Category Archives: taking care of your health

Should doctors be environmentalists/advocates for the environment?

One thing that sometimes crosses my mind is whether physicians and other health care workers should also be environmentalists. After all the environment does play a role in people’s health. Contaminated water lead to outbreaks of water born diseases (John Snow, a London physician in the mid 1800’s is credited [at least in part] for ending a Cholera outbreak  by convince authorities to block use of a water pump at the center of the outbreak).  The cholera outbreak following the earthquake in Haiti several years ago is another example. Polluted air leads to increased respiratory disease.

Though in the U.S. and other developed nations with functioning governments, the chances of contaminating water with sewage is low. The one exception could be when severe weather overloads the septic systems in an area. However even in the Northeast U.S. where I live, beaches are monitored for coliform bacteria (this is a generic term for bacteria that live in our guts) and closed when the counts are too high.

Air quality effects health of populations – there were reduced hospitalizations in parts of Ireland after there were bans placed on burning coal.  When lead was taken out of gas (well, actually prevented from being put in gasoline…), blood levels of lead dropped. It’s a neurotoxin and high blood levels can affect brain development in children (hence the ban of lead in paint in the U.S.), and function in adults. For water, it’s not just bacterial contamination/pollution that is important. Chemical pollution can also affect health. Toxins can build up in the food chain – this is part of the reason why it’s suggested that pregnant women limit their intake of certain fish, for example. Mercury builds up in fish at the top of the food chain, such as in Tuna, and can adversely affect people neurologically and adversely affect developing brains. Studies continue to show an association between air pollution and respiratory  deaths.

Given the number of of medications that are derived in whole or part from the plant and animal world (aspirin, reserpine, taxol, digoxin, penicillin, streptomycin, are all plant and fungal products), an argument could be made that making sure plant and animal species don’t become extinct because it might affect future drug discovery. Before you say “but wait,….” think of this: heparin is derived from the linings of Pigs. ACE inhibitors were discovered through research on snake venom. There are some newer medications for Type 2 Diabetes which are derived/grew out of research on saliva from a lizard known as the Gila monster.

 

Men’s Health

My previous post was about women’s health. In this post I am going to review a couple of aspects of Men’s health. Most of the things men should be doing are things  people of both genders should be doing to stay healthy: stop smoking, exercising, eating a healthy diet, maintaining a healthy weight (or loosing weight if overweight).  Staying up to date with immunizations, such as yearly flu vaccination, is also important. Getting screened yearly for hypertension is important. Skin cancer screening is also important, though this might only need to be done every 2 years depending on whether you have any suspicious moles or lesions, prior history, you and your dermatologist’s comfort levels for yearly vs every other year screening. Cholesterol screening at appropriate intervals is important (a healthy male in his 20’s with no risk factors for heart disease only needs his cholesterol checked every 5 years or so. Older men and those with risk factors require monitoring more frequently and perhaps yearly if risk factors are present or if on treatment to lower cholesterol). I won’t get into more details about screening or other issues covered already in other posts.

Perhaps the biggest controversy in mens health is prostate cancer screening. The U.S. Preventive Services Task Force actually recommends against routine screening for prostate cancer in healthy men of all ages. Even the American Urological association recommends against screening for prostate under the age of 64 and in men with life expectancy of less than 10 years. For screening, a conversation with your primary care doctor is warranted before getting the test. The main reason it is controversial is that one runs the risk of finding a prostate cancer which is indolent (slow growing), non aggressive that one is likely to die with than of – meaning one is likely to die of some other disease before the prostate cancer becomes a problem. At this time we don’t have enough information to know what low grade/early prostate tumors are going to become aggressive and turn into problems. One therefor runs the risk of over treating something that would not be a problem.

Occasionally I’ve had patients ask for testosterone levels and had to talk to patients about testosterone replacement. Testosterone levels are not something  routinely checked unless there is a clinical reason (if there is loss of libido, erectile dysfunction, and so forth, then it’s worth getting). Testosterone replacement has been associated with an increased risk of heart disease so replacement benefits needs to be worth the increased risk.

Although I probably run the risk of repeating myself by saying this, but reducing the risk of heart disease, lung cancer, colorectal cancer by exercising, watching what one eats and getting appropriate screening applies to men’s health as well.

Random Thoughts on Women’s health

I’m dividing this post into two parts. The first is on the recommendations for screening in females. The other part is some general thoughts on women’s health in general (and are somewhat generalizable to anyone’s health, male or female). The recommendations are taken from USPSTF related sites.

If you’ve read any or all of my earlier posts, you know I’m into screening and catching diseases early, especially if there is treatment for the particular disease.

Women should get pap smears every 3-5 years with HPV testing. The frequency depends on a woman’s age, whether the pap smear is negative and the results of HPV testing. It is important that the HPV testing be done via one of the five tests that are FDA approved: the unapproved tests from what I understand are more prone to error. Ask your doctor if he or she knows whether the lab he or she uses is FDA approved.

Screening for STIs (sexually transmitted infections) is suggested. This includes syphilis and HIV in high risk individuals.

Breast cancer screening (mammography) is done every 1-2 years starting at 50 (the old recommendations were every two years starting at 40, then yearly after age 50). BRAC testing should only be done if there is a family history of breast, ovarian, peritoneal cancer.

Bone density should be done at least once after age 64. However one can consider doing bone densitometry at an earlier age.

As much time and energy that people put into screening for breast cancer, cervical cancer, etc I think there a tendency forget about screening for heart disease and colorectal cancer, things I think people tend to see as “a man’s disease”.   However in 2010, 23.5% of deaths in women were due to heart disease,  and 22.1% were due to cancer deaths (this includes all cancer deaths, not just breast cancer).  Lung cancer killed 70,000 women whereas breast cancer killed 40,000 women that same year. These are  for the most part “lifestyle diseases” in as much as most lung cancer is caused by smoking; diet, lack of exercise, obesity contribute to heart disease. These are all things that are modifiable to a  great extent.

The Prevention Prescription, part 3

In my previous two posts I’ve written about different kinds of prevention (eg, primary, secondary, etc as well as vaccination which is a form of primary prevention). In this post I am going to talk about a couple of different things relating to prevention.

The first is that there are preventative measures which sometimes fall into more than one category. By this I mean that if we counsel someone to change their diet and exercise more because they’ve had a heart attack, give them aspirin, a statin, etc. that we’re engaging in tertiary prevention. However if they are on their way to becoming diabetic but because of the change in diet and increase the amount of exercise they do, and therefore lower their risk of Diabetes Mellitus, then one could argue that’s primary prevention (or secondary if they have metabolic syndrome…).

I’m a firm believer in using medication to lower cholesterol, blood pressure, etc when and if appropriate. However, I think we give short shrift to diet, exercise and sleeping enough as preventative measures to prevent or delay multiple medical problems.  Even if someone needs to be on medication, lifestyle changes are important to keep up. Exercise and diet do not become less important just because someone’s started medication. One recent study published in the New England Journal of Medicine comparing intensive lifestyle changes+usual care as compared to usual care did not reduce death. However there was evidence for a better quality of life and less need for medication, at least early on. There is a lot of evidence that enough exercise and good dietary practices can prevent and delay Diabetes. And for those that are cost conscious, a half an hour a day of walking is a lot cheaper than most medications!

There is a push by some physicians to actually prescribe exercise the same way we prescribe medications. Books have even been published on the matter!!

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The Prevention Prescription, Part 2

In my last post I talked about vaccination, which is a form of primary prevention: it is the prevention of disease. There is also the concept of secondary prevention. In the case of secondary prevention, one has already has a disorder and doesn’t know it. Secondary prevention prevents the disease from getting to the point where it causes symptoms or complications (this is paraphrasing the definition on the CDC website). The example the CDC website uses is excising/taking a biopsy of a suspicious skin lesion before it becomes cancerous. Colonoscopy could also be put in the category of secondary prevention if pre cancerous polyps are found and removed before they become cancerous.

Sometimes it can be difficult to convince people to do some secondary prevention. Colonoscopy is one such item it is sometimes challenging to convince people to do. It is inconvenient as one needs to take a day off from work (if one is of working age and is working), has to have someone who’s willing to drive them home and requires taking things to clean their colon out so the colonoscopy can be done. When someone has a problem that can only be diagnosed by colonoscopy (eg: weight loss, fevers, and blood in the stool which could be a sign of inflammatory bowel disease, for example) people are worried enough about their health to get it.

Tertiary prevention is when one is trying to prevent complications or side effects of a disease which is already present. Examples of this are anticoagulation in people with atrial fibrillation, use of ACE inhibitors to prevent or slow kidney disease in diabetics.

In my next post I’ll take more about prevention and why it’s important.

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The Prevention Prescription, part 1

I suppose this is going to have some overlap with some of what I’ve already written. Even though I treat adults, I am routinely (every month or two)  giving people vaccines against various preventable diseases. Tetanus, diphtheria and pertussis being the most common vaccination I give, though I think perhaps only vaccination against influenza could be as or more as that in absolute numbers.  By the time most people get to me, they’ve had a majority of their vaccinations (except perhaps for those that didn’t exist when they were growing up or weren’t recommended outside of certain high risk groups).  Most people don’t seem to have a problem with getting a Tetanus/Diphtheria/Pertussis booster. Influenza vaccination seems harder to take for some people.

Other folks seem to take offense at getting any immunizations at all. Perhaps if we went back in time to an  era when people died of polio (1952 saw what is reported to be the worst epidemic in U.S. history: 57,628 cases,  3,145 died and 21,269 people were left with paralysis of some degree). People developed rubella while pregnant (between 1962 and 65 when there was a worldwide pandemic – an estimated 12.5 million rubella cases occurred in the United States.  There were a resulting  2,000 cases of encephalitis, 2,100 neonatal deaths, and 20,000 infants born with Congenital Rubella Syndrome).

I could go on about how vaccination has either eliminated disease (the last case of smallpox was in 1978) or vastly reduced the number of affected people. In some countries, vaccination has eliminated diseases (the U.S. has been polio free for the past 30 years) or vastly reduced the rate (only 223 reported cases worldwide in 2012 with only three countries being considered endemic for polio).

One might ask why an internist is writing about vaccinating against “childhood diseases”.  Viruses and bacteria do not know the ages of the people they infect. A lot of diseases are mild(er) in children but have higher complication rates in adults. Varicella (the chicken pox virus) can come back in adulthood and cause shingles as well as an encephalitis. Varicella is also a worse disease in adulthood and not everyone gets the disease in childhood. It’s now routinely recommended that if one is going to be around young children (I.E. infants) or in healthcare that people get vaccinated against Pertussis to prevent it spreading. People forget or don’t know how many lives have been spared because of vaccination and that a lot of diseases that caused death and disability are thankfully gone or almost gone. Part of my job is not just to treat illness but try and prevent it as well. With vaccinations it’s important not to forget them even in adults. It’s a matter of public health (preventing pertussis spreading to one of my patients’ children, grandchildren, nieces and nephews, etc): prevention of disease in my adult patients as well as those they come in contact with.  I also am trying to prevent disease on the individual patient level as well. If my patients aren’t getting the natural ‘booster shots’ of exposure to their (grand-)children while they’re infectious for varicella, there is the potential for waning immunity which puts them at risk for reactivation (I.E. Shingles in the case of varicella).

As time goes by, I think there is, and will be an appreciation that vaccination isn’t ‘The Answer” for everything. There is an appreciation that immunity wanes for some vaccinations, eg tetanus and diptheria, which is why it’s recommended to get boosters. It may be the case for the MMR vaccine as well. That immunization doesn’t always prevent a given disease is not  a reason to avoid vaccination. If we thought that way in other areas of our lives, we would not lock our car doors, the doors to our houses, look both ways before crossing the street because “doing these things don’t prevent cars being stolen, houses broken into or being run over by a car”.

Sometimes convincing people of the power of prevention is the hard part.

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Four of the best things to do for your health.

Correlation between smoking and lung cancer in...

Correlation between smoking and lung cancer in US males, showing a 20-year time lag between increased smoking rates and increased incidence of lung cancer. (Photo credit: Wikipedia)

Four of the best things to do for your health.

1) Don’t start smoking. Stop smoking if you’ve already started.

 If someone asked you to pick up a habit that increased the risk of all of the following (and would cost you roughly $33-77 dollars a week depending on where you live, brand, etc), would you do so? Here are some of the things that smoking increases the risk of: lung cancer, colon cancer, bladder cancer, esophageal cancer, kidney cancer, pancreatic cancer, cervical cancer, vascular disease including aortic aneurysms and strokes. It increases the risk of fractures in post menopausal women. It increases the risk of low birth weights in infants. There is an increased chance of developing cataracts. For men in their 30s and 40s, it increases the risk of erectile dysfunction by 50%.

According to the CDC, smoking contributes to 443,000 deaths annually in the U.S.

2) maintain a healthy weight.

obesity raises the risk of multiple diseases: Diabetes Mellitus – type 2, high blood pressure, colon cancer (though the mechanism isn’t known how). It increases the risk of breast cancer (adipose tissue has an enzyme that converts testosterone to estrogen), osteoarthritis and more. There are no easy ways of doing this. At its simplest it means taking in the same amount of calories you expend. Granted if you’re overweight, you need to expend more calories than you take in.

3) Exercise

On top of helping maintain a healthy weight, excercise has many beneficial effects. Exercising reduces the risk of alzheimer’s disease, some cancers, it can improve mood, helps reduce blood pressure and can help prevent and treat diseases such as type 2 diabetes.  The suggested minimum is 150 minutes of moderate physical activity a week, which comes out to approximately 20 minutes a day. It can be something as simple as walking. The what of exercise (what kind) is less important than the regularity of actually getting exercise.

4) Have a healthy diet.

Potential health benefits of apple consumption...

Potential health benefits of apple consumption. (See Wikipedia:Apple#Health_benefits). Model: Mikael Häggström. To discuss image, please see Template talk:Häggström diagrams (Photo credit: Wikipedia)

Diet is the mainstay treatment in a lot of diseases. Whether it’s DM-2, high cholesterol, coronary heart disease (even if you’re on medication for any of these, maintaining an appropriate, healthy diet becomes no less important). In one study coming out of Lydon, France (known as the Lydon Study), people who were put onstandard treatment and who were switched to mediterranean diet with N-3 fatty acid supplementation (as opposed to just the  standard treatment) decrease their mortality after a heart attach by 66% (their mortality went from 17% down to 10%). This was independent of weight loss, decrease in cholesterol, etc. A dietary/lifestyle program promoted by Dr. Ornish which uses lifestyle changes, exercise and a vegetarian low fat diet (10-20% of calories from fat rather than the 20-30 used in the AHA step II diet) has been shown to reverse Coronary Heart Disease and is covered by medicare. A mediterranean style diet is also associated with decreased death from heart disease, a decreased risk of certain cancers as well as a decreased risk of dementia. At this point I won’t go into a huge discussion about diet (I’m likely to blog more about this in the future on multiple occasions).

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resiliency

Resilient:

(of a person or animal) able to withstand or recover quickly from difficult conditions.

DERIVATIVES:resilience noun, resiliency noun, resiliently adverb

It’s taken me a bit longer to do this post than I originally had hoped it would. Given the events in Boston this past  few weeks, this word resilience has been going through my mind a lot. Though it did also go through my mind due to other recent events as well (Newtown CT, Aurora CO among others). I do not want to sound as if I am medicalizing whatever caused the people who killed and maimed over 170 people. However, being the optimist that I am, I think people’s basic makeup is to be nice to other people and have a “live and let live” attitude to others that they disagree with or have no particular connection to.  I sometimes wonder what happened to people that would drive them to commit such acts of horror, that overcomes whatever resiliency that would otherwise keep them functional, reasonably happy people.

As a practicing physician I often get to see a side of people that they don’t often show others. There are the people who have gone through whatever traumas life has presented them and are married, have children and work. Others don’t seem as lucky, as if somehow given the same number and intensity of  shocks to their system used up whatever resiliency they have. They seem to go from moment to moment as if their lives are going to collapse. Anxiety seems to seep from their pores when they come into my office.

I have no answers as to why some people are more resilient than others. Often people who grew up in tough situations (few resources at home, single parents, drugs/violence in the neighborhood) make the news for getting into Harvard, Yale or some other school and “made it”. Was it that their parents and teachers helped them stay resilient. What about the people who are mirror images … they have caring parents who model being nice, giving to others, tolerance, don’t have  to worry about where if they are getting their next meal and where it’s coming from but somehow end up being unable to say no to whatever demon (now I’m speaking figuratively here, not literally) overwhelms whatever their resiliency can handle and they end up having issues (for lack of a better word) with drugs, violence or whatever.

Perhaps this will be my only foray into making any sort of commentary on society or sounding like I’m living in left field (or perhaps the peanut gallery) but: perhaps in addition to the three ‘Rs that are taught in school, Resilience should be added as a fourth R. Does it need to be  separate class? Probably not, life doesn’t happen in discrete blocks (I don’t spend one hour doing math, another hour ‘doing’ history, another ‘doing English’  i.e. reading writing, explaining things to people either verbally or in writing, and so forth)  and some things in school shouldn’t  either. Just learning that a bad grade in one test or class doesn’t mean the end of the world. Nor does having difficulty with one class or multiple subjects if given the skills/help in figuring out what helps someone learn. Ideally it’s something people should learn at home.

For something that affect health and quality of life, resilience is probably underrated. It is not the cure for all ills (if one is resilient, it doesn’t make one immune to getting cancer, diabetes, hypertension, etc). I suspect those who are more resilient are more able to deal with any chronic illness they might have and are more likely to take medication (if needed), follow up with any lifestyle changes that would affect their health (diet and exercise don’t become less important in diabetics once they start medication).  Would someone who’s resilient be less likely to do something that the  bombers did, that I don’t know. The answer to that, I leave to the psychiatrists, public health officials, philosophers, and those who actually do research in the area.

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Evaluating health care claims

In some ways this post is a continuation of my previous one titled “…because it’s natural”. In a lot of diseases such as DM-2, Alzheimer’s, and heart disease, there are multiple mechanisms that contribute to either the disease itself or to it’s complications. Two mechanisms of disease that seem to get a lot of space on TV, print and on the internet is that of inflammation and oxidation. Whether it is someone promoting a “super food” that has a lot of antioxidants in it (or a lot of anti-inflammatory activity), or a pill that has plant extracts in it that reduce oxidation or inflammation, the claims should be  taken with a grain of salt. For example in some cases, there may be multiple good studies that show taking said supplement does act as good antioxidant. However this doesn’t mean that the supplement will improve one’s health or lengthen lives. This is a problem with using what’s called a surrogate endpoint. Don’t get me wrong, using surrogate endpoints can be useful when the more significant and relevant endpoints are things to be avoided (death or disability for example) or might not happen for years  – I don’t think a study that would take 30 years to start showing something works would get funding – or finding enough people to study would be practical. It helps if a change in the surrogate endpoint has already been shown to be related to reduction in a particular disease’s morbidity or mortality.There are also observational studies that show certain things (high vitamin A levels, higher beta-carotene intake) are associated with lower levels of a particular disease state. Sometimes using a surrogate endpoint  (or  noticing an association between two things such as high levels of vitamin A and lower rates of a particular disease) ends up leading to people doing negative studies. For example, many deaths after a heart attack are related to arrhythmias. A study called the CAST (short for Cardiac Arrhythmia Suppression Trial) showed  higher mortality in people who were on anti arrhythmia drugs. It doesn’t mean that the drugs didn’t have a role in other disorders. I have a feeling it means that we were just asking the wrong question (even though it needed to be asked and answered) about treating arrhythmias after heart attacks. I use the example of the CAST study to make the point that showing something changes the level of something (either up or down) that is thought to be involved in causing disease – be it inflammation, oxidation, arrhythmia or otherwise – doesn’t mean it affects the disease it is said to. It may be that to treat a disease with anti-inflammatory medications (or substances), one also needs to block other pathways of that disease as a well for any to be effective. This is why most cancers are treated with more than one drug. This is why people are often on more than one blood pressure medication. As I mentioned in my last post, any claims should have data supporting that they work. The results should be reproducible, hopefully other by other researchers. Getting back to my original assertion from the start of this particular blog post, if someone is touting a “superfood” for health, It is appropriate to ask if it actually improves health, decreases complications, etc. In my opinion, just to say something is a “super food”  because it is a ‘super anti oxidant’ is blowing smoke.  That isn’t to say that anti-oxidant rich foods don’t promote good health. There are too many studies that are negative that to look at one thing and say “this is the holy grail of food”. This also undersimplifies things too greatly. It’s better, in my opinion, to say “these are the types of foods/eating (or habits if one is talking about other aspects of lifestyle) that are associated with good health. For examples, many of the studies that show that olive oil intake is inversely related to cognitive decline are more agnostic about what role each component in olive oil plays, despite showing benefits. Is it the kinds of fatty acids in olive oil? Is it the polyphenols that act as antioxidants?  Is it the anti-inflammatory chemicals in olive oil? I suspect the answer is yes, it is all three. Is it the answer to everything: just have olive oil and you’ll live to 100? I doubt it. My bottom line on health care claims:

Be critical but open minded: ask the following questions: “Does it actually affect or prevent disease? Does it decrease complications of the disease and not just something thought to be associated with disease or complications thereof?”. If the answer is “yes, it does reduce _fill in the blank_ and there is a proportional reduction in the amount of deaths/strokes/people going on dialysis/etc then you have a winner. IF the answer is “it does reduce _fill in the blank_” but there is no reduction in _fill in this blank as well_” it may mean that the answer is more complicated than we think. It may mean that the wrong question(s) were asked, or the right ones hadn’t been asked.

Also be wary of claims that make a product or procedure seem that it’s THE ANSWER for a particular disease. It may be a piece in the puzzle, but in order to be considered as such, the answer to the question ‘where’s the proof’ should be along the lines of “here are the studies…”

If the person makes statements like “doctors are in the pockets of ‘big pharma’ and aren’t interested in curing disease”, then be wary. I think most doctors get into this business to make people better. If there was a pill that taken once or twice cured someone of his or her type 2 diabetes (and did not cause some other severe life threatening disease), I think most doctors would use that pill.

Also ask if this the first study of something? Often a treatment is found in a study to be helpful. The numbers of people may be small. Due to the nature of studies, the participants are typically more homogenous than the population as a whole. Once larger studies are done, the benefits of a medication/procedure, etc may not be as large as initially thought.

Another question ot ask is this better than what we have now? Though it could be asked of a new medication, I’m primarily thinking here of new surgical procedures (eg, robotic surgery for certain things). If offered ask: is the rate of complications less with the new procedure? Is mortality less? Is the recovery time quicker with the new procedure?

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… because it’s natural.

I think with this post I am going a bit off topic (or at least getting on a soap box for a bit). Occasionally a patient will say that they don’t want to take a medicine because they want to try other treatments first, like loosing weight or exercising, if,  for example, they were just diagnosed with adult onset diabetes (also known as Diabetes Mellitus, type 2). Now if their numbers (eg, a glycosylated hemoglobin) that is at or near goal for a treated diabetic, that might not be an unreasonable approach. After all, even if someone is put on a diabetes medication, anti-hypertensive, etc, diet and exercise don’t become less important in treating whichever disease they have.  What concerns me at times is if the reason someone doesn’t want medication for a treatment is because the medication is “not natural” and that they want to try something that is derived solely from natural products.

Now on one hand this might not be totally unreasonable in that many common medications are derived from natural products. Think of aspirin and penicillin (the latter produced by fungi known as penicillium).   Streptomycin is another drug initially derived from a natural source. Digoxin/Digitalis is produced by the Foxglove Plant (which was used to treat what we now call congestive heart failure.  Digoxin and digitalis are still used at times). Morphine is derived from Poppies. The list goes on. As I don’t work for a pharmaceutical company, I don’t know how many of these medications are 100% man made vs being derived from plant sources. Given that a pill has a known quantity of a known medicine, I’d rather take that than risk a stroke or some other complication. My biggest issue is someone wants to take a  supplement to treat a disease “because it’s natural” and because “it’s safe”. I want to see the proof that it works before I’d recommend it. Note, if we’re talking about a disease that won’t kill you tomorrow, or next week, I try to be open minded if a patient wants to try something else first.

Having said that, when someone’s reason for wanting to use an herbal treatment, a supplement, etc to treat a disease because natural products are safe/safer than medications, I am apt to give them a list similar to this: Carbon Monoxide, Snake venom, Radium, Ricin, Atropa Belladona (nightshade), Botulinum toxin, etc. Aside from being toxic, they are all natural products as well. It is my way of hopefully, and gently, pointing out that natural doesn’t always mean safe or non toxic.  If someone is hawking a natural product as a “cure” for something, it’s reasonable to ask the following questions:

1) Is it safe?

2) Does it work? What is the proof that it works? For medications it’s multiple trials that are reproducible and show (usually) a clinically significant difference in cure/length of disease/significant decrease in morbidity or mortality. In some cases it is a change in a surrogate end point. Do the natural products have the same level of proof? Of note, a celebrity spokesperson or the fact an infomercial exists isn’t proof. In my mind if someone is saying that “studies show…” then they should be able at some point to tell you where to find the studies, or provide the references themselves. Obscure or non peer reviewed journals don’t count. Nor should there only be one study showing benefit (it should be a really compelling article if there is only one).

3) What are the alternatives?

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