid/Nuernberg%20Article%20Lipid%20catagory.pdf

Eggs
Omega 3
http://cat.inist.fr/?aModele=afficheN&cpsidt=2262877

Here's a start. The AJCN article in the post above this briefly discusses the plant/fruit aspect of the debate. I forgot where I stashed my list of articles on that. That AJCN article really is an excellent overview of why it is so important to pay attention to nutrition in the modern world:

http://www.ajcn.org/cgi/content/full/81/2/341

 

[8744]

Hardly, what I'm saying is that the modern diet and lifestyle means that we are sorely lacking in things that were once automatically ingrained parts of our lives. Otherwise we woudln't be as sick and as messed up as we are. But medicine remains largely ignorant of the science of nutrition and exercise, which leaves it powerless to truly understand the role they play in health. And ineffective in advocating meaningful change in patients' lives that will lead to greater health.

We are sick and messed up because we are, generally, living a lot longer than we used to giving things time to wear out and go bad that previously rarely had time to. Our ancestors did not have pristine, whole food diets that provided them with the optimum amount of every nutrient required to live healthy lives. On the contrary, people used to live, breed, and die in what we would today consider extreme squalor and poverty, eating what they could and enjoying life spans a half of what they are today. A little bit of sanitation, a little bit of medical care, some agricultural progress leading to a more stable food supply and life spans and health increased as has average height, bone health, and every other indicator you could measure.

Countering this is modern preference for a sedentary lifestyle and the availability of cheap, high fat, high sugar, low fiber calories. There is nothing "lacking," there is just too much of it.

Or look at it like this, you are healthy because you exercise, eat a sensible diet, and are concerned enough about your health to moderate your irregular pleasures, not because you carefully tune your intake of supplements, the effects of which are marginal at best. The "Number Needed to Treat" for your cohort for whatever catastrophe you are trying to prevent by taking large doses of Vitamin D is probably in the hundreds of thousands which is the hallmark of a generally ineffective and uneconomical therapy (like expensive statins in men with slightly high cholesterol but no other risk factors for heart disease). Likewise, my 400-pound forty-year-old diabetic patient with early congestive heart failure does not need a carefully constructed schedule of supplements or anything fancy at all except that he needs to stop smoking, start walking, put down the fried chicken, and otherwise modify his lifestyle. His Number Needed to Treat for pushing his next heart attack back a year or living an extra five years by walking a half-hour every day is probably two or three, meaning that a half hour walk is a highly effective therapy for his cohort.

The other crap is of only marginal utility which is, once again, the problem with American medicine, that is, that we spend a great deal of money and effort on the margins.

In other words, most of the "bang for your buck" with nutrition and exercise are in the obvious things that are fairly simple to describe and understand. The rest of it useful but well in the realm of decreasing marginal return where we devote money and effort chasing the marginal things, reducing relative risk but at the same time barely nudging the "absolute risk" of the condition we are trying to treat.

I can't be more clear than that. It is the money spent on the margins that is bankrupting us without giving any real benefit. Crunchy, happy happy things that cost money are no different in this respect than essentially worthless high-tech medical procedures except that an unnecessary heart cath costs ten grand once but regular visits to your nutritionist, dietician, or worse yet, a chiropractor or naturopath who are actually not even adding anything to the margins costs ten thousand dollars over the course of several years. The presumption on this thread that "low tech" medicine and CAM are not part of the problem of excessive spending is absolutely wrong.

 

[8744]

"Doc, do you think I have lung cancer because I was exposed to Agent Orange?"

"Well...that and the fact that you have been smoking a pack a day for fifty years."

 

[masterofmonkeys]

PB, amazingly the more I read your posts, the more I realize we actually have quite similar viewpoints. But if you actually looked at the EPA/DHA/omega3/omega6 research you'd realize that the NNT is pretty tiny. So tiny in fact that if I could tell patients two things it'd be 'take your fish oils and take your damn dog for a walk'.

But I counter your assertion that we are sick simply because we live longer, as you yourself refute in that you recognize the importance of lifestyle. Why were things like dementia, DM2, and CHD relatively unheard of even in long-lived populations in asia until the advent of the western diet?

I'd also say that the view you take of history is wayyy too short. You have given a pretty decent rundown of the past 10,000 years of human history. Problem is physically, our skeleton goes back about 1.8 million years, our muscle distribution, endocrinologic profiles, and activity patterns we evolved for probably go back about 800,000 years and for all practical purposes we stopped evolving 100,000 years ago from a physical standpoint.

Brain size, stature, lean body mass, and rates of disease (as much as we can ascertain from the fossil record) were respectively higher, taller, greater, and lower in the paleolithic times than they were during early agriculture up through relatively recent times. Admittedly they were likely to get wounded in tribal conflict or eaten by dire wolves, but thems the breaks...

H. heidelbergensis, ca 500,000 years ago stood 5'10 and a muscular 180-190lbs with cranial vault volumes that rival our own.

And contrary to your belief, if you research paleodiet (as a field, not just the popular book) you realize that in fact before the advent of agriculture and civilization our ancestors DID eat a healthy and varied diet of tubers, fruits, fish, and meats. They didn't get a lot of refined grains, sugars, or saturated fats. And from reconstructions of the paleolithic period and looking at the primitive peoples who still exist who aren't 'edge people', we find they do too. Our diet today looks a lot different than it did back then, and we pay a price for it.

Did they get exactly 347mg of phosphatidylserine, 2000IU of Vitamin D, 1000mg of EPA, 500mg of DHA, and have a perfect 1:1 O6/O3 ratio? (those numbers were mostly pulled out of my rear end by the way). No, but they almost certainly did better in that respect than we do.

reductio ad absurdum is an oft employed rhetorical device, but in this case it means you completely missed my broader point.

 

[stewiegriffin81]

But if you actually looked at the EPA/DHA/omega3/omega6 research you'd realize that the NNT is pretty tiny. So tiny in fact that if I could tell patients two things it'd be 'take your fish oils and take your damn dog for a walk'.

That's quite a hefty statement. Where's your evidence?

My evidence for omega 3 doesn't indicate anything of the kind:

Hooper, et al (2006). "Risks and benefits of omega 3 fats for mortality, cardiovascular disease, and cancer: systematic review". British Medical Journal. 332.

The conclusion of this systematic review?

"Long chain and shorter chain omega 3 fats do not have a clear effect on total mortality, combined cardiovascular events, or cancer."

 

[gujuDoc]

Master of Monkeys,

You will find that there is an ignore function on these forums. I've used it in the past for a poster that was rightfully banned a long time ago so I should know.

But frankly, I agree with the other poster that you can just ignore by not reading and responding to the posts. Though I don't know how that makes for a fair discussion. A fair discussion is one in which both opionions are represented equally regardless of whether or not you agree with them.

 

[masterofmonkeys]

That's quite a hefty statement. Where's your evidence?

My evidence for omega 3 doesn't indicate anything of the kind:

Hooper, et al (2006). "Risks and benefits of omega 3 fats for mortality, cardiovascular disease, and cancer: systematic review". British Medical Journal. 332.

The conclusion of this systematic review?

"Long chain and shorter chain omega 3 fats do not have a clear effect on total mortality, combined cardiovascular events, or cancer."

try GISSI prevenzione.

DART trial secondary prevention post-MI had an NNT of 28.

Lyon diet secondary prevention post-MI NNT of 23

But I'm talking about the effects of improving O6/O3 balance in general morbidity and mortality. There are admittedly few RCTs out there on this but quite a bit on the rates of disease in populations that are have high ratios versus low ratios, and even better, in populations that 30 or 40 years ago had low ratios but now have high ratios. Being an upper/upper-middle class Indian myself this is the population I'm most familiar with displaying this exact phenomenon. Rises in rates of CHD and alzheimers have closely paralleled a rise in the O6/O3 ratios. I've already linked to papers discussing these phenomena.

Demonstrated improvement in cognition in MCI (possible preventive effects of dementia as proxied by rates of alzheimers in low O6/O3 populations), decrease of intensity of therapy in inflammatory arthritides, improvement in asthma control, breast/prostate cancer survival, etc.

Keep in mind (and this is where 'systematic reviews' often fail--the basic science side of the equation) that a proper study evaluating the effects of n-3 fatty acid supplementation needs to be one that uses adequate levels (800mg doesn't cut it), both EPA and DHA, and that causes a large enough change in O6/O3 ratios (at least 5:1, preferably 2.5:1, and ideally 1:1) Because of the different actions of EPA vs DHA and the nature of the relationship between n-6 and n-3 fatty acids, a negative study that doesn't adequately address the above, is a poor quality study regardless of blinding, followup, and homogeneity of study populations.

Here's an entire friggin book on the subject:
http://books.google.com/books?hl=en...eGLi&sig=BTsHyJt1RGrnRuJQGg_V0WJdx0M#PPP10,M1

Admittedly, this guy is a serious fan of EPA/DHA and it might cloud his scientific judgment, but then again, maybe he's a fan of it because of his scientific judgment.

 

[stewiegriffin81]

Firstly, don't cherry pick the studies. For starters, what about DART-2?

Secondly, given that the best evidence is only for secondary prevention of SCD post MI, this isn't the same as recommending that everyone should increase their omega-3. Look, Omega-3 might have a useful effect, and it is likely that it is efficacious for post MI secondary prevention. However, I'm concerned at the fact that you are clearly overstating your case. The evidence is not that clear, pure and simple. For every positive trial, there are a number of negative trials.

Jenkins, et al (2008). "Hetergeneity in Randomized Controlled Trials of Long Chain (Fish) Omega-3 Fatty Acids in Restenosis, Secondary Prevention and Ventricular Arrhythmias". Journal of the American College of Nutrition. 27, 3.

 

[masterofmonkeys]

Master of Monkeys,

You will find that there is an ignore function on these forums. I've used it in the past for a poster that was rightfully banned a long time ago so I should know.

But frankly, I agree with the other poster that you can just ignore by not reading and responding to the posts. Though I don't know how that makes for a fair discussion. A fair discussion is one in which both opionions are represented equally regardless of whether or not you agree with them.

Sorry, a fair discussion is one in which people approach with open minds, argue the facts, and don't distort each others' arguments.

I'm doing my darnedest to be reasonable in the hopes that other future doctors might consider the importance of the basic building blocks of health in their future practice.

I'm not getting much reasonableness in return.

 

[masterofmonkeys]

Firstly, don't cherry pick the studies. For starters, what about DART-2?

Jenkins, et al (2008). "Hetergeneity in Randomized Controlled Trials of Long Chain (Fish) Omega-3 Fatty Acids in Restenosis, Secondary Prevention and Ventricular Arrhythmias". Journal of the American College of Nutrition. 27, 3.

Secondly, given that the best evidence is only for secondary prevention of SCD post MI, this isn't the same as recommending that everyone should increase their omega-3. Look, Omega-3 might have a useful effect, and it is likely that it is efficacious for post MI secondary prevention. However, I'm concerned at the fact that you are clearly overstating your case. The evidence is not that clear, pure and simple. For every positive trial, there are a number of negative trials.

Hardly, I was just compiling a list of O3 studies and reviews that included both positive and negative results, just passing on what I could get a hold of relatively quickly.

I take it you read up on the background info, about paleo diet, changes in O6/O3 ratios, epidemiologic differences between and within populations, nutritional studies on amounts of O3 needed for therapeutic effect, you know all the building blocks you need to do an effective study and figure out whether a study is properly constructed or not?

When studies are included that include both EPA and DHA, include adequate amounts, and produce a significant enough reduction in O6/O3 ratios, you do indeed find that a preponderance of evidence suggests a strong benefit in a multitude of health domains. This study cites some of these thresholds that need to be reached to see a therapeutic benefit.

Simopoulos AP.
The importance of the omega-6/omega-3 fatty acid ratio in cardiovascular disease
and other chronic diseases.
Exp Biol Med (Maywood). 2008 Jun;233(6):674-88. Epub 2008 Apr 11. Review.

could you send me a pdf of that review, my stupid university login isn't working for that journal.

By the way, here's some things that n-3FA supplementation will not do: improve insulin sensitivity, help you lose weight, decrease overall cancer risk, reduce cholesterol.

Edit:
http://www.pubmedcentral.nih.gov/articlerender.fcgi?tool=pubmed&pubmedid=18195289

Found this meta-analysis with negative results. I think it might be a comparison of the same three trials that the other used. But I can't say that for sure.

Surprise, surprise, only one of the three studies had the (optimistic in my opinion) minimum of 2g/day supplementation. It didn't address o6/o3 ratio so it's still a middling quality study. It also DID indeed show a reduction in events.

Even though all three were judged to be of 'high' quality it turns out they really weren't. Pooling these studies together to get a negative result is a lot like running a trial with 2.5mg of simvastatin and then making a lot of stink with a negative result. In fact, the word 'dose' only appears twice when they mention that they include studies of any dose and then again when they mention the dosages. Never is the difference in dosage discussed.

This is where real critical thinking and doing your own homework on the background research in reading the scientific literature comes into play.

Could you imagine a medication trial in which such logic was allowed?

I know this wasn't the study you cited, so i'd still like to see the one you mentioned. Just illustrating a point in the importance of knowing the basic science and background research in nutrition in order to be able to evaluate clinical studies.

 

[stewiegriffin81]

I take it you read up on the background info, about paleo diet, changes in O6/O3 ratios, epidemiologic differences between and within populations, nutritional studies on amounts of O3 needed for therapeutic effect, you know all the building blocks you need to do an effective study and figure out whether a study is properly constructed or not?

When studies are included that include both EPA and DHA, include adequate amounts, and produce a significant enough reduction in O6/O3 ratios, you do indeed find that a preponderance of evidence suggests a strong benefit in a multitude of health domains. This study cites some of these thresholds that need to be reached to see a therapeutic benefit.

The main problem here is that most trials don't actually publish the serum levels of omega 3. Both GISSI and DART (and DART 2) do not, for example. The Lyon trial does, kudos for them.

So we can't actually use the claim that perhaps the negative trials were negative due to insufficient omega 3 levels. We just don't know.

 

[masterofmonkeys]

The main problem here is that most trials don't actually publish the serum levels of omega 3. Both GISSI and DART (and DART 2) do not, for example. The Lyon trial does, kudos for them.

So we can't actually use the claim that perhaps the negative trials were negative due to insufficient omega 3 levels. We just don't know.

True on the serum levels. But I wouldn't venture that far. Unless it's an asian fish-eating population or mediterranean population, demographic nutritional studies indicate that they are likely to be quite deficient in n-3FA. I agree with you that it's impossible to know for sure without serum levels though.

When assessing an n-3FA study for quality here are my main criteria:
1. Dosage of n-3FA supplementation. It's hard to peg a solid number here, but you tend to see positive results with >2g/d and tend to see negative results with <2g/d. No one would write off a medication that didn't work at one dosage if it worked well at another dosage, which is why I think a threshold of some kind is critical. There are confounders here, such as the fact that mediterranean and asian fish-eating diets are already rich in n-3FA, which may explain why GISSI had such a positive effect despite only 850mg/d of n-3FA supplementation. If I were writing my own meta-analysis, I'd do some statistical analysis here to guide further research.
2. Type of n-3FA supplementation. ALA is the poorest quality n-3FA as it is only slowly converted to the active n-3FAs EPA and DHA. It also competes with dietary sources of n-6FAs for the same enzyme in conversion to those latter compounds. EPA seems to have more anti-inflammatory effects, while DHA seems to be more neuroprotective and be more arrythmoprotective. These are broad generalizations and we are still elucidating their respective biological functions, so it's important to see a mix. Thus, in analysis of arrhythmia, eye function, and dementia I would tend to look for DHA. And for disorders related in part to inflammation such as asthma, arthritis, metabolic syndrome, and atherosclerosis, I would concern myself more with EPA.
3. Of course the all important O6/O3 ratio in the serum.
4. Finally cell membrane and serum concentrations of EPA and DHA.

I consider a 'no' quality study one that fails condition 1. A poor quality study one that passes condition 1. A moderate quality study one that passes condition 1 and 2. A good quality study one that passes 1-3. And an excellent one would contain all 4.

Only then would I even begin to look at the data. And in meta-analysis I would of course look for a dose-response relationship, which none of the negative reviews that I've read so far have done, any of which you can eyeball one and I'm too lazy to run the numbers cuz i'm not getting a pub out of this work.

You might have different criteria, but those are mine. *shrug*

 

[facetguy]

True on the serum levels. But I wouldn't venture that far. Unless it's an asian fish-eating population or mediterranean population, demographic nutritional studies indicate that they are likely to be quite deficient in n-3FA. I agree with you that it's impossible to know for sure without serum levels though.

When assessing an n-3FA study for quality here are my main criteria:
1. Dosage of n-3FA supplementation. It's hard to peg a solid number here, but you tend to see positive results with >2g/d and tend to see negative results with <2g/d. No one would write off a medication that didn't work at one dosage if it worked well at another dosage, which is why I think a threshold of some kind is critical. There are confounders here, such as the fact that mediterranean and asian fish-eating diets are already rich in n-3FA, which may explain why GISSI had such a positive effect despite only 850mg/d of n-3FA supplementation. If I were writing my own meta-analysis, I'd do some statistical analysis here to guide further research.
2. Type of n-3FA supplementation. ALA is the poorest quality n-3FA as it is only slowly converted to the active n-3FAs EPA and DHA. It also competes with dietary sources of n-6FAs for the same enzyme in conversion to those latter compounds. EPA seems to have more anti-inflammatory effects, while DHA seems to be more neuroprotective and be more arrythmoprotective. These are broad generalizations and we are still elucidating their respective biological functions, so it's important to see a mix. Thus, in analysis of arrhythmia, eye function, and dementia I would tend to look for DHA. And for disorders related in part to inflammation such as asthma, arthritis, metabolic syndrome, and atherosclerosis, I would concern myself more with EPA.
3. Of course the all important O6/O3 ratio in the serum.
4. Finally cell membrane and serum concentrations of EPA and DHA.

I consider a 'no' quality study one that fails condition 1. A poor quality study one that passes condition 1. A moderate quality study one that passes condition 1 and 2. A good quality study one that passes 1-3. And an excellent one would contain all 4.

Only then would I even begin to look at the data. And in meta-analysis I would of course look for a dose-response relationship, which none of the negative reviews that I've read so far have done, any of which you can eyeball one and I'm too lazy to run the numbers cuz i'm not getting a pub out of this work.

You might have different criteria, but those are mine. *shrug*

Your criteria make sense. I have a few thoughts on this:
*Dosage: this is likely very critical in these studies. It is my hunch that doses approaching 5 g EPA/DHA are needed to drop levels of inflammation even more.
*When discussing omega-3 supplementation with patients, be sure to tease out the difference between total omega-3 dosage and EPA/DHA dosage. Depending on what they are taking, this could vary quite a bit. Omacor (or whatever it is called now) is 84% EPA/DHA, but OTC fish oil (particularly the cheaper ones) will be much lower in EPA/DHA. So, the patient may say they are taking 2000 mg of omega-3s, but this may only equate to 500 mg EPA/DHA, and it's the latter that matters. I do not believe Omacor is necessary for everyone, or even most people, and talk about over-priced!
*Agreed on ALA (flax). Not an adequate substitute (it may have other benefits, but not best for EPA/DHA boosting.)
*I would like to see more work on the use of Arachidonic Acid:EPA ratio as a marker.
*Remember the role of diet in all this. Improving omega-3 intake. Reducing omega-6 intake. Controlling insulin levels, as insulin increases funneling toward arachidonic acid and away from GLA on the omega-6 side, which of course leads to production of "bad" eicosanoids.

 

[masterofmonkeys]

*When discussing omega-3 supplementation with patients, be sure to tease out the difference between total omega-3 dosage and EPA/DHA dosage. Depending on what they are taking, this could vary quite a bit. Omacor (or whatever it is called now) is 84% EPA/DHA, but OTC fish oil (particularly the cheaper ones) will be much lower in EPA/DHA. So, the patient may say they are taking 2000 mg of omega-3s, but this may only equate to 500 mg EPA/DHA, and it's the latter that matters. I do not believe Omacor is necessary for everyone, or even most people, and talk about over-priced!
.

I use GNC triple strength since its the best combination of dosage and price I can find in pill form. It's slightly higher dosages than Omacor. I take two pills a day instead of 1, for anti-inflammatory effects, and because I do indeed eat a lot junk food (nice and rich in omega 6! wooh). The data seem to indicate it can be an NSAID-sparing agent, and personal experience has borne this out. Not saying I'm immune to placebo effect but considering I failed every NSAID except Mobic and Celebrex, i'm happy enough about that, regardless of whether its all in my mind or not. I think the data is clear enough, and even the rheumatologists agree on this, that it's worth a try on anyone who would otherwise be a long-term potent NSAID user.

The most cost effective way to get several grams is one of the liquid form (usually flavored lemon). It's supposedly well-tolerated, but blech!
http://www.bodybuilding.com/store/sea/pfo.html
That's a brand I've heard good things about. And is by far the cheapest method of n-3 supplementation.

 

[facetguy]

I use GNC triple strength since its the best combination of dosage and price I can find in pill form. It's slightly higher dosages than Omacor. I take two pills a day instead of 1, for anti-inflammatory effects, and because I do indeed eat a lot junk food (nice and rich in omega 6! wooh). The data seem to indicate it can be an NSAID-sparing agent, and personal experience has borne this out. Not saying I'm immune to placebo effect but considering I failed every NSAID except Mobic and Celebrex, i'm happy enough about that, regardless of whether its all in my mind or not. I think the data is clear enough, and even the rheumatologists agree on this, that it's worth a try on anyone who would otherwise be a long-term potent NSAID user.

The most cost effective way to get several grams is one of the liquid form (usually flavored lemon). It's supposedly well-tolerated, but blech!
http://www.bodybuilding.com/store/sea/pfo.html
That's a brand I've heard good things about. And is by far the cheapest method of n-3 supplementation.

The liquid isn't that bad, believe it or not, and I'm not even a big fish fan. In my house, we've used both liquid and capsule. The orange flavored liquid fish oils are a little better than the lemon, in my personal opinion. Currently, we're using Carlson's orange fish oil, but I've used a few others over the years. Another tip: for those patients that claim they can't take fish oil because they "burp them up", try an enterically coated fish oil capsule...usually works pretty well (and perhaps eventually address their digestive issues in general!).

 

[Doctor Grim]

I had an elderly pt who came in for a routine check up. Her BP was 196/95 and she was on a BB and CC.

I asked her if she was taking her meds as prescribed and she told me, "well, not really"

"Why not?" I countered.

"Uhm, my dentist told me not to take the am-amlo-amlodipine because it would make my teeth weaker." She replied.

"Your dentist say that? Why would he say such a thing?" I asked.

"Because doesn't it block the calcium from depositing on my teeth so my teeth would get weaker? That's why my dentist told me." She said.

So I spent the next 5 minutes explained to her why it is important to have her take all her meds as prescribed by a M.D. and her DDS cannot treat her BP.

 

[mlw47]

Here are the AHA Guidelines on fish oil:

http://circ.ahajournals.org/cgi/reprint/106/21/2747

and

http://circ.ahajournals.org/cgi/reprint/CIRCULATIONAHA.106.176158



Summary: Supplemental fish oil is clearly beneficial for secondary prevention after you already have CAD, but it's not proven to prevent CAD.




More AHA recommendations on diet and nutrition can be found here:

http://www.americanheart.org/presenter.jhtml?identifier=3004604

 

[masterofmonkeys]

well I'm very reassured to see that AHA at least has taken that stance on n-3 FA in secondary prevention.

I'm convinced its valuable for primary prevention and general health as well, but admittedly it took a lot of reading and evaluation from a variety of sources to convince myself of that.

 

[facetguy]

Here are the AHA Guidelines on fish oil:

http://circ.ahajournals.org/cgi/reprint/106/21/2747

and

http://circ.ahajournals.org/cgi/reprint/CIRCULATIONAHA.106.176158



Summary: Supplemental fish oil is clearly beneficial for secondary prevention after you already have CAD, but it's not proven to prevent CAD.




More AHA recommendations on diet and nutrition can be found here:

http://www.americanheart.org/presenter.jhtml?identifier=3004604

What is your personal opinion on the use of supplemental fish oil?

 

[mlw47]

What is your personal opinion on the use of supplemental fish oil?

My personal opinion is probably less informed then all of yours', and I could very well be wrong....


I don't have CAD and I don't take fish oil supplement. Instead I excercise a lot and try to keep a healthy diet with as many of the "SHAMS" fishes as possible ("SHAMS" = salmon, herring, anchovies, mackerel, sardines). A diet rich in fish is recommended by the AHA also.


In a few years from now my opinion might change -- the evidence might come to support N-3 fatty acid supplementation for primary prevention. Until then, I think it's best not to waste my money on those expensive pills and just try to eat a healthy diet. When did it become ok in our society for us to take a pill for nutrition instead of simply eating healthy?


If you currently are taking N-3 FAs hoping that it pays off in the long run, you may be right, but you may be wrong, so proceed cautiously when extolling the benefits of N-3 FAs. And even if you fish oil does prove to work, it will only be used in conjuction with diet and excercise, the "gold standard" of primary prevention. If you're currently not getting your >30m of excercise five days a week, then don't even bother popping those pills. Go buy some running shoes instead. Diet and excercise are the best investments you can make for your health.


There currently are a lot of clinical trials underway investigaing N-3 FAs. I'll reevaluate my position in a year or two when more evidence comes out. I suggest that everyone does the same because the literature is very interesting and rapidly changing.


For comparison, it used to be thought that antioxidants were the greatest thing ever. This, however, has fallen by the wayside (see below). Perhaps fish oil will have the same fate.....or perhaps not.



Recent antioxidant trials and effects on CA and mortality:

http://jama.ama-assn.org/cgi/content/full/2008.864

http://jama.ama-assn.org/cgi/content/abstract/290/4/476

http://jama.ama-assn.org/cgi/content/abstract/297/8/842

http://jama.ama-assn.org/cgi/content/abstract/294/24/3101

http://jama.ama-assn.org/cgi/content/abstract/294/1/56

http://jama.ama-assn.org/cgi/content/abstract/2008.862v1

 

[8744]

well I'm very reassured to see that AHA at least has taken that stance on n-3 FA in secondary prevention.

I'm convinced its valuable for primary prevention and general health as well, but admittedly it took a lot of reading and evaluation from a variety of sources to convince myself of that.

But you see, you wanted to be convinced. Therefore you sifted through those studies with an ingrained bias and made your judgement accordingly. Likewise, as studies that proved what the investigators were trying to prove are more likely to be published than those that did not, in the case of therapies whose effectiveness is not obvious (for example, those with a large Number Needed to Treat), you have a fairly large confirmation bias built into the literature already.

Insulin. Number needed to treat what it treats: One. Obviously effective for what it's supposed to do. No real research needed as I can see the effects with serial accuchecks before my very eyes.

Fish oil. Number needed to treat: Hundreds? Thousands? Not so obviously effective to prevent ischemic heart disease. Very difficult to set up a study to prove or disprove its benefits.

Now, in the case of fish oil if it's cheap and harmless there is no harm taking it. But what if it's ten dollars a month and it becomes the standard of care covered under insurance for everyone with any risk factors for heart disease (essentially half the population)? We're talking big money here with no proven benefit.

 

[mlw47]

Now, in the case of fish oil if it's cheap and harmless there is no harm taking it. But what if it's ten dollars a month and it becomes the standard of care covered under insurance for everyone with any risk factors for heart disease (essentially half the population)? We're talking big money here with no proven benefit.

I totally agree. People take these supplements because they think that at worst they're harmless. But it's not harmless to take $20-$40 a month out of a retiree's pocket to support their nutritional supplements when the supplements don't work. Worse to take it from the taxpayer's pocket still.

Money is a moral issue. Taking money from people in exchange for no benefit is immoral.

 

[masterofmonkeys]

But you see, you wanted to be convinced. Therefore you sifted through those studies with an ingrained bias and made your judgement accordingly.

You're absolutely right. I got a graduate degree in human evolution where I actually learned what we ate in the good old days. I've only been reading the nutrition and exercise literature for 5 years or so. I've been supplementing with N-3 FA for about a month or two. You do the math. I didn't particularly want to be convinced and I grumbled while buying my fish oil.

Likewise, as studies that proved what the investigators were trying to prove are more likely to be published than those that did not, in the case of therapies whose effectiveness is not obvious (for example, those with a large Number Needed to Treat), you have a fairly large confirmation bias built into the literature already.

I'll admit this is an unproven assertion, but you'll find that negative studies are almost popular when it comes to nutrition, at least in the medical literature.

Insulin. Number needed to treat what it treats: One. Obviously effective for what it's supposed to do. No real research needed as I can see the effects with serial accuchecks before my very eyes.

Fish oil. Number needed to treat: Hundreds? Thousands? Not so obviously effective to prevent ischemic heart disease. Very difficult to set up a study to prove or disprove its benefits.

Although admittedly there aren't any RCTs out there following people for 10-20 years on a low n-6/n-3 ratio diet versus a high n-6/n-3 ratio diet, the epidemiological data is out there and very compelling. Especially when you look at studies on n-6/n-3 ratio and health effects in populations that not so long ago had low ratios and now have high ratios.

I don't know of any major RCT in the works that'll look at the effects of manipulation of n-6/n-3 ratio and DHA and EPA intake with regard to psych, arthritis, metabolic syndrome, CHD, and alzheimer's, but I know that there is promising evidence in each of these areas. Who's going to fund that RCT? Who's going to do it?

If it does get started, do I want to be the doctor who has to tell my patient in 20 years, when/if we find that n-6/n-3 ratio is in fact an important global determinant of heath that 'hey, I'm sorry you have diabetes, heart disease, and alzheimer's. There was promising evidence that n-3FA intake could have played a large role in preventing all of these, but I didn't have a randomized control trial to prove it so I didn't suggest it.'

Part of any 'evidence-based' pursuit is using the knowledge at hand to develop an opinion on the practical application of the science. In this case, I am not discussing the use of n-3 FA as a treatment (even though it does have FDA approval for hypertriglyceridemia) but rather as part of general health maintenance (i.e. in the 'lifestyle' category of intervention).

I've linked to epidemiological research, evolutionary research, and a number of small trials on the potential benefits of n-3 FA supplementation. Where I've had access to negative meta-analyses and trials I've indicated the flaws in them where present.

You are certainly welcome to an opinion more based on contrarianism than an un-biased critical view of the literature, though.

 

[masterofmonkeys]

I totally agree. People take these supplements because they think that at worst they're harmless. But it's not harmless to take $20-$40 a month out of a retiree's pocket to support their nutritional supplements when the supplements don't work. Worse to take it from the taxpayer's pocket still.

Money is a moral issue. Taking money from people in exchange for no benefit is immoral.

lol because there's absolutely no evidence for possible therapeutic benefit.

 

[mlw47]

lol because there's absolutely no evidence for possible therapeutic benefit.

If the shoe fits...


I explained my opinion pretty in depth above, and I think I give fish oil pretty fair treatment. I'll leave it at that.

 

[masterofmonkeys]

My personal opinion is probably less informed then all of yours', and I could very well be wrong....

Ours could be too. Forming an opinion rather than quoting meta-analyses and reviews like they were scripture is the important thing👍

I don't have CAD and I don't take fish oil supplement. Instead I excercise a lot and try to keep a healthy diet with as many of the "SHAMS" fishes as possible ("SHAMS" = salmon, herring, anchovies, mackerel, sardines). A diet rich in fish is recommended by the AHA also.

Eating SHAMS=n-3 FA intake. Same deal. And same here as far as exercise. Except that I'm not big into meat of any kind (not a vegetarian, but I'm only the second generation in my family to eat meat *shrug*).

In a few years from now my opinion might change -- the evidence might come to support N-3 fatty acid supplementation for primary prevention. Until then, I think it's best not to waste my money on those expensive pills and just try to eat a healthy diet. When did it become ok in our society for us to take a pill for nutrition instead of simply eating healthy?

I've linked to a number of studies in this thread about the reduced nutritional content and increased n6/n3 ratio in everything from our milk and eggs to our meat and produce. At least I think I have. I've got a file on the comp with a bunch of bookmarks. Eating healthy is good, but as I said before, that's hard to do when 'healthy' food is less healthy than it used to be. With produce, one of the other issues is that they often contain substantially less minerals than they used to.

If you currently are taking N-3 FAs hoping that it pays off in the long run, you may be right, but you may be wrong, so proceed cautiously when extolling the benefits of N-3 FAs. And even if you fish oil does prove to work, it will only be used in conjuction with diet and excercise, the "gold standard" of primary prevention. If you're currently not getting your >30m of excercise five days a week, then don't even bother popping those pills. Go buy some running shoes instead. Diet and excercise are the best investments you can make for your health.

Agreed. Exercise and diet above all else. No amount of n-3 FA supplementation is going to make up for the fact that the only exercise you get is walking to the kitchen to open the fridge, and the only thing you get out of the fridge is junk. I've been convinced that n-3 FA intake and n-6/n-3 ratio is a crucial and often overlooked part of maintaining a healthy diet though.

For comparison, it used to be thought that antioxidants were the greatest thing ever. This, however, has fallen by the wayside (see below). Perhaps fish oil will have the same fate.....or perhaps not.

*shrug* I was never all that convinced by the antioxidant research. Vitamins are important or they wouldn't be vitamins, but at the same time they aren't the key to immortality. That said, the vitamin D research has shown that perhaps not all vitamins are huge letdowns.

 

[masterofmonkeys]

Just going to post a link with some commentary, as this is one of the most widely cited studies in my experience on the 'no clear benefit of n-3 supplementation' position. You can read if you're interested, or not.

http://www.bmj.com/cgi/content/full/332/7544/752

http://www.bmj.com/cgi/eletters/332/7544/752#130637

Read the paper and the letters. It's a fairly instructive exercise in recognizing the difference between 'high quality' in terms of trial methodology versus 'high quality' in terms of design of the intervention being studied itself.

I was fairly dismayed to see the inclusion of 'dietary advice' groups, short chain n-3 fatty acids (vegetable), limited analysis into dose-response, no attempt to look not only at total dosage, but also the individual amounts of EPA and DHA, and no discussion of being limited by the lack of assessment of n-6/n-3 ratio.

I posted my criteria on how I assess an n-3 FA study I think a page back.

The letters mention a lot of the finer points of the state of what we know about EFA and discuss some of the epidemiological data as well.

I'm sure many med students who read this consider it negative evidence. I wouldn't, for the above reasons.

 

[facetguy]

Since there's been some mention of NNT for various nutritional supplements, I thought perhaps someone could fill us in on some NNT data for popular medications?

After all, as mlw47 has said, "Money is a moral issue. Taking money from people in exchange for no benefit is immoral." I'm no expert, but I've seen some less-than-stellar NNTs out there for some very commonly prescribed (and very expensive) medications. So, should we as a society stop paying for meds with a high NNT? At least with supplements, society isn't paying, just the individual.

 

[Its_MurDAH]

You know I've read all 10 pages now.

I wonder if any MD's or med students ever go on to the CAM forums and start posting on their walls to "defend" themselves if someone posts a topic bashing allopathic medicine.

All these studies you are writing about, all these posts edited then re-edited a million times, all the mental energy that you are wasting is absolutely USELESS. You aren't gonna change a damn thing and, in the end, you all just end up looking like cry-babys with a serious case of MD-regretitis. I am talking, of course, to the two posters who are now DYING to respond to this post. Just drop it already.

 

[mlw47]

I'm no expert, but I've seen some less-than-stellar NNTs out there for some very commonly prescribed (and very expensive) medications. So, should we as a society stop paying for meds with a high NNT? At least with supplements, society isn't paying, just the individual.

http://www.nytimes.com/2008/12/03/health/03nice.html?ref=policy


Frankly, people are free to spend their own money how they want, to get whatever value they get from whatever drug they want. But the government (ie. Medicare) should use more discretion. Medicare plays a zero-sum game -- spending money on bad things takes it away from good things.

To prevent Medicare from going bankrupt, America needs to engage in some sort of discussion about rationing how our tax dollars are going to be spent. Because, again, money is a moral matter. How you spend your money is a reflection of what you value. Just ask any med student who's had to make a budget...

 

[facetguy]

You know I've read all 10 pages now.

I wonder if any MD's or med students ever go on to the CAM forums and start posting on their walls to "defend" themselves if someone posts a topic bashing allopathic medicine.

All these studies you are writing about, all these posts edited then re-edited a million times, all the mental energy that you are wasting is absolutely USELESS. You aren't gonna change a damn thing and, in the end, you all just end up looking like cry-babys with a serious case of MD-regretitis. I am talking, of course, to the two posters who are now DYING to respond to this post. Just drop it already.

I don't think it's a stretch to guess that I am one of the two you mentioned. First, if you had read more closely, you would see that I plan to apply to med school, which is how I ended up in these forums. It was never my intention to, as you say, 'defend' anything. However, the title of this thread caught my interest so I peeked inside. And, not surprisingly, I have found lots of uninformed opinions being offered, so I simply offered mine. And, as to the mental energy you speak of, posting in this forum ain't exactly rocket science, so I think you are perhaps being a bit dramatic (unless, of course, you found writing your post to require lots of mental energy, which I guess is always a possibility).

You seem tense. You should consider meditation or some similar activity. Perhaps you can make it your New Year's resolution.

 

[facetguy]

http://www.nytimes.com/2008/12/03/health/03nice.html?ref=policy


Frankly, people are free to spend their own money how they want, to get whatever value they get from whatever drug they want. But the government (ie. Medicare) should use more discretion. Medicare plays a zero-sum game -- spending money on bad things takes it away from good things.

To prevent Medicare from going bankrupt, America needs to engage in some sort of discussion about rationing how our tax dollars are going to be spent. Because, again, money is a moral matter. How you spend your money is a reflection of what you value. Just ask any med student who's had to make a budget...

From the article: "The United States already spends more than twice as much per capita on health care as the average of other industrialized nations, while getting generally poorer health outcomes."

Changing things will not be easy.🙁

 

[8744]

http://www.nytimes.com/2008/12/03/health/03nice.html?ref=policy


Frankly, people are free to spend their own money how they want, to get whatever value they get from whatever drug they want. But the government (ie. Medicare) should use more discretion. Medicare plays a zero-sum game -- spending money on bad things takes it away from good things.

To prevent Medicare from going bankrupt, America needs to engage in some sort of discussion about rationing how our tax dollars are going to be spent. Because, again, money is a moral matter. How you spend your money is a reflection of what you value. Just ask any med student who's had to make a budget...

Exactly. I have a lot of extremely old, demented, incredibly sick patients who are using an order of magnitude more of Medicare money than they ever put into it. They are sent in for what are essentially minor exacerbations of their horrific medical problems and their families want everything done, every study and lab test possible, "Just to be safe." Consquently we end up spending thousands of dollars per visit it confirm that these elderly patients are, in fact, sick and dying from their chronic medical conditions. It is kind of selfish when you think about it; bankrupting their grandchildren to buy, at great cost, a couple or three extra months of life.

My in-laws who are in their 80s see nothing wrong with this or with things like sheltering their assets so the someone else will payfor their nursing home care. It is kind of immoral.

 

[Droopy Snoopy]

I don't think it's a stretch to guess that I am one of the two you mentioned. First, if you had read more closely, you would see that I plan to apply to med school, which is how I ended up in these forums. It was never my intention to, as you say, 'defend' anything. However, the title of this thread caught my interest so I peeked inside. And, not surprisingly, I have found lots of uninformed opinions being offered, so I simply offered mine. And, as to the mental energy you speak of, posting in this forum ain't exactly rocket science, so I think you are perhaps being a bit dramatic (unless, of course, you found writing your post to require lots of mental energy, which I guess is always a possibility).

You seem tense. You should consider meditation or some similar activity. Perhaps you can make it your New Year's resolution.

My perusal of the literature suggests a direct link between pretentiousness and comma usage.

 

[facetguy]

My perusal of the literature suggests a direct link between pretentiousness and comma usage.

Tic, perhaps you can contribute and give us your thoughts on the NNT issue (or any issue, for that matter)?

 

[Droopy Snoopy]

Tic, perhaps you can contribute and give us your thoughts on the NNT issue (or any issue, for that matter)?

I already contributed my Penn & Teller link 9 loooong pages ago. Sums up my position pretty nicely:

 

[facetguy]

I already contributed my Penn & Teller link 9 loooong pages ago. Sums up my position pretty nicely:

Tic, maybe I missed it, but I didn't see anything about NNT data in that video. Maybe you can take a stab at it? I'm just trying to advance the discussion, so how about you add something meaningful this time. (And 'gateway drug to alternative medicine'? Did you think of that all by yourself?)

 

[stewiegriffin81]

There's a new systematic review on fish oil:

Leon, et al (2008). "Effect of fish oil on arrhythmias and mortality: systematic review". British Medical Journal. 337.

Conclusion: Fish oil supplementation was associated with a significant reduction in deaths from cardiac causes but had no effect on arrhythmias or all cause mortality. Evidence to recommend an optimal formulation of EPA or DHA to reduce these outcomes is insufficient. Fish oils are a heterogeneous product, and the optimal formulations for DHA and EPA remain unclear.

 

[facetguy]

There's a new systematic review on fish oil:

Leon, et al (2008). "Effect of fish oil on arrhythmias and mortality: systematic review". British Medical Journal. 337.

Conclusion: Fish oil supplementation was associated with a significant reduction in deaths from cardiac causes but had no effect on arrhythmias or all cause mortality. Evidence to recommend an optimal formulation of EPA or DHA to reduce these outcomes is insufficient. Fish oils are a heterogeneous product, and the optimal formulations for DHA and EPA remain unclear.

Yes, the mechanism of fish oil's benefits needs more study, as the above study seems to disagree with earlier studies, including the GISSI study. But, it is clear that there are indeed benefits to fish oils.

 

[facetguy]

The American Academy of Pediatrics makes recommendations regarding CAM:
http://pediatrics.aappublications.org/cgi/content/full/122/6/1374

Some key quotes from the study, in my view:

"A growing number of pediatric generalists and subspecialists have begun to offer complementary therapies and advice as part of their practice. In addition, there is a growing number of academic pediatric integrative medicine programs and new initiatives to promote systematic sharing, support, and dissemination of information to improve collaborative and comprehensive care."

"Pediatricians and other clinicians who care for children have the responsibility to advise and counsel patients and families about relevant, safe, effective, and age-appropriate health services and therapies regardless of whether they are considered mainstream or CAM."

"Pediatricians should seek continued and updated knowledge about therapeutic options available to their patients, whether they are mainstream or CAM, and about the specific services used by individual patients to ensure that issues of safety, appropriateness, and advisability of CAM can be addressed. Only then can pediatricians appreciate the concerns of their patients and families and offer them the thoughtful and knowledgeable guidance they may require."

"Finally, if the pediatrician confirms that the patient is seeing a CAM provider, the pediatrician can (with the permission of the patient and family) include the CAM provider in overall care-coordination activities."

"Maintain current knowledge of popular complementary therapies and evidence-based resources about them. Become familiar with the definitions, terms, and uses of CAM and learn about specific CAM therapies patients are using. Pediatricians are encouraged to educate themselves about the modalities and professionals that are available in their practice area."

The last paragraph is perhaps the most relevant to this thread. Many of the CAM bashers haven't lifted a finger to "educate themselves" about CAM at all, and instead have already decided after zero due diligence that ALL of CAM is bogus, unsafe and/or unhelpful. Regardless of how you feel about CAM, it's here, people utilize it, and physicians need to do at least some leg work to become more educated about it.

As I stated earlier, it is in your better interests to familiarize yourself with a chiropractor in your area, someone you can trust to help you with MSK cases. As for the rest of the CAM world, you're on your own.

 

[mlw47]

The last paragraph is perhaps the most relevant to this thread. Many of the CAM bashers haven't lifted a finger to "educate themselves" about CAM at all, and instead have already decided after zero due diligence that ALL of CAM is bogus, unsafe and/or unhelpful.

There is no such thing as "alternative medicine": there is that which is scientifically proven, and there is that which is not. Until there is proof, the tooth fairy belongs in the same category as crystal light therapy.



People don't use alternative medicine because it works. People use alternative medicine because they think that it works. Whether harmonic healing (more) or non-contact therapeutic touch works is a separate issue. Its existence is not proof of its efficacy.


"Alternative medicine" practitioners prey upon the hope of sick people, and take their money in exchange for less guarantee then what you get when you buy a toaster at Target. After it came to light that it was bad, Vioxx was taken off the market. What professional or governmental body will outlaw the practice of violet angelic energy ray therapy if it proves not to work? There is no accountabiliy. What a business model! No wonder people want to practice alternative medicine.

 

[facetguy]

There is no such thing as "alternative medicine": there is that which is scientifically proven, and there is that which is not. Until there is proof, the tooth fairy belongs in the same category as crystal light therapy.

People don't use alternative medicine because it works. People use alternative medicine because they think that it works.

Now you are a better judge of how a particular therapy works for a patient than the patient himself? Your theory, I assume, is that EVERY patient who ever improved via some form of CAM treatment got better because of placebo, right?

Whether harmonic healing (more) or non-contact therapeutic touch works is a separate issue. Its existence is not proof of its efficacy.

"Alternative medicine" practitioners prey upon the hope of sick people, and take their money in exchange for less guarantee then what you get when you buy a toaster at Target.

Is your theory that EVERY CAM practitioner has ulterior motives? Are none of these people in it for the right reasons? And as far as taking money is concerned, have you seen the dollars involved on the pharmaceutical end of things? And guarantee?? How about we have that conversation about the NNTs of some common medications.

After it came to light that it was bad, Vioxx was taken off the market.

I think we can all agree that this is quite an understatement! The Vioxx story is a little more involved than that...just ask all those who died.

What professional or governmental body will outlaw the practice of violet angelic energy ray therapy if it proves not to work?

I'm guessing none, unless of course the FBI's elite tactical teams find out about all the injuries and deaths being caused by violet angelic energy ray therapy. Then there would be hell to pay for sure!

There is no accountabiliy. What a business model! No wonder people want to practice alternative medicine.

I'll try to get you a link for the downloadable application to the Violet Angelic Energy Ray Therapy Academy of the Universe. I think you'd be excellent at it...so don't give up your dream!!

 

[facetguy]

A few interesting recent papers on Vitamin D:

*Discusses 'non-classic actions' of vitamin D. A nice reminder of the new model of vitamin D action. It's more than the old model of skin --> liver --> kidney activation. Most (perhaps all) cell types have vitamin D receptors, respond to 25-OH-D, and convert it on the spot to 1,25 for autocrine/paracrine use. Makes all the difference.
http://jcem.endojournals.org/cgi/content/abstract/94/1/26


*All-cause mortality:
Arch Intern Med. 2008 Aug 11;168(15):1629-37

Arch Intern Med. 2008 Jun 23;168(12):1340-9 (also cardiovasc mortality); highest quartile was still low at 28 ng/mL but still appears protective.

Arch Intern Med. 2007 Sep 10;167(16):1730-7 (earlier all-cause study)


*Cardiovascular risk association:
Curr Opin Clin Nutr Metab Care. 2008 Jan;11(1):7-12

*Looks like a nice overall update (I don't have full text though):
Clin Chem Lab Med. 2008 Dec 22. [Epub ahead of print]

 

[mlw47]

That's great. The more it becomes evidence based, the less it becomes "alternative". It's amazing how as more research is done in CAM, the less CAM there is! One day when we know everything, the world will be rid of CAM. That will be a glorious day.

 

[Ginzo]

Now you are a better judge of how a particular therapy works for a patient than the patient himself?

Humans have numerous cognitive quirks that murk up perception, cause them to make associations where none exist, etc.

For example, the vocal group of parents who believe that vaccines cause autism even though there is a tremendous amount of epidemiological evidence indicating that this is not the case.

Or what about the group of HIV patients who deny that it causes AIDS? Many of these individuals have gone to their graves, like Christine Maggiore recently, due to this false belief.

 

[fahimaz7]

I'd like to nominate this thread to the Hall of Fame.

 

[facetguy]

Humans have numerous cognitive quirks that murk up perception, cause them to make associations where none exist, etc.

Do you mean, for example, the association of "I had low back pain before I was treated by the chiropractor and now it's gone following treatment."? Does an association not exist there? I just think it is at least arrogant for one to claim that all of these CAM patients are nuts/mistaken/gullible/etc because they claim to have benefitted from some type of 'non-standard' treatment. (FWIW, I think an arguement can be made that chiropractic, given it's level of scientific investigation, is barely even in the CAM camp anymore.)

I understand your point and agree to some extent. But I don't think anyone should claim to somehow know for certain that none of these CAM patients benefit, as we have seen some claim in this thread.

 

[Ginzo]

Do you mean, for example, the association of "I had low back pain before I was treated by the chiropractor and now it's gone following treatment."? Does an association not exist there?

Honestly I'm unfamiliar with chiropractic in terms of how much empirical support it has, but the same principle always applies. We're all prone to making false attributions, wishful thinking, etc. This includes doctors and every other kind of health care professional. This is why the scientific method was developed: to get around these very human limitations.

 

[78222]

Wow, I can't believe this thread is still going: after 500 posts eek:😱

 

[SouthernSurgeon]

Wow, I can't believe this thread is still going: after 500 posts eek:😱

Well to be fair, I think about 490 of them are by the same poster...