The Economist on Alternative Medicine

Alternative medicine
Think yourself better
Alternative medical treatments rarely work. But the placebo effect they induce sometimes does
May 19th 2011 | from the print edition


ON MAY 29th Edzard Ernst, the world’s first professor of complementary medicine, will step down after 18 years in his post at the Peninsula Medical School, in south-west England. Despite his job title (and the initial hopes of some purveyors of non-mainstream treatments), Dr Ernst is no breathless promoter of snake oil. Instead, he and his research group have pioneered the rigorous study of everything from acupuncture and crystal healing to Reiki channelling and herbal remedies.

Alternative medicine is big business. Since it is largely unregulated, reliable statistics are hard to come by. The market in Britain alone, however, is believed to be worth around £210m ($340m), with one in five adults thought to be consumers, and some treatments (particularly homeopathy) available from the National Health Service. Around the world, according to an estimate made in 2008, the industry’s value is about $60 billion.

Over the years Dr Ernst and his group have run clinical trials and published over 160 meta-analyses of other studies. (Meta-analysis is a statistical technique for extracting information from lots of small trials that are not, by themselves, statistically reliable.) His findings are stark. According to his “Guide to Complementary and Alternative Medicine”, around 95% of the treatments he and his colleagues examined—in fields as diverse as acupuncture, herbal medicine, homeopathy and reflexology—are statistically indistinguishable from placebo treatments. In only 5% of cases was there either a clear benefit above and beyond a placebo (there is, for instance, evidence suggesting that St John’s Wort, a herbal remedy, can help with mild depression), or even just a hint that something interesting was happening to suggest that further research might be warranted.


It was, at times, a lonely experience. Money was hard to come by. Practitioners of alternative medicine became increasingly reluctant to co-operate as the negative results piled up (a row in 2005 with an alternative-medicine lobby group founded by Prince Charles did not help), while traditional medical-research bodies saw investigations into things like Ayurvedic healing as a waste of time.

Yet Dr Ernst believes his work helps address a serious public-health problem. He points out that conventional medicines must be shown to be both safe and efficacious before they can be licensed for sale. That is rarely true of alternative treatments, which rely on a mixture of appeals to tradition and to the “natural” wholesomeness of their products to reassure consumers. That explains why, for instance, some homeopaths can market treatments for malaria, despite a lack of evidence to suggest that such treatments work, or why some chiropractors can claim to cure infertility.

Despite this lack of evidence, and despite the possibility that some alternative practitioners may be harming their patients (either directly, or by convincing them to forgo more conventional treatments for their ailments), Dr Ernst also believes there is something that conventional doctors can usefully learn from the chiropractors, homeopaths and Ascended Masters. This is the therapeutic value of the placebo effect, one of the strangest and slipperiest phenomena in medicine.

Mind and body

A placebo is a sham medical treatment—a pharmacologically inert sugar pill, perhaps, or a piece of pretend surgery. Its main scientific use at the moment is in clinical trials as a baseline for comparison with another treatment. But just because the medicine is not real does not mean it doesn’t work. That is precisely the point of using it in trials: researchers have known for years that comparing treatment against no treatment at all will give a misleading result.

Giving pretend painkillers, for instance, can reduce the amount of pain a patient experiences. A study carried out in 2002 suggested that fake surgery for arthritis in the knee provides similar benefits to the real thing. And the effects can be harmful as well as helpful. Patients taking fake opiates after having been prescribed the real thing may experience the shallow breathing that is a side-effect of the real drugs.

Besides being benchmarks, placebos are a topic of research in their own right. On May 16th the Royal Society, the world’s oldest scientific academy, published a volume of its Philosophical Transactions devoted to the field.

One conclusion emerging from the research, says Irving Kirsch, a professor at Harvard Medical School who wrote the preface to the volume, is that the effect is strongest for those disorders that are predominantly mental and subjective, a conclusion backed by a meta-analysis of placebo studies that was carried out in 2010 by researchers at the Cochrane Collaboration, an organisation that reviews evidence for medical treatments. In the case of depression, says Dr Kirsch, giving patients placebo pills can produce very nearly the same effect as dosing them with the latest antidepressant medicines.

Pain is another nerve-related symptom susceptible to treatment by placebo. Here, patients’ expectations influence the potency of the effect. Telling someone that you are giving him morphine provides more pain relief than saying you are dosing him with aspirin—even when both pills actually contain nothing more than sugar. Neuro-imaging shows that this deception stimulates the production of naturally occurring painkilling chemicals in the brain. A paper in Philosophical Transactions by Karin Meissner of Ludwig-Maximilians University in Munich concludes that placebo treatments are also able to affect the autonomic nervous system, which controls unconscious functions such as heartbeat, blood pressure, digestion and the like. Drama is important, too. Placebo injections are more effective than placebo pills, and neither is as potent as sham surgery. And the more positive a doctor is when telling a patient about the placebo he is prescribing, the more likely it is to do that patient good.

Despite the power of placebos, many conventional doctors are leery of prescribing them. They worry that to do so is to deceive their patients. Yet perhaps the most fascinating results in placebo research—most recently examined by Ted Kaptchuk and his colleagues at Harvard Medical School, in the context of irritable-bowel syndrome—is that the effect may persist even if patients are told that they are getting placebo treatments.

Unlike their conventional counterparts, practitioners of alternative medicine often excel at harnessing the placebo effect, says Dr Ernst. They offer long, relaxed consultations with their customers (exactly the sort of “good bedside manner” that harried modern doctors struggle to provide). And they believe passionately in their treatments, which are often delivered with great and reassuring ceremony. That alone can be enough to do good, even though the magnets, crystals and ultra-dilute solutions applied to the patients are, by themselves, completely useless.

From the Economist regarding Alternative Medicine

Medicine
There is no alternative
Virtually all alternative medicine is bunk; but the placebo effect is rather interesting
May 19th 2011 | from the print edition


IT IS, you might suppose, always good to have an alternative. In medicine, though, that is a controversial proposition. Alternative and complementary medicine are mostly quackery. Yet they are very popular. Clearly, they have something that mainstream medicine does not. The question is, what?

A few treatments (mostly herbs containing active drug molecules) do have proven benefits. A few others look worthy of further investigation. But from acupuncture, via homeopathy, to “quantum healing”, the vast majority, some 95%, offer nothing more than the placebo effect—the strange and inadequately explained tendency of certain medical conditions to respond to anything the patient thinks is directed at treating them, even when the treatment in question could not possibly have a direct effect on the disease.

It is thus a great pity that Edzard Ernst, the first professor of alternative medicine (that is, real scientific professor) and the man who demonstrated that 95% of the industry was hokum, is about to retire early (see article). It is an even greater pity that funding to his department at Britain’s Exeter University looks likely to be cut. For the message needs to be broadcast that alternative medicine is a colossal waste of money. Globally, the industry is estimated to be worth some $60 billion a year. That is a lot to pay for placebos.


The world’s advertising-standards offices should thus crack down on bogus claims—including the idea that there is such a thing as “alternative medicine” in the first place. If it works, it is a medicine and should be regulated like one. If it doesn’t work, it isn’t a medicine. Whenever scientifically challenged celebrities, such as the Prince of Wales, waffle on about it in ways that suggest it is outside the realm of scientific scrutiny, they too should be denounced by academics and proper doctors.

That should not, however, blind those proper doctors to the one thing, among all the claptrap, the so-called alternative does have to offer. Placebos can bring relief, especially from nerve-related problems like pain and depression. They may also reach further than that. There is growing evidence that the strength of a person’s immune system is affected by his mental state, too: a healthy mind really does count, especially in an unhealthy body. You do not necessarily have to dress up placebos in the trumpery of alternative medicine: studies show placebos also work when patients are just given fake pills that they think are proper medicines and even when they know they are placebos. But the alternative-medicine industry plainly excels as a placebo delivery service.

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For all the nonsense, the industry follows the famed advice of Sir William Osler, one of the fathers of (real) medicine: “care more particularly for the individual patient than for the especial features of the disease.” The industrialisation of patient care often depersonalises the process of treatment. The average length of an appointment with a British family doctor, for example, is eight minutes. However, complementary and alternative therapists—perhaps because they are usually private—take much longer. Patients reward them by believing (wrongly but usefully) that it is the specifics of the therapy that are bringing relief, rather than the attention itself. Proper doctors could learn from this. Veterans have always known the importance of a bedside manner. More home visits and fewer telephone consultations might work wonders.

from the print edition | Leaders

YOGA MAKES TREATMENT FOR CANCER MORE EFFECTIVE

Yoga helps breast cancer patients

WASHINGTON
Friday, May 20, 2011

BREAST cancer patients who practice yoga experience lower stress and improved quality of life compared to counterparts who do stretching exercises, a US study indicated on Wednesday.

Researchers at the University of Texas MD Anderson Cancer Center studied 163 women with an average age of 52 who were undergoing radiation therapy for breast cancer, ranging from early onset to stage three.

The women were randomly assigned to one of three groups yoga, simple stretching and no instruction in either.

Those assigned to yoga or stretching practiced in one-hour sessions three times a week for the duration of the six-week radiation therapy.

At the end of their radiation treatment, they were asked to report on their own health and well-being at one, three and six months after treatment, and they also underwent tests to measure heart function and stress hormone levels.

Women in the yoga and stretching groups each reported less fatigue than the non-exercise group.

But women who did yoga reported "greater benefits to physical functioning and general health ... (and) were more likely to perceive positive life changes from their cancer experience than either other group."

The yoga group also saw the "steepest decline in their cortisol across the day, indicating that yoga had the ability to regulate this stress hormone," the study said.

"This is particularly important because higher stress hormone levels throughout the day, known as a blunted circadian cortisol rhythm, have been linked to worse outcomes in breast cancer."

The study was carried out at US sites, and the yoga practice techniques and instructors were provided by India's largest yoga research institution, Swami Vivekananda Yoga Anusandhana Samsthana in Bangalore.

Lead author Lorenzo Cohen said yoga likely helped patients deal with the transition from cancer treatment back to regular life.

"The transition from active therapy back to everyday life can be very stressful as patients no longer receive the same level of medical care and attention," Cohen said.

"Teaching patients a mind-body technique like yoga as a coping skill can make the transition less difficult."

The researchers are working on a phase III clinical trial to further study how yoga may lead to better physical functioning in breast cancer patients.

A separate study released last month suggested that regular yoga practice by cardiac patients was able to cut irregular heartbeat episodes in half.

AFP

Immigrants Craving to be American and Fat

Immigrants adopting American diets, to their detriment
4:26 PM Wednesday May 18, 2011
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'Dietary decline' means even though immigrants have a lower rate of obesity when they arrive in the US, switching to American fare is helping them to catch up.
Immigrants to the United States often ditch their ethnic diets for high-calorie American fare, partly because it is cheap and easy to find but also as a way to fit in, a new study shows.

Immigrants who eat American are consuming, on average, 182 extra calories and seven additional grams of saturated fat compared to immigrants who stick to their traditional diet, leaving the fast-food immigrants more likely to become obese and suffer chronic illnesses related to obesity.

In fact, immigrant children who have lived in the US for 15 years are as prone to obesity as American-born kids, one in three of whom is overweight or obese, says the study by researchers from the University of Washington, University of California-Berkeley and Stanford University.

Earlier studies have identified the phenomenon of "dietary decline after arrival in the US" in many immigrant groups, including from Africa and Latin America.

But the researchers in this study, conducted by the US-born child of Indian immigrants, Sapna Cheryan; the daughter of Chilean immigrants, Maya Guendelman; and French immigrant Benoit Monin, focused on whether Asian-Americans "consume American foods...


to convey that they belong in America."

In the first of two experiments conducted for the study, a group of Asian-Americans was "threatened" by being asked if they could speak English, and then asked to note down their favorite food. A control group noted down their preferred dish without having their American-ness "threatened".

"'Do you speak English' doesn't seem so bad on the face of it, but if you're the target, it does feel that you're being singled out because of the way you look or your skin colour," Cheryan told AFP.

The threatened group in the first experiment was three times more likely than the unthreatened group to say they liked a typical American dish like macaroni and cheese or a hamburger best.

In the second experiment, Asian-Americans were asked to choose from items on a menu listing typically American fare like bacon, lettuce and tomato sandwiches, fried chicken, hot dogs and hamburgers; or one featuring Asian fare like sushi, pad Thai rice noodle dishes, or chicken teriyaki.

Sixty per cent of participants whose American identity was questioned - they were told they "had to be an American" to be in the experiment - chose food from the US menu while the majority of those in the non-threatened control group - 70 per cent - chose items from the Asian menu.

The Asian-Americans who were trying to assert their US identity after having it challenged were eating "the caloric and fat equivalent of an extra four-piece order of McDonald's Chicken McNuggets over those who were not threatened," says the study.

That adds up over time, and even though immigrants have a lower rate of obesity when they arrive in the United States, switching to American food is helping them to catch up to US-born Americans, one in four of whom is obese, says the study, which will appear in the June issue of Psychological Science.

- AFP

Obesity in America: The Obese dont see it as a problem!

Overview
When it comes to obesity, Americans have no difficulty recognizing that our society has a
problem. The majority agree that obesity is the number one threat to public health.

And it is:
More than six out of ten people in the United States are overweight or obese.

But seeing themselves as part of the problem and doing something about it? That’s a very
different story.

A new study of 1,500 Americans, ages 18-65, by Catalyst Healthcare Research finds:
• Most adults who are overweight or obese – even the well-educated – say their health is
excellent or good.
• Most of the overweight or obese say their fitness level is the same as it was last year,
suggesting that they are not motivated to change.
• That attitude is reflected in their exercise patterns: More than half either don’t exercise at
all or merely engage in “naturally occurring exercise,” such as walking up the stairs in their
own home.

“These results suggest that health advocates, health providers, and health plans face a much
deeper problem than merely persuading people of the benefits of losing weight,” says Dan
Prince, president of Catalyst Healthcare Research. “They must find ways to help people face
the hard truth about themselves, while society continues to send mixed messages that soften
the psychological stigma of being overweight.”

Can Happiness be Measured?

Some happy states have high suicide rates, says study

WASHINGTON
Tuesday, April 26, 2011

DOES misery really love company?

An intriguing new study suggests that may be the case.

Researchers who study how people's sense of well-being varies from place to place decided to compare their findings with suicide rates.

The surprising result: The happiest places sometimes also have the highest suicide rates.

"Discontented people in a happy place may feel particularly harshly treated by life," suggested Andrew Oswald of the University of Warwick in England.

Or, put another way by co-author Stephen Wu of Hamilton College in Clinton, New York, those surrounded by unhappy people may not feel so bad for themselves.

But Wu urged caution in drawing conclusions, saying: "I don't think that means if you are unhappy you should be around others who are unhappy." Their study ranked Utah as the No 1 US state for residents' sense of well-being, but it also scored a high No 9 in suicide rate. By contrast New York State ranked a low 45th in well-being, but an even lower 50th in suicides.

The researchers came up with their rankings from a federal survey of behavioral risk factors and US Census Bureau numbers on suicide rates.

Sonja Lyubomirsky, a psychology professor at the University of California, Riverside, who wasn't involved in the research, agreed that living around people who are, on average, pretty satisfied with their lives, when you are not, can make you feel more miserable.

In an interview by email, she said the findings remind her of an effect researchers have discussed in cases where a city with a reputation for being a good place to live also has a high suicide rate.

The idea is, "If you're unhappy there, you conclude, 'something must be really wrong with me,' or 'nothing will make me happy,' so you're more likely to get depressed and take your life," said Lyubomirsky, who researches happiness and well-being.

However, she added, other things may also be at play.

She suggested there may be other factors that states with high life satisfaction have in common that could be associated with high suicide rates. For example, if they are more likely to be rural, that could mean people also are more isolated. Religious beliefs that vary among states may also have an effect, she said.

John F. Helliwell of the University of British Columbia, who has studied well-being and suicide rates internationally, said suicides tend to peak when days are longer, "not as you might have thought, when days are shortest." Researchers have suggested that when people who are unhappy see others in happy, social situations such as picnics, that may bring their own crisis to a head.

The new study, which has been accepted for publication in the Journal of Economic Behavior & Organization, looked at the 50 US states and Washington, DC.

It lists the top 10 states for well-being as Utah, Louisiana, Colorado, Minnesota, Wyoming, Hawaii, Arizona, Delaware, Florida and Nevada.

Four of those states also are in the top 10 for suicide rates, with Nevada ranked 3rd, Wyoming, 5th; Colorado, 6th; and Utah, 9th. Among the others, Arizona was 11th and Florida, 15th.

The 10 states with the lowest well-being ratings are: Kentucky, West Virginia, Pennsylvania, Indiana, Missouri, Ohio, New York, Massachusetts, Michigan and Rhode Island.

Just one of those states, West Virginia, is among the top 10 for suicides, ranking No 8. The only other state in the top 20 was Kentucky at 16th. Wu noted that international studies have found that Scandinavian countries also display high satisfaction levels and high suicide rates.

But the researchers said that because of variations in culture and suicide-reporting systems, it's hard to make comparisons from one country to another.

To develop their data, Wu and colleagues used information collected by the federal government in the Behavioral Risk-Factor Surveillance System, a monthly survey designed to gather health data and identify emerging problems. One survey question asks people how satisfied they are with their life and the responses to that from people aged 18 to 85 formed the basis for the well-being assessment.

The survey interviews more than 350,000 people each year. The suicide rankings are based on mortality data reported by the Census Bureau in 2008.

LOSARTAN an ARB blocker may help SARCOPENIA

SARCOPENIA
Losartan Restores Skeletal Muscle Remodeling and Protects Against Disuse Atrophy in Sarcopenia
Tyesha N. Burks1, Eva Andres-Mateos1, Ruth Marx1, Rebeca Mejias1, Christel Van Erp1, Jessica L. Simmers1, Jeremy D. Walston2, Christopher W. Ward3 and Ronald D. Cohn1,4,*
+ Author Affiliations

1McKusick-Nathans Institute of Genetic Medicine, Johns Hopkins University School of Medicine, Baltimore, MD 21205, USA.
2Division of Geriatric Medicine and Gerontology, Johns Hopkins University School of Medicine, Baltimore, MD 21205, USA.
3University of Maryland School of Nursing, Baltimore, MD 21205, USA.
4Department of Pediatrics and Neurology, Johns Hopkins University School of Medicine, Baltimore, MD 21205, USA.
*↵To whom correspondence should be addressed. E-mail: rcohn2@jhmi.edu
ABSTRACT

Sarcopenia, a critical loss of muscle mass and function because of the physiological process of aging, contributes to disability and mortality in older adults. It increases the incidence of pathologic fractures, causing prolonged periods of hospitalization and rehabilitation. The molecular mechanisms underlying sarcopenia are poorly understood, but recent evidence suggests that increased transforming growth factor–β (TGF-β) signaling contributes to impaired satellite cell function and muscle repair in aged skeletal muscle. We therefore evaluated whether antagonism of TGF-β signaling via losartan, an angiotensin II receptor antagonist commonly used to treat high blood pressure, had a beneficial impact on the muscle remodeling process of sarcopenic mice. We demonstrated that mice treated with losartan developed significantly less fibrosis and exhibited improved in vivo muscle function after cardiotoxin-induced injury. We found that losartan not only blunted the canonical TGF-β signaling cascade but also modulated the noncanonical TGF-β mitogen-activated protein kinase pathway. We next assessed whether losartan was able to combat disuse atrophy in aged mice that were subjected to hindlimb immobilization. We showed that immobilized mice treated with losartan were protected against loss of muscle mass. Unexpectedly, this protective mechanism was not mediated by TGF-β signaling but was due to an increased activation of the insulin-like growth factor 1 (IGF-1)/Akt/mammalian target of rapamycin (mTOR) pathway. Thus, blockade of the AT1 (angiotensin II type I) receptor improved muscle remodeling and protected against disuse atrophy by differentially regulating the TGF-β and IGF-1/Akt/mTOR signaling cascades, two pathways critical for skeletal muscle homeostasis. Thus, losartan, a Food and Drug Administration–approved drug, may prove to have clinical benefits to combat injury-related muscle remodeling and provide protection against disuse atrophy in humans with sarcopenia.