Consumer health a guide to intelligent decisions 9th edition pdf

Consumer Health

A Guide to Intelligent Decisions

9TH EDITION

STEPHEN BARRETT WILLIAM M. LONDON MANFRED KROGER

HARRIET HALL ROBERT S. BARATZ

9TH EDITION

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BARRETT LONDON KROGER HALL

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Make Good Decisions about Your Health Care The most comprehensive consumer health text available, Consumer Health: A Guide to Intelligent Decisions offers a panoramic view of the health marketplace. You’ll learn how to sharpen your critical consumer skills so you can distinguish valid health claims from those that are fraudulent or misleading. By offering science-based facts and guidelines, Consumer Health provides the tools you need to make smart decisions about health care products and services for yourself and your family.

Some of the many new and revised topics include:

Updated information on health care economics, refl ecting the most recent legislation and debates regarding insurance and mandatory coverage and how it affects you.

New and expanded material on complementary and alternative medicine, including the latest on fad diseases, “energy medicine,” accreditation standards, and diploma mills.

Current research and information on nutrition and weight management, including “detox” products, the Dietary Guidelines for Americans 2010, and the newly-designed MyPlate food guide.

About the Authors

Stephen Barrett, M.D., has been investigating and writing about consumer health issues for more than 40 years. His Quackwatch website serves as a clearinghouse for information on health frauds and quackery. He serves as Vice President of the Institute for Science in Medicine, is a Fellow of the Committee for Skeptical Inquiry, edits Consumer Health Digest, and is a peer-review panelist for several top medical journals.

William M. London, Ed.D., M.P.H., is a health educator and professor in the Department of Public Health at California State University, Los Angeles. He is also the associate editor of Consumer Health Digest, co-host of the Credential Watch website, and a member of the editorial board of the journal FACT (Focus on Alternative and Complementary Therapies: An Evidence-Based Approach).

Manfred Kroger, Ph.D., is Professor Emeritus of Food Science and Professor Emeritus of Science, Technology and Society at The Pennsylvania State University, where he has won several teaching awards. He is a science communicator for the Institute of Food Technologists and is scientifi c editor of its online journal, Comprehensive Reviews in Food Science and Food Safety. He is also associate editor of the Journal of Food Science and a scientifi c advisor to the American Council on Science and Health.

Harriet Hall, M.D., a retired family physician and colonel, served 20 years in the U.S. Air Force. Her administrative positions included chief of clinic services and director of base medical services. She now devotes her time to investigating questionable health claims and writing and lecturing about pseudoscience, quackery, “alternative medicine,” and critical thinking. She is a contributing editor to both Skeptical Inquirer and Skeptic magazines and a founding member and editor of the Science-Based Medicine blog.

Robert S. Baratz, M.D., D.D.S., Ph.D., an expert on quality of care, is president and medical director of South Shore Health Care in Braintree, Massachusetts, where he practices internal, oral, and occupational medicine. He serves on the medical faculties of Boston University and Tufts University and is used as a consultant by many regulatory and law enforcement agencies.

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CONSUMER HEALTH A Guide to Intelligent

Decisions

STEpHEN BARRETT, MD Author, Editor, Consumer Advocate Webmaster, Quackwatch Network

Chapel Hill, North Carolina

WiLLiAM M. LONDON, EDD, MpH Professor, Department of Public Health

California State University Los Angeles, California

MANfRED KROgER, pHD Professor Emeritus of Food Science

Professor Emeritus of Science, Technology and Society The Pennsylvania State University

University Park, Pennsylvania

HARRiET HALL, MD Retired Family Physician

Puyallup, Washington

ROBERT S. BARATz, MD, DDS, pHD President and Medical Director, South Shore Health Care

Braintree, Massachusetts

Ninth Edition

CONSUMER HEALTH: A gUiDE TO iNTELLigENT DECiSiONS, NiNTH EDiTiON

Published by McGraw-Hill, a business unit of The McGraw-Hill Companies, Inc., 1221 Avenue of the Americas, New York, NY 10020. Copyright © 2013 by The McGraw-Hill Companies, Inc. All rights reserved. Previous editions © 2007, 2002, 1997. Printed in the United States of America. No part of this publication may be reproduced or distributed in any form or by any means, or stored in a database or retrieval system, without the prior written consent of The McGraw-Hill Companies, Inc., including, but not limited to, in any network or other electronic storage or transmission, or broadcast for distance learning.

Some ancillaries, including electronic and print components, may not be available to customers outside the United States.

RECYCLED

This book is printed on recycled, acid-free paper containing 10% postconsumer waste.

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ISBN 978-0-07-802848-9 MHID 0-07-802848-5

Vice President & Editor-in-Chief: Michael Ryan Vice President & Director of Specialized Publishing: Janice M. Roerig-Blong Publisher: David Patterson Executive Editor: Christopher Johnson Marketing Coordinator: Colleen P. Havens Development Editor: Darlene Schueller Senior Project Manager: Lisa Bruflodt Cover Designer: Studio Montage, St. Louis, Missouri Design Coordinator: Brenda A. Rowles Buyer: Sue Culbertson Media Project Manager: Sridevi Palani Primary Typeface:11-point Times Composition: Stephen Barrett, M.D. Printer: Quad/Graphics

All credits appearing on page or at the end of the book are considered to be an extension of the copyright page.

Library of Congress Cataloging-in-Publication Data

Consumer health : a guide to intelligent decisions / Stephen Barrett ...[et al.]. — 9th ed. p. cm. Includes bibliographical references and index. ISBN 978-0-07-802848-9 (alk. paper) 1. Medical care. 2. Health products. 3. Quacks and quackery. 4. Consumer education. I. Barrett, Stephen, 1933- RA410.5.C645 2013 362.1--dc23 2011039127

www.mhhe.com

Stephen Barrett, M.D., a retired psychiatrist who resides near Chapel Hill, North Carolina, has achieved national renown as an author, editor, and con- sumer advocate. In addition to heading Quackwatch, he is vice president of the Institute for Scientific Medicine and a Fellow of the Committee for Skeptical Inquiry (formerly called CSICOP). In 1984, he received an FDA Commissioner’s Special Citation Award for Public Service in fighting nutrition quackery. In 1986, he was awarded honorary membership in the American Dietetic Association. From 1987 through 1989, he taught health education at The Pennsylvania State University. In 2001 he received the Distinguished Service to Health Educa- tion Award from the American Association for Health Education. He has been listed in Who’s Who in America since 2001 and is also listed in Who’s Who in Science and Engineering, Who’s Who in Medicine and Health Care, and Who’s Who in the World. An expert in medical communications, Dr. Barrett operates 25 Web sites; edits Consumer Health Digest (a free weekly electronic newsletter); is medical editor of Prometheus Books; and is a peer-review panelist for several top medical journals. His 51 books include The Health Robbers: A Close Look at Quackery in America and seven of the previous editions of Consumer Health. His other major works include Dubious Cancer Treat- ment, published by the Florida Division of the American Cancer Society; Health Schemes, Scams, and Frauds, published by Consumer Reports Books; The Vitamin Pushers: How the “Health Food” Industry Is Selling America a Bill of Goods, published by Prometheus Books; and Reader’s Guide to “Alternative” Health Methods, published by the American Medical Associa- tion. His Quackwatch Web site, which serves as a clear- inghouse for information on health frauds and quackery, has won more than 70 honors and awards. Since moving to North Carolina in 2007, he has been swimming com- petitively and has won 25 state championship events.

William M. London, Ed.D., M.P.H., is a professor in the Honors College and the Department of Public Health at California State University, Los Angeles. He

is also associate editor of Consumer Health Digest, co-host of the Credential Watch Web site, a consultant to the Committee for Skeptical Inquiry, a Quackwatch advisor, an advisor to the American Council on Science and Health (ACSH), a founding fellow of the Institute of Science in Medicine, a member of the review board of the American Journal of Health Behavior, and a member of the International Editorial Board of the journal FACT (Focus on Alternative and Complementary Therapies: An Evidence-Based Approach). He was an associate professor and chair of the Department of General Studies at Charles Drew University of Medicine and Science, where he led the initiation of the Master’s Program in Urban Public Health. He has also been an associate professor of health education at Kent State University; founding president of the Ohio Council Against Health Fraud; president of the National Council Against Health Fraud; faculty mentor in public health at Walden Univer- sity; professor of Health Sciences at Touro University International; associate professor and director of the Graduate Program in Health Care Management at Col- lege of St. Elizabeth; director of public health for ACSH; director of communications at Columbia University’s Mailman School of Public Health; and executive direc- tor of RAP, Inc., a nonprofit mental health and senior citizens service agency in Genesee County, New York.

Manfred Kroger, Ph.D., is Professor Emeritus of Food Science and Professor Emeritus of Sci- ence, Technology and Society at The Pennsylvania State University, where he has won several teaching awards. He is a science communicator for the Institute of Food Technologists and is scientific editor of its online journal, Comprehensive Reviews in Food Science and Food Safety. He also serves as associate editor of the Journal of Food Science, an ACSH scientific advisor, and a technical editor for Prometheus Books. He has conducted research in analytical chemistry (pesticide residues), food composition, fermented milk products, and dairy processing technology. Even though retired, he remains professionally active at Penn State and nation- ally and internationally. His university courses included

About the Authors

iii

food laws and regulations, toxicology, introductory food science, dairy technology, and a very popular university- wide general education course entitled “Food Facts and Fads.” His other professional activities include lecturing at public and professional meetings, expert testimony in court and at government hearings, and translation of German writings. In 1999 he was elected as a Fellow of the Institute of Food Technologists. In 2003, he served as the editor of the Proceedings of the 12th World Congress of Food Science and Technology.

Harriet Hall, M.D., is a retired family physician who resides in Puyallup, Washington. She served for 20 years in the U.S. Air Force, from which she retired in 1989 as a full colonel. In addition to practicing family medicine and flight medicine, she held administrative positions including Chief of Aerospace Medicine and Director of Base Medical Services. Since retiring, Dr. Hall has devoted her time to investigating questionable health claims and writing and lecturing about pseudo- science, quackery, “alternative medicine,” and critical thinking. She is a contributing editor to both Skeptical Inquirer and Skeptic magazines and writes the latter’s “SkepDoc” column. She is also a founding member and editor of the Science-Based Medicine blog; an advisor to the Quackwatch network; an editorial review board member for the Natural Medicines Comprehensive Da- tabase; a Fellow of the Committee for Skeptical Inquiry; and a founding fellow and board member emerita of the Institute for Science in Medicine. Her 2008 book, Women Aren’t Supposed to Fly: The Memoirs of a Female Flight Surgeon, describes how she became a pilot and helped bring about equality for women physicians in the Air Force. Her Web site is www.skepdoc.info.

Robert S. Baratz, M.D., D.D.S., Ph.D.,who contrib-uted mainly to the medical and dental chapters of this book, is an internist, dentist, and researcher who resides in Newton, Massachusetts. The founder of four companies, he has also served as medical director for two others in the medical device and pharmaceutical industries. He has been involved with issues regarding the safety and proper use of drugs and biomaterials since 1980. He has served on the medical and dental faculties of Northwestern and Tufts universities. Currently he serves on the faculty of Boston University School of Medicine, having initially been appointed in 1976. His broad knowledge of interactions of materials and the body has been sought by numerous licensing boards, regulatory agencies, universities, government agencies, insurance companies, and professional associations. He is also an expert in medical database applications and analyses. Dr. Baratz has worked for more than 25 years in dental and medical practice for private, public, and government entities, including the Department of Veterans Affairs, The Daughters of Charity, and Beth Israel Hospital in Boston. He has also worked for the Agency for International Development. Currently he is President and Medical Director of South Shore Health Care in Braintree, Massachusetts, where he practices internal and occupational medicine. He has also served as NCAHF President; a scientific advisor to ACSH; and President of International Medical Consultation Services, Inc., of Newton, Massachusetts. In 1992, the American Dental Association gave him a Presidential Citation for his work in advancing oral public health. He has been listed in Who’s Who in America, Who’s Who in the World, and Who’s Who in Science and Engineering.

About the Authorsiv

More is known today about achieving and maintain-ing good health than ever before. Life expectancy is at an all-time high, and although there is still much room for improvement, health-related accomplishments have exceeded the fondest dreams of past visionaries. This progress has been partly due to a safer environ- ment that includes cleaner water, safer food, and better living space. Yet we hear plenty of news about the en- vironment that concerns us. Preventive and therapeutic medical care have advanced tremendously, yet we worry about the risks associated with immunization, cancer therapies, prescription drugs, surgery, and many other methods of treatment. How can we resolve our concerns and reap the benefits of modern scientific discoveries? The key is to become well-informed. The challenges involved are enormous. The health marketplace—the world of commercial activity for health-related products and services—is complex and dynamic. The Internet offers vast amounts of informa- tion, but much of it is not trustworthy. Health concerns can be overwhelming, especially for people confronted with medical crises. Quackery is more pervasive and far trickier than most people realize. (As noted by the late James Harvey Young, Ph.D., “Quacks never sleep.”) Health-care costs continue to rise despite numerous reform efforts. The rapidly growing older adult popula- tion faces a bewildering array of choices and obstacles for obtaining and paying for appropriate health care. It can also be difficult to determine what health care actu- ally costs and to obtain the best prices. In addition, many people lack access to adequate health care because of cultural, transportation, language, and economic barriers. Government and private agencies protect consumer rights in some ways but not others. The health-care industry is accountable to consumers to some extent, but quality is often elusive and abuses persist. Some scams are even facilitated by legislation and government policies. Consumer advocacy calls for justice and fair play in the marketplace. Yet many self-appointed “consumer advocates” do not act in the public’s interest. Although some are sincere and make a contribution, others engage in irrational business bashing or act from motives of per- sonal aggrandizement. Some business trade associations even pose as “consumer groups” and seek self-serving legislation.

Consumer Health offers a panoramic view of the health marketplace. It explains and supports the scientific methods that are essential for validating claims about how products and services affect health. It can help you to: • Understand how medical facts are determined and where

to get appropriate information and advice • Avoid wasting money on unnecessary, ineffective, or unsafe

products and services • Take care of yourself and minimize your need to spend

money on health products and services • Choose appropriate health products and services to meet

your needs • Get the most value out of your health dollars • Optimize benefits from encounters with health-care provid-

ers and facilities while minimizing the potential for harm • Assert and protect your rights • Set reasonable expectations for what health care can do • Evaluate how political issues affect access to health-related

innovations and accountability of marketers

The key to intelligent decision-making is to use relevant and accurate sources of information. Consumer Health is both an introductory text and a reference book on the opportunities and pitfalls of the health market- place. The various chapters offer hundreds of practical tips; the Appendix provides a comprehensive list of trustworthy sources. You will get the most out of the book by using the detailed Index to search for information and the Glossary for definitions of terms that might be unfamiliar. We also operate many Web sites that can supplement your coursework. Consumer Health Sourcebook (www. chsourcebook.com) provides hyperlinks to dependable online sources. It also links to Consumer Health Digest, a free weekly e-mail report of relevant news. Internet Health Pilot (www.ihealthpilot.org) is a gateway to ad- ditional trustworthy information. Quackwatch (www. quackwatch.org) and its many subsidiary sites provide comprehensive articles about quackery, health fraud, and consumer health strategy. All of these sites are accessible free of charge. Visiting them is a good way to enhance your learning experience.

Stephen Barrett, M.D. William M. London, Ed.D, M.P.H. Manfred Kroger, Ph.D. Harriet Hall, M.D. Robert S. Baratz, M.D., D.D.S., Ph.D.

To the Reader

v

Preface for Instructors

vi

As have previous editions, this ninth edition of Consumer Health emphasizes the opportunities and pitfalls in the health marketplace and aims to help students protect their health and their pocketbook.

Goal for This Revision The book’s fundamental purpose is to provide trustwor- thy information and guidelines to enable people to select health products and services intelligently. This edition culminates our review of thousands of books, journal articles, Web sites, agency reports, and feature stories, as well as our own original investigations and critiques. Readers will find the information useful in applying the caveat emptor (let the buyer beware) concept to the health marketplace. The underlying principles of consumer protection were identified in the Consumer Bill of Rights promul- gated by President John F. Kennedy and have guided the development of this textbook. President Kennedy declared that consumers have the right to purchase safe products and services, to be correctly informed, to freely choose products and services, and to be heard by the government and others when injustices occur. We strongly support consumer awareness and efforts to as- sert and protect these rights.

Intended Audience Consumer Health has been designed as a sole required textbook for consumer health courses. Selected chapters of the book (see “Publisher’s Notice” box) can also be useful as required or supplemental readings for other courses in health education; community health; public health; family and consumer sciences; consumer edu- cation; health psychology; medical sociology; human ecology; and social welfare. School districts will find Consumer Health useful as a reference for teachers and students as well as an aid in curriculum development. Professional health-care providers can use this text to prepare for public presentations and can make it avail- able in their offices for perusal by clients.

Timeliness of References Every topic in this book has been carefully researched. In most cases, the more than 1500 cited references

represent the latest authoritative information we could locate. Many more systematic reviews and meta-analyses have been cited in this edition than in previous editions. Some references may seem outdated. However, unless otherwise stated, we believe these still reflect the cur- rent marketplace. References more than 10 years old are included for historical reasons or because they provide insights or document the source of well-articulated quo- tations that are still timely. Some reports published long ago are the only ones available that address important concepts. Chapter 1 provides information on how to read cita- tions and locate the references cited in the text. Those that

Publisher’s Notice

McGraw-Hill Create™ Craft your teaching resources to match the way you teach! With McGraw-Hill Create, you can easily rear- range chapters, combine material from other content sources, and quickly upload content you have writ- ten like your course syllabus or teaching notes. Find the content you need in Create by searching through thousands of leading McGraw-Hill textbooks. Arrange your book to fit your teaching style. Create even allows you to personalize your book’s appearance by selecting the cover and adding your name, school, and course information. Order a Create book and you’ll receive a complimentary print review copy in 3–5 business days or a complimentary electronic review copy (eComp) via e-mail in minutes. Go to www.mcgrawhillcreate. com today and register to experience how McGraw-Hill Create empowers you to teach your students your way.

Electronic Textbook Option This text is offered through CourseSmart for both in- structors and students. CourseSmart is an online resource where students can purchase the complete text online at almost half the cost of a traditional text. Purchasing the eTextbook allows students to take advantage of CourseSmart’s Web tools for learning, which include full text search, notes and highlighting, and e-mail tools for sharing notes between classmates. To learn more about CourseSmart options, contact your sales representative or visit www.CourseSmart.com.

Preface for Instructors vii

may be especially useful for students seeking additional information are listed with boldface numbers. When citing material on Web sites, we report the publication date when the site identifies it. When no date is posted, we report when we last accessed the page.

Internet Integration Another important feature of this edition is its integra- tion with our Consumer Health Sourcebook Web site (www.chsourcebook.com). The “References” section of this site provides links to many full-text articles and to abstracts of most of the journal articles. Suggestions for course objectives, teaching/learning activities, a sample course outline, and links to hundreds of organizations that provide trustworthy information are also posted. We encourage students and instructors to subscribe to Consumer Health Digest, a free weekly e-mail news- letter edited by Dr. Barrett with help from Dr. London. (To subscribe, see www.ncahf.org/digest/chd.html.) At the publisher’s Web site (www.mhhe.com/bar- rett9e), instructors will find sample test questions and PowerPoint presentations to use with the book.

Organization As in the eighth edition, the text is broadly divided into six parts: I. Dynamics of the Health Marketplace focuses on past and present problems. After defining the major consumer health issues, it discusses how the scientific method is used to determine medical truths, how con- sumers can separate fact from fiction, how frauds and quackery can be identified, and how advertising and other marketing activities influence consumer decisions. II. Health-Care Approaches covers basic medical care and the services of many types of practitioners and facilities. III. Nutrition and Fitness integrates what consum- ers need to know about the extremely important topics of nutrition, weight control, and exercise. Its chapters provide the necessary tools to distinguish science-based methods from fads, fallacies, and scams. IV. Personal Health Concerns provides a guide to preventing and managing health problems, including several in which self-care is very important. Separate chapters cover cardiovascular disease and cancer with an emphasis on the choices consumers face. V. Other Products and Services covers a myriad of other subjects that affect most, if not all, consumers. These include drug products, skin care and image en- hancement, contraceptive methods, vision and hearing

aids, other devices, death-related services, and health- care facilities. VI. Protection of the Consumer focuses on legal and economic issues involved in protecting consumers. These include health insurance, health-care financing, consumer-protection laws and agencies, and strategies for intelligent consumers.

Features and New Material All features from the eighth edition have been retained. Many chapters contain vignettes (“Personal Glimpses”) to stimulate reader interest and “Consumer Tip” and “Consumer Insight” boxes that emphasize key points. Many checklists and “It’s Your Decision” boxes reflect “real-life” decisions that readers may face. The “Key Concepts” box at the beginning of each chapter states what we believe are the most important lessons to be learned from the chapter material. Extensive searches of the scientific literature, court documents, and other relevant reports over an 18-month period have provided information to update the contents of this edition.

• Chapter 1 (Consumer Health Issues) introduces the im- portant issues facing consumers in today’s marketplace. New material about cognitive bias explains how distortions of thinking can lead to inaccurate conclusions and faulty judgment.

• Chapter 2 (Separating Fact from Fiction) describes how the scientific community strives to determine what is factual and how consumers face an often bewildering array of information that can be unbalanced, inaccurate, and even fraudulent.

• Chapter 3 (Frauds and Quackery) explains why people are vulnerable and tells how to avoid quack practices. New material notes how loss of faith in many of our once-trusted institutions has made quack claims seem more credible.

• Chapter 4 (Advertising and Other Promotional Activities) describes how sellers market their wares and notes how the multilevel marketing industry thwarted a proposed Federal Trade Commission rule intended to curb its misleading practices.

• Chapter 5 (Science-Based Health Care) describes the training and professional activities of physicians and many ancillary providers. It also incorporates U.S. Preventive Services Task Force’s latest conclusions about screening tests, including its skepticism about routine PSA testing.

• Chapter 6 (Mental and Behavioral Help) provides a com- prehensive guide to mental help and notes that psychiatrists are shifting away from psychotherapy. The section on ques- tionable practices and practitioners has been expanded and cautions against the use of poorly trained “life coaches.”

• Chapter 7 (Dental Care) provides a comprehensive dental guide and warns against the increasing use of questionable

Preface for Instructorsviii

screening devices and expensive cosmetic dental proce- dures intended to create a “perfect bite.”

• Chapter 8 (The “CAM” Movement) describes a multitude of theories and practices that remain unsubstantiated and lack a scientifically plausible rationale. It also notes the failure of accrediting agencies to control the spread of unscientific teachings in professional schools (including medical schools).

• Chapter 9 (A Close Look at Chiropractic) spotlights the in- fluence of chiropractic on the consumer health marketplace and summarizes the latest research on spinal manipulation.

• Chapter 10 (Basic Nutrition Concepts) incorporates the latest Dietary Guidelines for Americans and the USDA Food Guidance System (Choose MyPlate) and tells where to get trustworthy nutrition information and advice.

• Chapter 11 (Nutrition Fads, Fallacies, and Scams) includes up-to-date evaluations of dietary supplement products and herbal products and background material on promoters of nutritional misinformation.

• Chapter 12 (Weight Control) notes the alarming increase of obesity in the United States and discusses appropriate and inappropriate weight-control measures.

• Chapter 13 (Fitness Concepts, Products, and Services) reviews the fundamental concepts typically addressed in personal health courses, but also includes important details about practitioners, information resources, products, ser- vices, popular misconceptions, and scams.

• Chapter 14 (Personal Health and Safety), which is a new chapter, focuses on health promotion, injury prevention, risk perception, self-care, and the management of asthma, diabetes, high blood pressure, and other chronic condi- tions. It also notes how information from the Internet and elsewhere can help or undermine prudent behavior. A new section warns against the widely circulating myths that undermine public health efforts.

• Chapter 15 (Cardiovascular Disease) contains new and updated information about risk factors for coronary heart disease and stroke and provides guidelines for reducing the risks.

• Chapter 16 (Cancer) covers cancer causation, prevention, diagnosis, and prognosis and contrasts science-based and dubious treatments. The new topics include vaccination against the human papilloma virus (HPV) and dubious information sources.

• Chapter 17 (Drug Products) includes new information about commonly used nonprescription (over-the-counter) drugs and how to save money on drug costs.

• Chapter 18 (Skin Care and Image Enhancement) covers a wide variety of topics related to skin care plus new material about image-enhancement schemes and frauds.

• Chapter 19 (Sexual and Reproductive Health) covers products and services related to sexual and reproductive functions. It includes new and updated information about birth control, birthing options, and hormone-replacement therapy, and prevention of sexually transmitted diseases.

• Chapter 20 (Health Devices) contains updated information about device regulation and expanded coverage of question- able devices that have been flooding the health marketplace. New topics include spinal decompression machines, “de- toxification” devices, and alleged performance enhancing bracelets.

• Chapter 21 (Coping with Death) provides current informa- tion on advance directives and organ donation and cautions about stem-cell clinics and “biologic age” testing.

• Chapter 22 (Health-Care Facilities) notes how the delivery of health-care services is changing and describes the salient features of various options. It also provides advice on how to choose among the various alternatives.

• Chapter 23 (Health Insurance) describes the basic types and features of health insurance and outlines the major provisions of the Patient Protection and Affordable Care Act.

• Chapter 24 (Health-Care Financing) provides the latest available statistics on national health expenditures, states why insurance reform has been desperately needed, and describes the decades-long struggle to control costs and increase access to medical care.

• Chapter 25 (Consumer Laws, Agencies, and Strategies) details the regulatory and educational activities of the U.S. Food and Drug Administration and the FTC; describes physician regulation; and indicates what consumers can do to help improve the health marketplace.

• The Appendix provides comprehensive lists of agencies and organizations that offer trustworthy information. The Consumer Health Sourcebook Web site links to most of them.

• The Glossary clarifies important jargon used in the book and defines other terms of interest to health consumers.

Acknowledgments The authors thank John E. Dodes, D.D.S., who reviewed the dental care chapter; Walter A. Zelman, Ph.D., of California State University (Los Angeles), who offered helpful suggestions for the chapters on insurance and health-care financing. The photograph on page 154 is reproduced with permission from Aurora & Quanta Productions, Portland, Maine. The VIPPS logo on page 358 appears with permission of the National Association of Boards of Pharmacy. Our project coordinator, who guided production and permitted this text to remain a powerful voice, was Vicki Malinee of Van Brien & Associates. Freelance editor Sarah West, of Belleville, Illinois, did her usual superb job of copy editing. We also thank the many instructors who continue to provide suggestions for new research and topics to include in the text.

i. DyNAMiCS Of THE HEALTH MARKETpLACE 1. Consumer Health Issues, 1 Misleading Information, 2 Quackery and Health Fraud, 5 Problems with Products, 6 Problems with Services, 7 Problems with Costs and Access, 8 Problems with Risk Perception, 8 The Need for Consumer Protection, 8 Intelligent Consumer Behavior, 10

2. Separating Fact from Fiction, 13 How Facts Are Determined, 14 Peer Review, 17 Trustworthiness of Sources, 19 Prudent Use of the Internet, 27 Further Suggestions for Consumers, 30

3. Frauds and Quackery, 33 Definitions, 34 Scope, 35 Vulnerability, 36 Hazards, 37 Common Misconceptions, 38 Recognizing Quackery, 41 Conspiracy Claims, 42 The Freedom-of-Choice Issue, 43

4. Advertising and Other Promotional Activities, 45 Psychologic Manipulation, 46 Puffery, Weasel Words, and Half Truths, 48 Marketing Outlets, 49 Professional Advertising, 49 Marketing by Hospitals, 50 Prescription Drug Marketing, 51 Nonprescription Drug Advertising, 53 Tobacco Promotion, 53 Food Advertising, 54 Dietary Supplement Promotion, 54 Mail-Order Quackery, 57 Weight-Control Promotions, 59 Youth and Beauty Aids, 59

Exercise and Fitness Products, 60 Program-Length Infomercials, 60 Multilevel Marketing (MLM), 61 Telemarketing Schemes, 62 Industry Self-Regulation, 62 Regulatory Agencies, 63

ii. HEALTH-CARE AppROACHES 5. Science-Based Health Care, 65 Health-Care Personnel, 66 Choosing a Physician, 70 Basic Medical Care, 75 Surgical Care, 80 Quality of Medical Care, 82 The Intelligent Patient, 85

6. Mental and Behavioral Help, 89 Who Should Seek Help?, 90 Mental Health Practitioners, 90 Psychologic Methods, 93 Drug Therapy, 94 Electroconvulsive Therapy, 95 Psychosomatic Disorders, 96 Inpatient Care, 96 Help for Addictive Behavior, 96 Selecting a Therapist, 97 Questionable “Self-Help” Products, 98 Questionable Practices, 100 Mismanagement of Psychotherapy, 107

7. Dental Care, 111 Dentists, 112 Allied Dental Personnel, 112 Tooth Decay, 113 Fluoridation, 114 Periodontal Disease, 115 Self-Care, 116 Dental Products, 117 Dental Restorations, 119 Endodontics (Root Canal Therapy), 120 Orthodontics, 120 Dentures, 121 Dental Implants, 121

Contents

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Dental X-Ray Procedures, 121 Questionable Procedures, 122 Dental Quackery, 124 Choosing a Dentist, 126

8. The “CAM” Movement, 131 Classification, 132 Popularity, 134 Common Themes, 135 Homeopathy, 137 Acupuncture and TCM, 141 Naturopathy, 143 Natural Hygiene, 145 Iridology, 145 Reflexology, 146 Cranial Therapy, 147 Aromatherapy, 147 “Energy Healing,” 147 Massage Therapy, 148 Psychic Healing, 148 Astrology, 151 Transcendental Meditation, 152 Unscientific Medical Practices, 154 Supportive Organizations 158 “Medical Freedom” Laws, 158 The NIH Center for Complementary and Alternative Medicine (NCCAM), 158

9. A Close Look at Chiropractic, 163 Historical Perspective, 164 Chiropractic Philosophy, 165 Chiropractic Education, 168 Research Findings, 169 Problems for Consumers, 170

iii. NUTRiTiON AND fiTNESS 10. Basic Nutrition Concepts, 175 Major Food Components, 176 Meeting Nutrient Needs, 179 Food-Group Systems, 182 Evaluating Your Diet, 183 Guidelines for Infants and Toddlers, 183 Vegetarianism, 184 “Fast Food,” 186 Nutrients of Special Concern, 186 Nutrition Labeling, 187 Trustworthy Information Sources, 191

11. Nutrition Fads, Fallacies, and Scams, 195 Food Faddism and Quackery, 196 Dietary Supplements, 197 Megavitamin Claims vs Facts, 203 Appropriate Use of Supplements, 206 “Organic” Foods, 206 “Health” and “Natural” Foods, 207 Raw Foods and “Juicing,” 213 “Medicinal” Use of Herbal Products, 213 Macrobiotic Diets, 219 Dubious Diagnostic Tests, 219 Promotion of Questionable Nutrition, 221 Promotional Organizations, 227 Prominent Individual Promoters, 228

12. Weight Control, 233 Basic Concepts, 234 Eating Disorders, 238 The U.S. Weight-Loss Marketplace, 240 Questionable Diets, 240 Prescription Drugs, 243 Nonprescription Products, 244 Low-Calorie Products, 246 Bariatric Surgery, 248 Dubious Products and Procedures, 248 Federal Trade Commission Actions, 250 Weight-Control Organizations, 252 Suggestions for Weight Control, 254

13. Fitness Concepts, Products, and Services, 259 Public Perceptions, 260 Benefits of Exercise, 261 Types of Exercise, 262 Components of Fitness, 262 Starting an Exercise Program, 263 Personal Trainers, 269 Sports Medicine Specialists, 270 Exercise Equipment and Supplies, 270 Exercise Facilities, 276 Martial Arts Training, 278 Children’s Exercise Centers, 278 Exercise While Traveling, 278 Exercise and Weight Control, 279 Nutrition for Athletes, 279 Anabolic Steroids, 281 Other “Ergogenic Aids,” 282

Contentsx

iV. pERSONAL HEALTH CONCERNS

14. Personal Health and Safety, 287 Types (Levels) of Prevention, 288 Health-Promoting Behaviors, 288 Safety Measures, 291 Indoor Air Quality, 291 Risk Perception, 292 Self-Diagnosis, 292 Managing Chronic Disease, 295 Self-Help Advice, 300 Self-Help Groups, 301 Questionable Self-Help Devices, 301 Internet Considerations, 301

15. Cardiovascular Disease, 305 Significance of Cardiovascular Disease, 306 Risk Factors for Coronary Heart Disease, 306 Blood Lipid Levels, 307 Cholesterol Guidelines, 309 Dietary Modification, 311 Lipid-Lowering Drugs, 315 Preventive Use of Aspirin, 317 Questionable Preventive Measures, 318 High Blood Pressure, 320 Heart Attacks, 322 Diagnostic Tests, 322 Surgery to Restore Blood Flow, 324 Cardiac Rehabilitation Programs, 326

16. Cancer, 329 Avoidable Causes of Cancer, 330 Preventive Measures, 331 Diagnosis, 331 Prognosis, 332 Evidence-Based Treatment Methods, 332 Diet and Cancer Prevention, 333 Susceptibility to Cancer Quackery, 334 Questionable Methods, 335 Promotion of Questionable Methods, 344 Trustworthy Information Sources, 345 Treatment Guidelines, 345 Consumer Protection Laws, 346

V. OTHER pRODUCTS AND SERViCES

17. Drug Products, 349 Medication Types, 350

Pharmacists, 351 Prescription Drugs, 353 Generic vs Brand-Name Drugs, 354 Drug Interactions, 355 Drug Recalls, 355 Counterfeit Drugs, 355 Internet Pharmacy Sales, 358 Over-the-Counter Drugs, 359 External Analgesics, 360 Internal Analgesics, 361 Antacids and Other Heartburn Remedies, 364 Antimicrobial Drug Products, 364 Cough and Cold Remedies, 365 Sore-Throat Products, 367 Ophthalmic Products, 367 Diarrhea Remedies, 368 Anti-Hemorrhoidals, 368 Laxatives, 369 Smoking Deterrents, 370 Stimulants for Fatigue, 371 Sleep Aids, 371 Motion Sickness Remedies, 372 Iron-Containing Products, 372 Home Medicine Cabinet, 373 Prudent Use of Medication, 373

18. Skin Care and Image Enhancement, 379 Cosmetic Regulation, 380 Soaps and Cleansers, 381 Moisturizers, 381 Questionable Claims, 382 Wrinkles and Age Spots, 383 Fade Creams, 384 Antiperspirants and Deodorants, 384 Acne Care, 384 Head Hair and Scalp Care, 386 Hair Loss, 388 Tattoos and Permanent Makeup, 389 Body Piercing, 390 Treatment of Common Foot Problems, 390 Poison Ivy, 390 Insect Repellents, 391 Sun Protection, 391 Camouflage Cosmetics, 393 Cosmetic Procedures, 393 Bogus Breast and Penis Enlargement Claims, 398

Contents xi

19. Sexual and Reproductive Health, 401 Menstrual Products, 402 Menstrual Problems, 403 Vaginal Hygiene, 404 Vaginitis, 405 “Jock Itch,” 405 Sexually Transmitted Diseases, 405 Contraception, 406 Voluntary Abortions, 410 Infertility, 411 Genetic Testing and Prenatal Counseling, 411 Pregnancy and Delivery, 411 Cord Blood Banking, 414 Infant Feeding, 414 Treatment of Menopausal Symptoms, 415 Alleged Sex Enhancers, 416 Genuine Help for Erectile Dysfunction, 416

20. Health Devices, 419 Medical-Device Regulation, 420 Vision Products and Services, 421 Hearing Aids, 427 Humidifiers and Vaporizers, 429 Personal Emergency Response Systems, 430 Latex Allergy, 430 Dubious Water Purifier Promotions, 430 Spinal Decompression Machines, 431 Quack Devices, 431 Consumer Strategy, 435

21. Coping with Death, 437 Advance Directives, 438 Viatical Settlements, 441 Donations of Organs and Tissues, 442 Hospice Care, 443 Euthanasia and Assisted Suicide, 444 Reasons for an Autopsy, 445 Body Disposition, 445 Coping with Grief, 448 Life-Extension/Anti-Aging Quackery, 448

22. Health-Care Facilities, 453 Accreditation, 454 Outpatient Medical Facilities, 454 Hospitals, 457 Home Care Services, 460

Contents

Assisted Living Facilities, 461 Nursing Homes, 461 Continuing Care Retirement Communities, 464

Vi. pROTECTiON Of THE CONSUMER

23. Health Insurance, 467 Background, 468 Comprehensive Medical Insurance, 468 Contract Provisions, 471 Types of Plans, 474 Consumer-Directed Expense Accounts, 476 “Concierge Medicine,” 476 Indemnity vs Managed Care, 477 Loss Ratios, 478 Choosing a Plan, 478 Medicare, 480 Medicaid, 481 Other Government-Sponsored Programs, 481 Long-Term–Care Insurance, 481 Dental Insurance, 482 Collection of Insurance Benefits, 483 Disability Insurance, 484

24. Health-Care Financing, 487 Health-Care Costs, 488 Cost-Control Methods, 492 Insurance Fraud and Abuse, 494 National Health Insurance (NHI), 498

25. Consumer Laws, Agencies, and Strategies, 503 U.S. Food and Drug Administration, 504 Federal Trade Commission, 515 U.S. Postal Service, 517 Other Federal Agencies, 517 State and Local Agencies, 518 Physician Regulation, 518 Nongovernmental Organizations, 519 Consumer Action, 522

Appendix: Trustworthy Sources of Information, 525 Federal Government Agencies, 526 Nongovernmental Organizations, 526

Glossary, 529

Index, 541

xii

Consumer HealtH Issues

Consumer health goes far beyond the decision to buy or not to buy. The ever increasing perplexity of the health care delivery system; the prevalence of myths and misconceptions about health, disease, and remediation; the widespread usage of unproven health products and services; and the rapidly escalating costs of health care have ushered in the need to educate individuals in the proficient, judicious and eco- nomical utilization of health information, products, and services. Niles l. KaplaN1

Evidence clearly demonstrates that people are susceptible to error even when choosing among a handful of alternatives to which they can devote their full attention.

Barry schwartz2

Chapter One

Reprinted with special permission from King Features Syndicate

Part One Chapter One

Part One Dynamics of the Health Marketplace2

• To get the most out of our health-care system, consumers must be knowledgeable and appropriately assertive.

• Virtually all legitimate health products and services have bogus counterparts.

• Intelligent consumers maintain an appropriate level of skepticism and recognize their susceptibility to perceptual distortions and cognitive biases.

• Consumer protection agencies are unable to deal with many of the complaints they receive.

• Everyone in a free society has a stake in maintaining high standards in the health marketplace.

Keep tHese poInts In mInd as You studY tHIs CHapter Key Concepts

Consumer health encompasses all aspects of the marketplace related to the purchase of health products and services. It includes such things as buying a bottle of vitamins, a cold remedy, a dentifrice, or exercise equipment and selecting a physician, dentist, insurance policy, book, Web site, or other source of information. Consumer health has both positive and negative as- pects. Positively, it involves the facts and understanding that enable people to make medically and economically sound choices. Negatively, it means avoiding unwise decisions based on deception, misinformation, or other factors. Worksheet 1-1 provides an opportunity to test your knowledge of consumer health issues.

1. Everyone should have a complete physical examination every year or two. 2. Fluoride toothpaste works so well that water fluoridation is no longer important. 3. It is difficult for busy people to eat a balanced diet. 4. People intelligent enough to graduate from college are unlikely to be victimized by quackery. 5. Accreditation of a school indicates that a regulatory agency considers its teachings sound. 6. Cigarette smoking is the leading cause of preventable death in the United States. 7. Sugar is a major cause of hyperactivity and other childhood behavioral problems. 8. In most states no special training is legally required to offer counseling to the public. 9. Antioxidant supplements have been proven to protect against heart disease, stroke, and cancer. 10. Homeopathic remedies are a safe and effective alternative to many drugs that doctors prescribe. 11. Taking large daily doses of vitamin C can cut the risk of catching colds in half. 12. All people age 21 or older should have their blood cholesterol levels checked once a year. 13. Administering more than one vaccine at a time can overload the immune system. 14. The American Medical Association can revoke the license of a doctor who is practicing improperly. 15. Government reports indicate that the best person to consult for back pain is a chiropractor. 16. Most retailers of dietary supplements and herbal products are well informed about the products they sell. 17. Protein or amino acid supplements help bodybuilders and other athletes improve their performance. 18. The emergency department of a nonprofit hospital is a relatively inexpensive place to get medical care. 19. Natural cancer cures are being suppressed because drug companies don’t want competition. 20. Most health-related books and magazine articles are vetted by experts prior to publication. 21. Government agencies screen many ads for mail-order health products before they are published.

test Your Consumer HealtH I.Q. Worksheet 1–1

T F T F T F T F T F T F T F T F T F T F T F T F T F T F T F T F T F T F T F T F T F

Only #6 and #8 are true. Fifteen correct answers suggests that you are fairly well informed. Twenty correct suggests that you are very well informed.

This chapter comments on misleading information; quackery; health frauds; and problems with health-care products, services, costs, and access. It also outlines the strengths and weaknesses of consumer-protection forces, how consumers make health-related decisions, and the characteristics of intelligent consumers.

mIsleadIng InformatIon Health information has become increasingly voluminous and complex. Even well-trained health professionals can have difficulty sorting out what is accurate and signifi- cant from what is not. Table 1-1 lists questions faced by many of today’s consumers.

Chapter One Consumer Health Issues 3

How can the significance of research reports be judged? How trustworthy are the media? How can trustworthy information sources be located?

What are the best ways to keep up-to-date on consumer health issues?

How can quacks and quackery be spotted? What should be done after encountering quackery or health fraud?

Is it sensible to try just about anything for health problems?

How should advertisements for health products and services be analyzed?

How should physicians, dentists, and other health-care specialists be selected?

What should be done about excessive or unreasonable professional fees?

When is it appropriate to obtain a second opinion about recommended surgery?

What periodic health examinations are advisable? How much should they cost?

Where can competent mental help be obtained? What kinds of toothbrushes and dentifrices are best? Can mouthwashes and dentifrices control the develop- ment of plaque on teeth?

When are dental implants appropriate? Do amalgam fillings pose any health hazard? What rights should buyers and sellers have in the health marketplace?

How trustworthy are chiropractors, naturopaths, and acupuncturists?

Is it advisable for people with back pain to see a chiropractor?

What is the best schedule for vaccinations? Is vaccination with Gardasil prudent? When are self-diagnosis and treatment appropriate? How should a hospital, nursing home, or convalescent facility be selected?

What are the pros and cons of using an ambulatory health-care center?

What facilities are available for people who need long- term care?

How can a balanced diet be selected? Does vegetarian eating make sense? When is it appropriate to use vitamin or mineral supplements?

Do antioxidant supplements prevent future diseases? Should “organic foods” or “health foods” be purchased? Are they worth their extra cost?

Can taking vitamin C supplements prevent or cure colds?

Should extra vitamins be taken during pregnancy?

Will taking calcium supplements help prevent osteoporosis?

Are any herbal products worth taking? How trustworthy is the advice given in health-food stores?

Are food additives dangerous? What is the safe way to lose and control weight? Are diet pills helpful or harmful?

Are electric vibrators and massage equipment useful for weight control or body shaping?

Which exercise equipment provides good value for its cost?

Is it a good idea to join a health club or exercise center? What principles should guide the evaluation and man- agement of blood cholesterol levels?

Can magnetic devices enhance athletic performance? Can any food or dietary measures prevent or influence the course of arthritis or cancer?

Does it make sense to undergo detoxification? How do pain relievers compare? Should laxatives be used? By whom? Is it a good idea to use generic drugs? What products are useful for self-care and family care? What is the best strategy for protecting against sun exposure?

Can any product help to grow, restore, or remove hair? Can wrinkles be removed with any product or with plastic surgery?

What forms of birth control are safest and most effective?

Are over-the-counter pregnancy test kits reliable? Are any over-the-counter drug products effective for menstrual cramps?

What can women do about premenstrual syndrome (PMS)?

Does the patenting of a health device ensure its safety and effectiveness?

How do the different types of contact lenses compare? Who should determine the need for eyeglasses, contact lenses, or a hearing aid?

How safe and effective is surgery to improve vision? Does it make sense to prepay funeral expenses? What services are available for the terminally ill? Which health coverage provides the best protection? How can consumers reduce their health-care costs? How much money should be budgeted for health care? What agencies and organizations help protect consumers?

Which consumer groups are trustworthy? How can one register a complaint about a health prod- uct or service?

Consumer HealtH QuestIons Table 1–1

Part One Dynamics of the Health Marketplace4

The media have tremendous influence. Thousands of radio and television stations broadcast health-related news, commentary, and talk shows. Thousands of maga- zines and newspapers carry health-related items, and thousands of health-related books and pamphlets are published each year. Thousands of books recommend unscientific health practices, as do countless Web sites, blogs, and other computerized information sources. Gunther3 has noted that the mass media have four main functions: to entertain, to inform, to carry adver- tisements, and to make money for their stockholders. In many cases what is transmitted depends on (a) how much it is expected to interest the target audience and (b) how advertisers may feel about it. Larkin,4 for example, has noted that many women’s magazines publish sensational claims and deliberately avoid information that might upset their advertisers. Fast-breaking news should be regarded cautiously. Many reports, though accurate, tell only part of the story.5 Unconfirmed research findings may turn out to

be insignificant. The simplest strategy for keeping up-to- date is to subscribe to trustworthy newsletters and other review sources that place new information in proper perspective (see Chapter 2). Advertising should also be regarded with caution (see Chapter 4). Many advertisers use puffery, “weasel words,” half-truths, imagery, or celebrity endorsements to misrepresent their products. Some marketers use scare tactics to promote their wares. Some attempt to exploit common hopes, fears, and feelings of inadequacy. Cigarette ads have used images of youth, health, vigor, and social acceptance to convey the opposite of what cigarette smoking will do to smokers. Alcohol ads stress fun and sociability and say little about the dangers of excessive drinking. Many ads for cosmetics exaggerate what they can do (see Chapter 18). Food advertising, though not usually deceptive, tends to promote dietary imbalance by emphasizing snack foods that are high in fat and calories. Radio and television infomercials abound with promoters of health misinformation.

Physicians were once able to carry in their little black bags most of the tools needed to diagnose and treat pa- tients. They could store in their own minds the informa- tion necessary for the majority of their work. Experience broadened one’s ability to handle difficult or unusual cases, and patients relied upon their physicians as the pri- mary source of infor mation on both health and disease. The logarithmic increase in biomedical knowledge ... has changed the doctor -patient relationship dramatically. The history and physical examination, once the basis for all medical practice, are now only the first exploratory steps in the process of making a diagnosis and planning a treat ment regimen. The immense proliferation of labora- tory tests, imaging techniques, and diagnostic procedures is stunning. The specialties of medicine have further branched into subspecialties as basic research and clini- cal knowledge have greatly expanded. Medical journals and textbooks have multiplied in number, along with the arrival of new means of information delivery. No individual physician, no matter how capable or experienced, is able to absorb and memorize more than a small portion of this database. This is true despite the fact that convenient access to the information is developing rapidly. One can search the literature rapidly with the National Library of Medicine’s MEDLINE service to discover the latest in diag nosis, treatment, and outcome for any disease, common or rare.

Personal Glimpse

With the rapid growth and popularization of the Internet, access to the universe of medical information has been fundamen tally altered. Physicians and the public may draw on the resources of medical discussion groups and refer ence databases with unprecedented ease. But a new dilemma comes with this wonderful ad- vance. For decades, inquisitive patients have turned to health letters and magazines to supplement the informa- tion gained from consultation with their physician. These publications filled a gap in doctor-patient communication. As demands on the physician’s time have multiplied, the explanations offered to patients are too often cursory and incomplete. As the concept of individual responsibility for health has grown, the computerized medical database has broadened the patient’s horizons.. . . It is too early to analyze the virtues and problems of the information revolution. But some are obvious. For example, a World Wide Web query for the keyword “health” found . . . documents, ranging from commercial health products and alternative therapies to issues of sexuality, obesity, aging, and environmental health. . . . Since even physicians can have difficulty sorting out the truth in cyberspace, imagine the problem for the average person browsing the Internet.

Michael Kashgarian, M.D.6

Doctors and Patients in Cyberspace

Chapter One Consumer Health Issues 5

Although many authoritative publications are avail- able, greater numbers of books, magazines, newsletters, and Web sites promote false ideas. Chapter 2 discusses this problem in detail and provides guidance on choosing trustworthy sources.

QuaCKerY and HealtH fraud Quackery is definable as the promotion of a false or unproven health method for profit (see Chapter 3). Fraud involves deceit. Despite tremendous progress in medical science and health education, Americans waste billions of dollars each year on products and services that are unsubstantiated or bogus. Dr. William Jarvis7 calls quackery “a national scandal.” Barrett and Herbert8 have noted:

People generally like to feel that they are in control of their life. Quacks take advantage of this fact by giving their clients things to do—such as taking vitamin pills, preparing special foods, meditating, and the like. The activity may provide a temporary psychological lift, but believing in false things can have serious consequences. The loss may be financial, psychological (when disillusionment sets in), physical (when the method is harmful or the person abandons effective care), or social (diversion from more constructive activities). . . . Quacks portray themselves as innovators and suggest that their critics are rigid, elitist, biased, and closed to new ideas. Actually, they have things backwards. The real issue is whether a method works. Science provides ways to judge and discard unfounded ideas. Medical science progresses as new methods replace less effective ones. Quack methods persist as long as they remain marketable.

Quackery promoters are adept at using slogans and buzzwords. During the 1970s their magic sales word was “natural.” During the 1980s the word “holistic” was popularized. Today’s leading buzzwords are “alterna- tive” and “complementary.” These terms are misleading because methods that do not work are not reasonable alternatives to proven treatment and combining them with standard methods increases cost but not effective- ness. This textbook places the words “alternative” and “complementary” in quotation marks when referring to unsubstantiated methods that lack a scientifically plau- sible rationale. Chapter 8 discusses them in detail. Although most people think of themselves as hard to fool, the majority of Americans are victims of quackery. Contrary to popular beliefs, for example: (a) most people who take vitamin supplements don’t need them; (b) vita- mins do not make people more energetic, more muscular, or less stressed; (c) “organically grown” foods are neither safer nor more nutritious than conventionally produced

foods; and (d) no nonprescription pill can produce rapid or permanent weight loss. Chapters 3, 11, and 12 cover these subjects thoroughly. Victims of quackery usually have one or more of the following vulnerabilities:

lacK of suspicioN: Many people believe that if something is printed or broadcast, it must be true or somehow its publica- tion would not be allowed. People also tend to believe what others tell them about personal experience.

desperatioN: Many people faced with a serious health problem that doctors cannot solve become desperate enough to try almost anything that arouses hope. Many victims of can- cer, arthritis, multiple sclerosis, and AIDS are vulnerable in this way.

alieNatioN: Some people feel deeply antagonistic toward scientific medicine but are attracted to methods that are “natural” or otherwise unconventional. They may also harbor extreme distrust of the medical profession, the food industry, drug companies, and government agencies.

Belief iN magic: Some people are easily taken in by the promise of an easy solution to their problem. Those who buy one fad diet book after another fall into this category.

False Beliefs Can Kill The danger of denying that the human immunodefi- ciency virus (HIV) is the causal agent of AIDS was spotlighted in 2005 by the sudden death of 3-year-old Eliza Jane Scovill of Van Nuys, California, during a bout of AIDS-related pneumonia. Eliza’s mother, Christine Maggiore, was HIV-positive. Medical man- agement of infected pregnant women had reduced the reported incidence of HIV/AIDS in children under age 13 from 952 in 1992 to only 59 in 2003. But Maggiore refused treatment for herself and did nothing to prevent transmission of the virus to her daughter. In fact, dur- ing her pregnancy, she even appeared on the cover of Mothering Magazine with the word AZT in a circle with the slash through it and the headline “HIV+ Moms Say NO to AIDS Drugs.” (AZT is an anti-AIDS drug.) Maggiore ran Alive & Well AIDS Alternatives, a nonprofit organization which falsely proclaimed that (a) most of the AIDS information the public receives was based on unsubstantiated assumptions, unfounded estimates, and improbable predictions and (b) the symptoms associated with AIDS were treatable with “non-toxic, immune enhancing therapies.” Maggiore herself died in 2008. Although an autopsy was not obtained, knowledgeable observers believe that she died of AIDS-related pneumonia.9

Personal Glimpse

Part One Dynamics of the Health Marketplace6

overcoNfideNce: Despite P.T. Barnum’s advice that one should “never try to beat a man at his own game,” some strong-willed people believe they are better equipped than scientific researchers and other experts to tell whether a method works.

problems wItH produCts In light of scientific and technologic advances, it is not surprising that many people believe that health is pur- chasable. The health marketplace abounds with products of every description to accommodate people’s desires. The problem areas include dietary supplements; herbal and homeopathic products; exercise devices; diet pills and potions; self-help books, recordings, and gadgets; youth and beauty aids; magnets; and some types of over- the-counter drug products. Thousands of “supplement” products are marketed with false claims that they can boost energy, relieve stress, enhance athletic performance, and prevent or treat numerous health problems (see Chapter 11). Ads for “ergogenic aids” feature champion bodybuilders or other athletes without indicating that the real reason for their success is vigorous training. Few supplement

products have any usefulness against disease, and most that do—such as niacin for cholesterol control—should not be taken without competent medical supervision. Although some herbs sold for medicinal purposes are useful, most are not, and some are dangerous (see Chapter 11). Because the U.S. Food and Drug Admin- istration (FDA) does not require standards of identity or dosage for herbal products, consumers may be unable to tell what the products contain or how to use them. Moreover, many of the conditions for which herbs are recommended are not suitable for self-treatment. The vast majority of mail-order health products are fakes (see Chapter 4). The common ones include weight-loss products (mostly diet pills), “hair restor- ers,” “wrinkle removers,” and alleged sex aids. Figure 1-1 illustrates the flamboyant claims found in ads for mail-order diet and “nerve” pills. Many worthless devices are claimed to “synchro- nize” brain waves, relieve pain, remove unwanted fat deposits, improve eyesight, relieve stress, detoxify the body, and ward off disease. Thousands of self- instructional products and programs are marketed with false claims that they can help people lose weight, stop

fIgure 1-1. Ads for dubious mail-order products. The diet pill ad was published in many magazines during the late 1970s. Although no product can “neutralize calories” or fulfill the other promises in this ad, countless “weight-loss” products have been advertised in this way. The “nerve tonic” ad is from a 1996 flyer from a company that specializes in herbal products. Some of its statements about body physiology are true, but most are not related to each other, and the overall message is pseudoscientific gibberish. No ingredients are identified, and no product can remedy the long list of problems listed in the ad. Promotions like these are still common today because regulatory agencies lack the resources to control them, many people are unsuspecting enough to buy them, and many magazine and newspaper publishers value ad revenues more than ethics.

Chapter One Consumer Health Issues 7

smoking, enhance athletic performance, quit drinking, think creatively, raise IQ, make friends, reduce pain, improve vision, restore hearing, cure acne, conquer fears, read faster, speak effectively, handle criticism, relieve depression, enlarge breasts, and do many other things (see Chapter 6). Magnets embedded in clothing, mat- tresses, or other products are falsely claimed to relieve pain, increase blood flow, boost immunity, and provide other health benefits (see Chapter 20). Multilevel companies market a wide variety of health-related products, almost all of which are either in- appropriate or overpriced (see Chapter 4). The products are sold by individual distributors who also attempt to recruit friends, neighbors, relatives, and others to do the same. Several million people are involved in multilevel marketing. Most over-the-counter drug products can be useful in self-care. However, many ads encourage pill-taking for insomnia, lack of energy, constipation, and other problems that may have better solutions. Homeopathic “remedies” are the only category of spurious products legally marketable as drugs. Figure 1-2 illustrates a product that does not contain any molecules of its alleged “active ingredient.” Exercise equipment varies greatly in quality, use- fulness, and price. Before investing in equipment, it is important to determine what it can do and whether it can meet one’s needs or will be too monotonous for regular use (see Chapter 13). Some devices are gimmicks that have little or no effect on fitness.

problems wItH servICes Although health care in America is potentially the world’s best, many practitioners fall short of the ideal, some are completely unqualified, and many consumers have problems with access and affordability. Many physicians prescribe too many drugs, order too many tests, fail to keep up-to-date, or pay insuf- ficient attention to preventive measures. Some do not spend sufficient time interviewing, examining, or advising their patients. Unnecessary surgery is also a significant problem. The percentage of physicians who furnish seriously deficient care is unknown. The Public Citizen Health Research Group (HRG)10 estimates that about 0.8% of physicians commit serious offenses each year, more than double the number actually disciplined. Practitioner discipline is covered in Chapter 25. The mental health marketplace is replete with un- qualified therapists, some of whom have no training whatsoever (see Chapter 6).

Most dentists provide competent care, but consum- ers should be alert to the signs of overselling and dental quackery. Dodes and Schissel11 also warn that many dentists fail to get optimal results because they work too quickly (see Chapter 7). Many people who represent themselves as “nu- tritionists” lack adequate training and engage in un- scientific and quack practices (see Chapter 11). Many commercial weight-loss clinics lack qualified personnel and promise too much in their advertising (see Chapter 12). A wide variety of practitioners engage in “alterna- tive” practices that are not science-based and lack proven value. This includes small percentages of medical and osteopathic physicians; large percentages of chiropractors, naturopaths, massage therapists, and acupuncturists; and others whose activities are described in Chapters 8 and 9.

fIgure 1-2. Homeopathic product “for the relief of colds and flu-like symptoms, such as fever, chills and shivering, body aches and pains.” The box states that its active ingredient is “Anas barbariæ hepatis et cordis extractum HPUS 200C.” This ingredient is prepared by incubating small amounts of a freshly killed duck’s liver and heart for 40 days. The resultant solution is then filtered, freeze-dried, rehydrated, repeatedly diluted, and impregnated into sugar granules. The “200C” designation means that the dilution (1:100) is done 200 times. If a single molecule of the original substance were to survive the dilution, its concentration would be 1 in 100200 (1 in 10400). The number 100200 is vastly greater than the estimated number of molecules in the universe. These numbers don’t make sense, and neither does purchasing the product. Ye, as noted in Chapter 8, t it is legal to market it as a nonprescription drug in the U.S.

Part One Dynamics of the Health Marketplace8

The quality of care in hospitals and nursing homes varies considerably from one to another. The best ones have well-trained nurses who monitor their patients closely. In some facilities, unlicensed personnel provide services for which they are not adequately trained. Pa- tients confronted with a succession of tests and consul- tants may feel frustrated and bewildered if the reasons for them are not explained. Noise may interfere with getting adequate rest. In some nursing homes, physical restraints or sedative drugs are used excessively, patients receive insufficient medical attention, and neglect by the nurs- ing staff results in infections and bedsores. Hospitals, long-term care facilities, and other health-care delivery systems are discussed in Chapter 22.

problems wItH Costs and aCCess Rising costs and lack of adequate insurance coverage have made high-quality health care unavailable to many people in the United States. The cost of health care in the United States has risen much faster than inflation for several decades and is approaching 18% of our gross domestic product. In 2009 close to 50 million Americans ages 19 to 64 had no health insurance12 and many others were underinsured. A recent study13 concluded that ill- ness and medical bills were linked to nearly two thirds of bankruptcies. Inefficiency, waste, and fraud are also serious problems. In 2009, after decades of inaction, the U.S. Congress enacted a hotly contested reform bill in an attempt to improve access and decrease the cost of health care. However, the new law only partially addresses the prob- lems, and powerful vested interests and many confused members of the public oppose its implementation (see Chapters 23 and 24). The funeral industry has a disgraceful record of price-gouging. Many funeral directors fail to disclose costs, add dubious items to their bills, and/or pressure emotionally vulnerable survivors into spending more than necessary (see Chapter 21). Although comparison shopping or joining a memorial society can greatly lessen the cost of death care, many people are not in a position to do these things. Prepaid funeral plans that are badly managed or fraudulent are also a serious problem.

problems wItH rIsK perCeptIon

People are most likely to take steps to take care of themselves when they perceive that doing so will reduce important health and safety hazards. But risk-communi- cation expert Peter M. Sandman, Ph.D.14 has concluded:

If you make a list of environmental risks in order of how many people they kill each year, then list them again in order of how alarming they are to the general public, the two lists will be very different. . . . The risks that kill you are not necessarily the risks that anger and frighten you . . . .

Media reports can greatly influence what people perceive as hazardous. For example, at various times, the media have promoted widespread fears that cellular phones, video display terminals, coffee, electric blan- kets, the artificial sweetener saccharin, commercial hair dyes, and potato chips pose serious risks. The American Council on Science and Health15 has noted that all of these scares were based on “questionable, hypothetical, or nonexistent scientific evidence.” FDA scientist Robert Scheuplein16 has noted that “scientists, managers and regulators who study risks for a living are constantly dismayed because the public seems to worry about the wrong risks.” Chapter 14 discusses health and safety risks and appropriate consumer responses to these risks.

tHe need for Consumer proteCtIon The caveat emptor doctrine (“let the buyer beware”), which originated in the Middle Ages, was based on the assumption that buyers and sellers had equal bargain- ing positions. This was reasonable because (a) goods (such as fresh vegetables and cloth) could be examined thoroughly for defects and (b) people bargained almost entirely with neighbors who risked severe social reper- cussions if they acted dishonestly. However, as trade expanded and technology advanced, it became apparent that individual caution is not enough. Even highly intelli- gent individuals may go astray in situations in which they lack expert knowledge or are emotionally vulnerable.

Protective Forces Because the caveat emptor philosophy is inadequate to protect health consumers, many of today’s laws are based on the concept of caveat vendor (let the seller beware), but gaps in consumer protection remain. Better enforce- ment of existing laws is also needed. The FDA is concerned about the safety, effective- ness, and marketing of foods, drugs, cosmetics, medical devices, and other health-related products. The FDA operates under powerful laws but lacks sufficient re- sources to handle the enormous number of violations it encounters. In addition, a 1994 law generated by the health-food industry and its allies has decreased the agency’s ability to regulate claims for dietary supple- ments and herbs (see Chapters 11 and 25).

Chapter One Consumer Health Issues 9

The Federal Trade Commission (FTC) has primary jurisdiction over most types of advertising. It administers a powerful law and has been enforcing it vigorously dur- ing the past decade. But, like the FDA, it can only act against a small percentage of the problems it encounters. State attorneys general enforce several types of consumer-protection laws. In most states, however, few health-related cases are pursued. State laws for licensing health professionals set minimum requirements for training and knowledge but do not specify that practices must be science-based. Even physicians and dentists are not required by law to practice according to scientific principles, although they generally do so. The quality of state regulation varies from state to state and from board to board. Many licens- ing boards lack the resources to investigate all of the complaints they receive. Those that oversee chiroprac- tors, naturopaths, acupuncturists, and massage therapists do very little to protect consumers against unscientific practices.

Accreditation agencies set standards for educa- tion and quality of care. Those serving schools for the science-based professions generally to do an excellent job but have failed to protect students from an invasion of “complementary and alternative medicine” teachings. The agencies that oversee chiropractic, naturopathy, acupuncture, and massage therapy schools make little or no effort to prevent unscientific teachings (see Chapters 8 and 9). Accreditation of hospitals, nursing homes, and other health-care facilities generally increases the quality of their care, but it also adds to the cost of administering that care. Hospitals oversee the activities of their staffs (see Chapter 22). Those that do so effectively provide a very valuable consumer-protection service to their communities. Insurance companies and other third-party pay- ers can refuse to cover services that are excessive or unsubstantiated. However, state legislatures and courts sometimes force them to pay for inappropriate treatment.

analYsIs of Consumer-proteCtIon forCes Table 1–2

Agency/Organization

School accreditation agencies

State licensing boards

Insurance companies

Medicare and Medicaid Managed care

plans

Professional societies Specialty boards

Advisory panels

Hospitals

Food and Drug Administration (FDA)

Federal Trade Commis- sion (FTC)

U.S. Postal Service State attorneys general Voluntary and consumer

groups

Potential Role

Improve the quality of training State laws set standards for entry into profession. Boards can act in cases of fraud, incompetence, or other unprofessional behavior

Gatekeeper function; can refuse to pay for unsubstantiated treatment

Can eject errant practitioners Can exclude or eject practitioners who don’t meet their criteria or who engage in unprofessional conduct

Set ethical standards for members Set high performance standards and ensure them by rigid examinations

Issue guidelines based on professional consensus

Credentialing and peer-review processes can restrict unqualified practitioners

Regulates food, drugs, and cosmetics; can act against drugs and devices that are not proven safe and effective

Can act against false advertising

Can stop frauds involving use of the mail Can stop fraudulent activities Can educate the public and campaign for

stronger laws

Limiting Factors

Teachings are not required to be science-based

Licensure does not ensure that a profession practices scientifically. Board resources are limited; courts may delay or overrule board actions; many dubious practitioners are unlicensed

Laws or court actions may force companies to pay for unsubstantiated procedures

Fraud can be difficult to detect Selection criteria may be based on economic factors rather than quality of care; laws and court actions can force managed-care plans to accept practitioners they don’t want

Have no legal power; cannot influence nonmembers Unrecognized boards may have low standards or be bogus

Have no legal power; some guidelines conflict with others

Practitioners not on hospital staff are unaffected; some hospitals have lax standards

Limited resources, especially if court action is required; current laws interfere with regulation of vitamins, herbs, and homeopathic products

Very aggressive but has limited resources and tends to move slowly

No recent regulation of mail-order health products Can pursue only a small percentage of complaints Many groups are underfunded; some promote

quackery

Part One Dynamics of the Health Marketplace10

practitioners and the health-food industry want the laws weakened (see Chapters 8, 11, and 25). Table 1-2 summarizes the functions and limitations of the protective forces just discussed.

IntellIgent Consumer beHavIor Intelligent health consumers have the following characteristics: 1. They understand the logic of science and why scientific testing is needed to test and to determine which theories and practices are valid. Chapter 2 covers this in detail. They also understand and guard against their own vulnerabilities and cognitive biases (see Personal Glimpse Box on page 12). 2. They seek reliable sources of information. They are appropriately skeptical about advertising claims, statements made by talk-show guests, and “break- throughs” reported in the news media. New information, even when accurate, may be difficult to place in perspec- tive without expert guidance. Most physicians, dentists, allied health professionals, health educators, government

Professional societies set standards for their mem- bers, but they lack the force of law and have little or no influence on nonmembers. Some societies can help consumers settle disputes over billing and ethical issues. Recognized specialty boards set standards (through examinations) to identify practitioners who have achieved a high level of professional competence. Some “specialty boards” lack professional recognition, and some are bogus (see Chapter 5). Many health-related agencies and organizations issue voluntary guidelines for science-based practices. The most comprehensive set is maintained by the U.S. Preventive Services Task Force. Its reports, as discussed in Chapter 5, examine the best current evidence for benefits and harms of various screening tests and preven- tive measures and make recommendations based on the benefit/harm ratio. Voluntary and consumer groups serve as watchdogs, information sources, and legislative advocates. Some deal with many health-related issues; others deal with few. Some advocate strengthening consumer-protection laws. Groups that represent the interests of “alternative”

Cognitive bias is a general term for distortions of thinking that are difficult to eliminate and can lead to inaccurate judgment and faulty conclusions. Many types of cogni- tive bias influence choices related to health care. Some common ones are listed below. How vulnerable do you think you are to each type?

availaBility cascade: a self-reinforcing process in which a collective belief gains more and more plausibility through its increasing repetition in public discourse (“repeat something enough and it will become true”).

BaNdwagoN effect: the tendency to do (or believe) things because many other people do (or believe) the same.

halo effect: the tendency for a person’s positive or negative traits to “spill over” from one area of their personality to another in others’ perceptions of them. We are inclined to accept statements by people we like.

illusory correlatioN: inaccurately perceiving a relation- ship between two events, either because of prejudice or selective processing of information.

iNterloper effect: the tendency to value third-party con- sultation as objective, confirming, and without motive.

mere exposure effect: the tendency to express undue lik- ing for things merely because of familiarity with them.

It’s Your Decision

Cognitive Bias

iNgroup Bias: the tendency for people to give preferential treatment to others they perceive to be members of their own groups.

Negativity Bias: the tendency to pay more attention and give more weight to negative than positive experiences or other kinds of information.

Neglect of proBaBility: the tendency to completely disregard probability when making a decision under uncertainty.

overcoNfideNce effect: excessive confidence in one’s own answers to questions.

illusioN of coNtrol: the tendency to overestimate one’s degree of influence over external events.

pseudocertaiNty effect: the tendency to make risk-averse choices if the expected outcome is positive, but make risk-seeking choices to avoid negative outcomes.

reactaNce: the urge to do the opposite of what someone wants you to do out of a need to resist a perceived at- tempt to constrain your freedom of choice.

wishful thiNKiNg: the formation of beliefs and the making of decisions according to what is pleasing to imagine instead of by appeal to evidence or rationality.

zero-risK Bias: preference for reducing a small risk to zero over a greater reduction in a larger risk.

Chapter One Consumer Health Issues 11

agencies, professional societies, and health-related vol- untary organizations are reliable (for more information see Chapter 2 and the Appendix). 3. They maintain a healthy lifestyle. This reduces the odds of becoming seriously ill and lowers the cost of health care. Prudent consumers avoid tobacco products, eat sensibly, exercise appropriately, maintain a reason- able weight, use alcohol moderately or not at all, and take appropriate safety precautions (such as wearing a seat belt when driving). 4. They select practitioners with great care. It has been said that primary-care physicians typically know a little about a lot and specialists typically know a lot about a little. The majority of people would do best to begin with a generalist and consult a specialist if a problem needs more complex management. 5. They undergo appropriate screening tests and, when illness strikes, use self-care and professional care as needed. Excellent guidebooks are available to help decide when professional care is needed (Chapter 14).

6. When a health problem arises, they take an active role in its management. This entails understanding the nature of the problem and how to do their part in dealing with it. People with chronic illnesses, such as asthma, diabetes, or high blood pressure, should strive to become “experts” in their own care and use their physicians as “consultants.” 7. They communicate effectively. They present their problems in an organized way, ask appropriate questions, and tactfully assert themselves when necessary. 8. They are wary of treatments that lack scientific support and a plausible rationale. These are discussed throughout this book. 9. They are familiar with the economic aspects of health care. They obtain appropriate insurance coverage, inquire in advance about professional fees, and shop comparatively for medications, eyeglasses, and other products. 10. They report frauds, quackery, and other wrong- doing to appropriate agencies and law enforcement

Are you sufficiently informed to be able to make sound decisions? Do you maintain a healthy lifestyle? From what sources do you seek information when needed? Professional health organizations/individuals Health books, magazines, newsletters Government health agencies Advertisements, retail salespeople Newspapers Radio/television Laypersons you know To what extent do you accept statements in news reports at face value? To what extent do you accept statements in ads at face value? How well can you identify quacks, quackery, fraudulent schemes, and hucksters? When selecting health practitioners, to what extent do you: Talk with or visit before the first regular appointment? Check/inquire regarding qualifications/credentials? Ask friend/neighbor about reputation? Inquire about fees and payment procedures? Do you undergo appropriate periodic medical examinations? Do you undergo appropriate periodic dental examinations? When you have been exposed to a fraudulent practice, quackery, or a substandard product or service, to what extent do you report your experience?

Consumer HealtH profIle Worksheet 1–2

This exercise can help you analyze your approach to health information and professional care. Place an X in the column to the right that best represents your answer. (VM = very much; M = much; S = some; L = little; N = none.) VM M S L N

Part One Dynamics of the Health Marketplace12

officials. Consumer vigilance is an essential ingredient of a healthy society. Worksheet 1-2 can help you evaluate your approach to the health marketplace.

summarY Consumer health encompasses all aspects of the mar- ketplace related to the purchase of health products and services. Although health care in America is potentially the world’s best, many problems exist. Health information is voluminous and complex. Many practitioners fall short of the ideal, and some are completely unqualified. Quackery is widespread. The marketplace is overcrowded with products, many of which are questionable. Rising costs and lack of adequate insurance coverage have reached crisis levels. Consumer protection is limited. Only well-informed individuals can master the com- plexity of the health marketplace. Intelligent consumers maintain a healthy lifestyle, seek reliable sources of information and care, and avoid products and practices that are unsubstantiated and lack a scientifically plausible rationale.

referenCes* 1. Kaplan NL. Consumer health: The times they are a-changing.

Health Education 11(6):3, 1980. 2. Schwartz B. The Paradox of Choice. New York, 2004, Harper-

Collins Publishers, p 73. 3. Gunther M. Quackery and the media. In Barrett S, editor. The

Health Robbers: How to Protect Your Money and Your Life, ed 2. Philadelphia, 1980, George F Stickley Co.

4. Larkin M. Confessions of a former women’s magazine writer. NutriWatch Web site, March 26, 2000.

5. Schwitzer G. The future of health journalism. Public Health Forum 18(3):19e1–19e3, 2010.

6. Kashgarian M. Doctor and patient in cyberspace, or take two aspirins and e-mail me in the morning. Yale Medicine 30(2A):22–24, 1996.

7. Jarvis WT. Quackery: A national scandal. Clinical Chemistry 38:1574–1586, 1992.

8. Barrett S, Herbert V. The Vitamin Pushers: How the “Health Food” Industry Is Selling America a Bill of Goods. Amherst, N.Y., 1994, Prometheus Books.

9. Gorski D. Christine Maggiore and Eliza Jane Scoville: Living and dying with HIV/AIDS denialism. Science-Based Medicine Blog, Jan 5, 2009.

10. Wolfe SM, Laurie P. Ranking of state medical board serious disciplinary actions in 2002. HRG Web site, April 2004.

11. Dodes JE, Schissel MJ. The Whole Tooth. New York, 1997, St. Martin’s Press.

12. Number of uninsured skyrockets 4.3 million to record 50.7 mil- lion in 2009. Physicians for a National Health Program news release, Sept 16, 2010.

13. Himmelstein DU and others. Medical bankruptcy in the United States, 2007: Results of a national study. American Journal of Medicine 122:741–746, 2009.

14. Sandman P. Risk communication: Facing public outrage. Peter Sandman Risk Communication Web site, Nov 21, 2001.

15. Facts vs. Fears. New York, 2004, American Council on Science and Health.

16. Scheuplein R, quoted in Segal M. Is it worth the worry? Deter- mining risk. FDA Consumer 24(6):7–11, 1990.

17. Welcome to the DOI System. The Digital Object Identifier System Web site, accessed Sept 23, 2011.

1. Benson JS. FDA activities protect public. FDA Consumer 25(1):7–9, 1991.

Author Title

Publication Volume(Issue):Pages, Year

How to Locate References The format this textbook uses for references to maga- zine and journal articles is:

√ Consumer Tip

Online documents and journal article abstracts are easily accessed through the “references” pages of the Consumer Health Sourcebook Web site (www. chsourcebook.com). Since 2000, more than 45 million online journal articles have been assigned permanent Digital Object Identifier (DOI®) numbers that enable them to be located with the search engine at www.doi.org/index. html.17 Scientific journals are also housed at medical school and hospital libraries. Many libraries have full-text online access, and most can obtain books and article reprints through the interlibrary loan process. Using Google to search for an article’s title may locate a full-text-copy that has been posted.

*In this text, citations numbered in boldface type are recommended for further reading.

Separating Fact From Fiction

One of the factors that makes America great is our freedom of speech. To maintain this freedom, we must also run a risk. False prophets can get up on pedestals (such as radio and television talk shows) and tell you almost anything they please. Gabe Mirkin, M.D.1

Finding the occasional straw of truth awash in a great ocean of confusion and bamboozle requires intelligence, vigilance, dedication and courage. But if we don’t practice these tough habits of thought . . . we risk becoming a nation of suckers, up for grabs by the next charlatan who comes along. Carl SaGan2

An inability to comprehend even basic statistical concepts can trans- form modern youth into victims in search of an irrational belief system that will needlessly harm, panic, and abuse.

PaSquale aCCarDo, M.D. ronalD linDSay, M.D.3

Be careful about reading health books. You might die of a misprint. Mark Twain

“By God! You can fool all of the people all of the time!”

© medical economics, 1982

Chapter Two

Consumers who wish to make intelligent decisions about health matters must address several ques-tions: What are scientific facts? How can they be identified? To what extent should people believe what they read and hear? Where can valid information be found? This chapter explains how scientific methods are used to determine facts, how health information is dis- seminated, and how reliable information can be obtained.

How FactS are DetermineD Trustworthy health information comes primarily through exposing hypotheses (assumptions) to critical examina- tion and testing. A hypothesis is scientific only if it is testable and can predict measurable events. It is gener- ally not a good idea to invest resources in investigating hypotheses that lack a plausible rationale. The scientific method offers a way to evaluate infor- mation to distinguish fact from fiction. It does not rely on reports of personal observations and experiences as evidence of fact. Rather, it provides an objective way to collect and evaluate data. Astronomer Carl Sagan said that “science is a way of thinking much more than it is a body of knowledge.” He also noted2:

At the heart of science is an essential tension between two seemingly contradictory attitudes—an openness to new ideas, no matter how bizarre and counterintuitive they may be, and the most ruthless skeptical scrutiny of all ideas, old and new. This is how deep truths are winnowed from deep nonsense. Of course, scientists make mistakes in trying to understand the world, but there is a built-in error-correcting mechanism: The collective enterprise of creative thinking and skeptical thinking together keeps the field on track.

The scientific method has at least three noteworthy characteristics:

• Scientific methods are essential for validating health claims and other information.

• Under the rules of science (and consumer protection), those who make a claim bear the burden of proof.

• Scientific research requires proper study design, the highest possible accuracy of measurement or observation, and appropriate statistical analysis of the findings.

• Don’t assume that information is valid simply because it is broadcast or published. No magical superforce is protect- ing the marketplace against misinformation.

• The best way to avoid errors is to use trustworthy sources of information. It is far more sensible to use reliable “in- formation filters” such as Consumer Reports on Health rather than trying to integrate newsbits on one’s own.

Keep tHeSe pointS in minD aS You StuDY tHiS cHapter Key Concepts

First, it is self-correcting. Scientists do not assume that this method discovers absolute truth but rather that it produces conclusions that subsequent studies may modify. In this sense, science is cumulative. Second, the scientific method requires objectivity. Findings must not be contaminated by the personal beliefs, perceptions, biases, values, or emotions of the researcher. Research results often lead to new questions that should be explored. Third, experiments must be reproducible. One study, taken alone, seldom proves anything. To be valid, one researcher’s findings must be repeatable by others. As summarized by Haack4:

What is distinctive about inquiry in the sciences is . . . sys- tematic commitment to criticism and testing, and to isolating one variable at a time; experimental contrivance of every kind; instruments of observation from the microscope to the

The Scientific Method in Action5

In 1978 researchers at Mt. Sinai Hospital in Miami Beach, Florida, compared the effects of chicken soup, cold water, and hot water on the clearance rate of nasal mucus. Each liquid was consumed through a straw from a covered cup or open vessel. A videotaping system was used to record the advance of tiny radioactive discs as mucus carried them out the nose. Cold water slowed mucus flow, but chicken soup and hot water sipped from an open cup speeded it up. Since chicken soup outperformed hot water, the researchers concluded that it appeared to have a special ability to clear a stuffy nose. Mom and Grandma were right!

Personal Glimpse

Part One Dynamics of the Health Marketplace14

different studies, (c) whether it is clear that the risk marker preceded the disease, (d) whether the dose and not just the mere presence of the marker predicts disease risk, and (e) whether, in light of what else is known, it appears logical that the marker is responsible. Controlled clinical trials compare an experimental group of people who receive the treatment being tested and a control group of people who receive a different treatment or no treatment. For example, members of the experimental group may receive a pill with active ingredients, whereas those in the control group receive another treatment, an inert substance (placebo), or no treatment. Studies may be conducted “blind” or “double- blind” to minimize or eliminate the effect of bias on data collection and interpretation. In blind studies the participants do not know which treatment they receive. In double-blind studies neither the people administer- ing the treatment nor the experimental subjects know who gets what. In crossover studies participants in two or more groups are switched from one intervention to another after a specified period of time. Some studies do not use control groups. Ernst and others10 have warned that experimental subjects who receive placebos should not be classified as “untreated” and that many people fail to distinguish between a placebo response and the improvement that results from the natural course of an illness. Chapter 3 discusses this subject further. Large, randomized, well-controlled, double-blind studies in which several medical centers participate are considered the gold standard of research trials.11 Be- cause such studies are very expensive to conduct, they are reserved for questions of great importance. Long- term research (“outcomes research”) is also needed to

questionnaire; sophisticated techniques of mathematical and statistical modeling; and the engagement, cooperative and competitive, of many persons, within and across generations, in the enterprise of scientific inquiry.

The long list of references cited in Chapter 15 of this text illustrates the enormous amount of effort that can be involved in developing important conclusions.

Research Design Scientific research requires proper study design, the highest possible accuracy of measurement or observa- tion, and appropriate statistical analysis of the findings. The conclusions are then used to develop new theories or modify old ones. Science writer Rodger Doyle6 has compared the types of studies medical scientists use to investigate health and disease:

CaSe STuDieS involve systematic observation of people who are ill.

laboraTory exPeriMenTS include studies of animals, living tissue, cells, and disease-causing agents.

ePiDeMioloGiC STuDieS analyze data from various population groups to identify factors related to the occurrence of diseases.

ConTrolleD CliniCal TrialS offer the most credible evidence.

Anecdotal reports are personal observations that have not been made under strict experimental conditions. Competent researchers may use anecdotes for suggest- ing new hypotheses, but never as supporting evidence. The fact that a person recovers after doing something is rarely sufficient to demonstrate that the recovery was caused by the action taken and is not simply coincidental. Moreover, reports of personal experiences can be biased, inaccurate, or even fraudulent. Well-designed experi- ments involving many people are needed to establish that a treatment method is effective. Without them, even honest, competent doctors can be misled by their clinical experiences.7 Epidemiologists search for “risk markers” (predic- tors of a disease) by comparing people with different characteristics.8 These markers can include personal characteristics (e.g., weight, blood cholesterol levels), personal activities (taking vitamins, exercising regularly, smoking cigarettes), and environmental factors (inhal- ing radon gas or tobacco smoke) that are statistically related to specific diseases. Before concluding that any relationship is causal rather than coincidental, however, epidemiologists must consider: (a) the strength of the association, (b) the consistency of the association in

Any procedure proposed to treat human disease should be subject to the same standards of safety and effectiveness that apply to usual medical procedures. It is, however, unacceptable to require any scientific body to examine every proposed claim. There will never be enough facilities to consider the avalanche of proposals. Very simply, the burden of proof rests with the proponents. . . . Testimonials and anecdotal accounts, no matter how enthusiastic, do not constitute proof. Public enthusiasm and interest do not create validity. Edward H. Davis, M.D.9

√ Consumer Tip

Chapter Two Separating Fact from Fiction 15

compare the effectiveness of proven options.12 Table 2-1 illustrates the typical steps in a clinical investigation. It is important that research findings not be overgen- eralized. Conclusions based on data from one population may not apply to another, and the results obtained from animal or test-tube studies may not be applicable to humans. The importance of scientific testing was strikingly demonstrated by a study of mammary artery ligation, a surgical procedure used in the 1940s and 1950s for treating angina pectoris (chest pain resulting from coronary artery disease). Proponents believed that tying off the mammary arteries stimulated the growth of new blood vessels that would increase the supply of blood to the heart muscle. The procedure was considered ef- fective until double-blind controlled tests demonstrated that pretending to operate (merely cutting the skin of the patient’s chest wall) was as effective as tying off the mammary arteries.13 Misuse of Statistics Many people tend to accept statistical data without ques- tion. To them, any information presented in quantitative

form is correct. Advertisers, quacks, and pseudoscien- tists often cite invalid data or misrepresent valid data to promote their wares. Strasak and colleagues14 have identified 47 statistical errors in medical research. The common ones that can cause confusion include:

biaS: A factor that may cause people to make erroneous obser- vations or draw erroneous conclusions. For example, in a study of vitamin C and the common cold, participants who knew they were taking vitamin C reported fewer colds than those who were taking it but did not know it.15

non SequiTur: The stated conclusion does not follow from the facts.

inSuffiCienT DaTa: Small amounts of data limit the certainty of results. Tests done on small numbers must usually be confirmed by larger studies.

nonCoMParable DaTa: Care must be taken when groups are compared. For example, people who eat the most sugary cereals are at lowest risk of developing cancers. But don’t conclude that eating sugary cereals reduces cancer risk. Those who eat the most sugary cereals tend to be children, and the risk of cancer is much lower in children than it is in adults.

nonrePreSenTaTive DaTa: Improper sampling techniques (lack of random sampling) may yield data that do not accurately

tYpical StepS in a clinical inveStigation Table 2–1

Step A question or problem is identified. A hypothesis is formulated. A limited aspect of the hypothesis is se-

lected for testing. A study is designed.

The study is conducted. Data are collected, recorded, and tabu-

lated. The data are analyzed to determine

whether the results appear significant or were likely to occur by chance alone.

A determination is made on whether the hypothesis has been supported or refuted.

The study may be repeated by the re- searchers or by others to verify their results or conclusions.

Studies relevant to this area are reviewed.

Example What is the effect of vitamin C on the common cold? Supplementation with vitamin C can reduce the incidence of colds. Will daily administration of 1000 mg of vitamin C prevent colds?

Sixty adults will be given 1000-mg tablets of vitamin C daily for 4 months, and 60 of comparable age, race, sex, and health status will be given an inactive substance (placebo tablets). The participants will not know which they receive (a blind study).

Volunteers are obtained and instructed on how to proceed. There were six colds in the vitamin C group and seven in the placebo

group. The small difference between the two groups could easily have

occurred by chance alone and therefore is not “statistically significant.”

The hypothesis was not supported. The experiment found no evi- dence that vitamin C supplements reduce the incidence of colds.

Many double-blind experiments have found that supplementation with vitamin C does not prevent colds (see Chapter 11).

Skilled reviewers agree that enough well-designed studies have been done to conclude that vitamin C megadoses do not prevent colds.

Part One Dynamics of the Health Marketplace16

represent the study population or group. For example, to determine which car the average American likes best, it would not be appropriate to poll only owners of one make of car, those living in one region, or even those listed in a telephone book (since many people have a nonpublished number, a cell phone, or no telephone). Figure 11-1 provides another example.

ConfuSion of aSSoCiaTion anD CauSaTion: A finding that taking dietary supplements is associated with fewer missed work days does not mean that dietary supplements prevent people from getting sick. Other factors associated with taking supplements, such as having a healthier overall lifestyle, may be the real reason for reduced sick days among the supplement users.

oMiSSion of an iMPorTanT faCTor: Many individuals who feel helped by an unorthodox remedy have taken it together with effective treatment but credited the unorthodox remedy.

In How to Lie with Statistics, Darrell Huff16 describes how drug research data can be misrepresented by us- ing biased samples, meaningless averages, purposeful omissions, illogical conclusions, and deceptively drawn charts. He notes that a basic technique used by charla- tans when they present testimonial evidence is the post hoc, ergo propter hoc fallacy: “This happened after that, therefore this was caused by that.” The fact that someone who smokes 50 cigarettes and drinks heavily each day lives to age 95 does not mean that these habits are healthful. Huff says that to analyze a statement, one should ask, “Who says so? How does he know? How did he find out? Is anything missing? Does it all make sense?”

Manufacturers are quick to take advantage of pre- liminary research that may appear to support increased use of their products. In 1988 the Physicians’ Health Study Group17 reported that aspirin use every other day had reduced the incidence of heart attacks among 11,000 generally healthy physicians. The researchers concluded that although aspirin might help prevent heart attacks, the study’s results should not be applied to the gen- eral population and that doctors should weigh potential risks as well as benefits when advising their patients. (Chapter 17 discusses this further.) Within days after the report was published, aspirin ads began referring to it and suggested that consumers ask their doctors whether aspirin might help them. The FDA commissioner, who believed that the ads were likely to encourage inappropri- ate self-medication, warned manufacturers that aspirin did not have FDA approval for preventing heart attacks in healthy people and that continuing the ads would trig- ger regulatory action. Fish oils, calcium supplements, antioxidant vitamins, and high-fiber products have also been marketed in ways that oversimplify or exaggerate the significance of research findings.

peer review Peer review is a process in which work is reviewed by others who usually have equivalent or superior knowl- edge. It may be used during the development or execu- tion of a study, as well as afterward. When studies are completed, researchers strive to publish their results in journals so that others can use or criticize the findings and science can advance. Detailed standards for report- ing and evaluating studies have been published.18 The best scientific journals are peer-reviewed by experts; papers submitted for publication are reviewed by two or more expert referees, then accepted, modified, or rejected by the editor. The peer-review process is im- perfect but can usually screen out “obviously flawed and unreliable manuscripts.”19 Reports from more than 5000 peer-reviewed scientific journals are listed in the Index Medicus and its online counterpart MEDLINE. Such listing is a favorable sign but not a guarantee of quality. The quality of peer review varies from journal to journal, and even the best ones occasionally publish articles that deserve to be rejected. Moreover, in recent years, many low-quality journals that promote unsci- entific (“alternative”) methods have been included in the Index Medicus. The two most prestigious American medical journals are JAMA (Journal of the American Medical Association) and The New England Journal of Medicine. JAMA has more than 3000 names in its reviewer-referee file.

Personal Glimpse

Self-Persuasion Charlatans are not the only people who engage in the post hoc, ergo propter hoc fallacy. As noted by Lisa Feldman Barrett, Ph.D., professor of psychology at Northeastern University:

People try to connect things that happen to them. In doing this, they lean toward ideas that fit their expectations and away from those that do not. Suppose somebody believes that vitamins provide energy. On a day when he feels energetic, he attributes that feeling to the vitamin, rather than to other factors, such as the quality of his sleep the night before. On a day when he feels fatigued, however, he doesn’t register the experience as evidence against his belief. The scientific method safeguards against these tendencies by forcing people to look at disconfirmatory evidence and examine alternative explanations.

Chapter Two Separating Fact from Fiction 17

Systematic Reviews A systematic review is a literature review focused on a single question that tries to identify, appraise, and synthesize all high-quality research evidence relevant to that question. Systematic reviews of high-quality randomized, controlled trials are crucial to evidence- based medicine. The selection of articles for inclusion is usually performed by reviewing the titles and abstracts of the articles identified and excluding those that do not meet eligibility criteria. Then the data are abstracted in a standardized format. The methods used to gather and analyze the data should be transparent enough to allow others to repeat the process. Systematic reviews commonly include a meta- analysis, a statistical approach for “averaging” the results of studies that address closely related research hypotheses. When doing this, the reviewers must give appropriate weight to the quality and size of each study. If the studies differ so much that it makes no sense to try to find an average effect, the reviewers will not do a meta-analysis. Systematic reviews can be done by organizations and agencies as well as by individuals. Several that are given great weight by the medical community are described here. The American Medical Association’s Council on Scientific Affairs studies many medical issues and re- ports to the AMA’s House of Delegates. Once accepted, these reports help shape AMA public policies and may be published in JAMA. The National Academy of Sciences issues the Di- etary Reference Intakes (see Chapter 10) and many other reports by expert committees. The National Institutes of Health Consensus De- velopment Program, begun in 1977, has held about 100 consensus conferences in which experts meet for several days to discuss a topic and issue a report. Except for the acupuncture report (discussed in Chapter 8), the reports reflect a scientific consensus. The American College of Physicians’ Clinical Ef- ficacy Assessment Project focuses primarily on relatively new procedures. The U.S. Preventive Services Task Force publishes recommendations for preventive services that prudent health professionals should offer their patients in the course of routine clinical care. These recommendations, which represent the pooled judgment of many experts, are discussed in Chapters 5, 14, and 19. The Agency for Health Care Research and Quality (AHRQ), a component of the U.S. Public Health Ser- vice, was established in 1989 to enhance the quality,

appropriateness, and effectiveness of health services. Formerly called the Agency for Health Care Policy and Research (AHCPR), it has published many clinical practice guidelines with separate versions for clinicians and consumers. The Cochrane Database of Systematic Reviews, updated quarterly, is an electronic journal of systematic reviews produced by the Cochrane Collaboration, an international network of individuals and institutions committed to preparing systematic reviews of the effects of health care and disseminating them on CD-ROM and through the Internet. Established in 1993, it hopes to cover the entire spectrum of medical interventions.20 The National Guideline Clearinghouse (NGC) is an Internet-based public resource sponsored by the AHRQ, in partnership with the AMA and America’s Health Insur- ance Plans. The Web site summarizes more than 2500 clinical practice guidelines that have met its criteria. It should be noted, however, that NGC does not develop, produce, approve, or endorse the guidelines represented on its site and that some promote unscientific practices that this book criticizes in Chapters 8 and 9. Poor quality reviews can lead clinicians to the wrong conclusions and ultimately to inappropriate treatment decisions. In 2011, the Institute of Medicine (IOM) addressed this issue by recommending standards for systematic reviews21 and the development of clinical practice guidelines.22

Publication Bias Scientific journals are more likely to publish positive studies than negative ones. This occurs because editors and reviewers tend to favor positive results and experi- menters are more likely to write up studies with positive findings than with negative findings.23 The resultant situation—referred to as publication bias—may make something appear more significant than it actually is. Publication bias was vividly demonstrated by a study in which three versions of a bogus article were sent to 101 consulting editors of two psychology journals. The submissions were identical except that one reported positive results, one reported near-positive results, and the third reported no significant results. The positive versions received three times as many recommendations for publication and were rated as better designed.24 In recent years, drug companies and researchers have been accused of suppressing studies and data unfavor- able to their products.25 In response to this concern, 11 medical journals announced that in 2005 they would stop considering reports of clinical trials that had not been registered in a public trials registry before or at the time

Part One Dynamics of the Health Marketplace18

they began to enroll patients.26 The need for the policy was underscored by a study of 122 journal articles that concluded that about half of them had been incompletely reported, harm was more likely to be unreported, and 65% had inconsistencies between primary outcomes defined in the most recent protocols and those defined in published articles.27

Conflict of Interest Financial conflicts of interest can affect the objectivity and trustworthiness of research conduct and publications. For example, researchers whose funding comes from a drug company may be concerned that negative reports may cut off future funding. Industry is now the leading funder of medical research, and much research is con- ducted in nonacademic settings. Industry also is involved in funding evidence reviews and practice guidelines. Conflicts of interest cannot be completely elimi- nated, but awareness of the problem has increased the use of countermeasures. For example, prospective medical journal authors and speakers at accredited courses are required to provide a written disclosure of any financial tie they may have to the subject matter. The IOM28 has urged medical institutions to strengthen their conflict- of-interest policies and asked Congress to require health-related manufacturers to publicly disclose pay- ments they make to pharmaceutical, biotechnology, and device firms and to report through a public Web site the payments they make to doctors, researchers, academic health centers, professional societies, patient advocacy groups, and others involved in medicine. Scientific Misconduct Occasionally, individual scientists publish or attempt to publish bogus research data. The extent of this type of fraud is not known, but its existence presents one more argument for replicating studies. Peer review, high- quality journals, and the demand for replication make detection likely when fraud occurs. Physicist David Goodstein, who has worked with federal agencies to develop guidelines for defining misconduct in science, reported that between 1980 and 1987 only 21 cases of misconduct involving doctors or biologists came to light—which was only three ten-thousandths of all scientists who received research grants.29 Unconfirmed studies, particularly when inconsistent with other stud- ies, seldom have a major impact on what physicians do. Thus, although scientific fraud occurs, it seldom affects patient care. One corrupted study that did affect patient care was published in 1998 by The Lancet, Britain’s premier

medical journal. In it, Dr. Andrew Wakefield and col- leagues suggested that the measles-mumps-rubella (MMR) vaccine might be linked to autism. The paper didn’t declare that cause-and-effect had been dem- onstrated, but at the press conference announcing its publication, Wakefield attacked the triple vaccine, and he has continued to do so ever since. Subsequent stud- ies have found no connections, but sensational public- ity caused immunization rates in the United Kingdom to drop more than 10% and has left lingering doubts among parents worldwide. In 2010, the British Gen- eral Medical Council, which registers doctors in the United Kingdom, concluded that Wakefield had acted dishonestly, irresponsibly, unethically, and callously in connection with the research project and its subsequent publication. Lancet retracted the paper 5 days later, and Wakefield’s medical license was subsequently struck from the register.30

truStwortHineSS oF SourceS It can be extremely difficult for consumers, and some- times even for health professionals, to determine the accuracy of health information. Separating fact from fiction can be a complex and time-consuming process. The reasons for this difficulty include:

• Advice from laypersons may be based on hearsay and personal experience rather than scientific data. Factual information, especially when several individuals are in- volved, is often distorted in transmission.

• Many false ideas “feel right” or seem commonsensical to people who lack the technical knowledge to evaluate them.

• Preliminary and limited scientific studies may be overem- phasized by the media.

• Research data published by experts may conflict sufficiently to cause public confusion.

• Inaccurate health information may be disseminated purely for reasons of self-interest or profit.

• Claims that treatments are based on scientific evidence may not be true. Schick and Vaughn31 have noted that un- scientific practitioners often cite or misconstrue “scientific findings” to support their views.

• “Confirmation bias” can play a decisive role. As noted by Carroll,32 people tend to give more weight to data that support their beliefs, and those who become blinded to evidence refuting a favored hypothesis “cross the line from reasonableness to closed-mindedness.”

Hitchins33 has noted that “extraordinary claims require extraordinary evidence and that what can be as- serted without evidence can also be dismissed without evidence.”

Chapter Two Separating Fact from Fiction 19

Professionals. Most health professionals give reliable advice, but scien- tific training does not guarantee reliability. For example:

• Adelle Davis promoted inaccurate and dangerous nutrition advice despite adequate training in nutrition. As noted in Chapter 11, many of the scientific studies she cited to back up her theories had no relevance to them.

• Robert Atkins, M.D., best known for his low-carbohydrate diet, promoted many types of disreputable treatments (see Chapter 12).

• Andrew Weil, M.D., a Harvard Medical School graduate, mixes sound and unsound advice (see Chapter 11).

Several chapters of this book suggest how to identify professionals who engage in unscientific practices. Many lines of questionable nutrition products have been marketed with endorsements by scientists with respectable credentials. The most notable case occurred with United Sciences of America, Inc., a multilevel company that sold dietary supplements claimed to be effective in preventing cancer, heart disease, and many other diseases. Literature from the company said that its products had been designed and endorsed by a 15-per- son scientific advisory board that included two Nobel prize-winners. However, four members of the board told investigators that they had neither designed nor endorsed the products. A few other multilevel companies claim to be guided by scientific boards, and a few supplement manufacturers have used endorsements by individual practitioners in advertisements. Barrett,34 who believes that all such practitioners hold minority viewpoints, has warned:

Vitamin product endorsements by doctors—no matter how prestigious they are—should be viewed with extreme cau- tion. All I have seen so far have included claims that were unproved and also illegal.

Nonprofessionals. Many consumers have misconceptions about the factors that influence health. People who share their experiences and knowledge may believe in unproven and unscien- tific methods. Such people often are highly motivated to spread their beliefs. Testimonials from movie stars, professional athletes, and other celebrities are commonly used to promote questionable health methods. National organizations exist to promote “alternative” cancer rem- edies (Chapter 16), the Feingold diet (Chapter 6), and other dubious methods. Millions of people have been involved in the sale of dietary supplements and other products through multilevel companies such as Herbalife and The Trump Network (see Chapter 4).35

Pseudoscientists. A pseudoscience is a set of ideas put forth as scientific when they are not. Pseudoscientists misuse and distort scientific evidence to support whatever products or services they promote. They may use scientific terminol- ogy and data to concoct theories that seem plausible to laypersons. They are often sophisticated in manipulating situations to gain notoriety and acceptance. They may write articles and books and may also reach consumers through television and radio programs. Some are “nutri- tion consultants” with “degrees” from diploma mills and nonaccredited schools. Several observers have described characteristics that can help consumers distinguish pseudoscientists from true scientists. Hatfield,36 for example, has noted:

Generally speaking, an establishment scientist has attended and graduated from an accredited university, belongs to one or more well-respected professional organizations, conducts carefully controlled and documented research, and reports these findings in professional journals that maintain high standards for accepting research papers. By contrast, those claiming to be an alternative to es- tablishment science have no common set of standards or practices from which measurements and comparisons can be made or quality of performance judged. Personal testimonies and causal observations quite often serve as the basis of their research rather than act as the impetus to begin research.

Peterson37 has likened improperly designed research to a man rowing a boat from only one side:

No matter how long or how hard he works, he never succeeds in doing anything except going in a circle, never realizing that it isn’t his dedication or his strength but his method that is flawed. Until fringe research puts both oars in the water, it is doomed to remain where it has always been: spinning aimlessly near the shores of science.

True medical scientists have no philosophical commitment to particular treatment approaches, only a commitment to develop and use methods that are safe and effective for an intended purpose. Several observ- ers have noted that pseudoscientists use hypotheses and data differently from scientists. Whereas scientists test hypotheses, abandon disproved ones, and welcome re- view of their findings and conclusions, pseudoscientists reject findings that contradict their beliefs and accuse critics of prejudice and conspiracy.38,39 In this regard, Criss40 explains why we should not as- sume that people with strange ideas are modern Galileos:

To be a true analogy, these people would have to do experi- ments, make observations, and bring these results for all to

Part One Dynamics of the Health Marketplace20

see and question in an open forum. Further, they would have to be denied freedom of speech and press, or any expression all over the land—for that was the injunction against Galileo in 1616! It was as a result of this experience that the scientific method was adopted among scientists. . . . It has allowed the replacement of old ideas with new ones, and has provided a means of judging, and discarding, unfounded ideas.

Beyerstein43 has noted that “alternative” practitioners rarely produce scientific data:

Unless an unconventional therapist keeps detailed records of a sufficiently large number of patients with the same complaint, we have no way of knowing whether the reported number of “cures” exceeds the normal unaided rate of recovery for the symptoms in question. Fringe practitioners rarely keep such data, preferring to publicize lists of satisfied customers rather than the percentage of the total cases that they represent. In addition, because alternative healers practically never carry out long-term follow-up studies, neither do we know how many of their clients receive temporary symptom relief rather than a genuine cure.

Educational institutions. Educational standards are maintained through a sys- tem of accreditation by agencies approved by the U.S. Secretary of Education or the Council on Recognition of Postsecondary Accreditation. Accredited institutions tend to have well-trained faculty members and provide reliable guidance to their students. However, Chapters 8 and 9 note that acupuncture, chiropractic, naturopathy, and massage therapy schools have their own accredita- tion agencies, even though much of their teachings are unscientific. Nonaccredited schools that teach health subjects are usually untrustworthy, and some are diploma mills that issue “degrees” and certificates whose only requirement is the payment of a fee. Chapter 11 discusses the problem of bogus nutrition credentials. Many elementary and high school teachers of health subjects have had minimal formal training in these subjects and hold beliefs similar to those of the general public. Consequently, many misconceptions are passed from teacher to student. In 1983, Dr. Roger Lederer, professor of biology, and Dr. Barry Singer, associate professor of psychology, California State University,44 noted that problems existed even at universities:

In recent years the teaching of pseudoscience and quackery in universities has become common and apparently accepted under the aegis of academic freedom. Typically the material is not formally presented as “Pseudoscience 101,” but is offered as a component of a regular course.

Over the years, at many schools, the situation has become even worse. As Mole45 has summarized:

“Science and society” classes do not nurture the critical think- ing abilities of students. They only nurture a deep suspicion toward all truth claims, particularly those claims perceived to clash with the political ideals of students. . . . If there are no valid criteria for accepting the truth of science, then virtually any idea about the empirical world is valid and there are no authoritative reasons to reject or accept any particular idea.

Many medical schools, hospitals, and professional organizations offer courses they identify as “alternative,” “complementary,” and/or “integrative” methods. Some are appropriately critical, but most provide a forum for promoters. The Accreditation Council for Continuing Medical Education (ACCME) states that “all the recom- mendations involving clinical medicine in a CME activ- ity must be based on evidence that is accepted within the profession of medicine as adequate justification for their indications and contraindications in the care of patients.” However, the ACCME has been very lax in

Historical Perspective

The Pseudoscience of Biorhythms

Creation of biorhythm theory is attributed to Wilhelm Fleiss, a German surgeon who postulated in the 1890s that behavior was determined by innate “male” and “female” rhythms of the body. Current theory postulates three cycles: a 23-day physical cycle, a 28-day emotional cycle, and a 33-day intellectual cycle. Proponents claim: (a) each cycle begins at the exact moment of birth and oscillates up and down with absolute precision throughout life; (b) when the cycles are high, people are likely to be at their best; when they are low, the opposite is true; and (c) on critical days, when the cycles are changing, people are easily distracted and most prone to accidents. Bainbridge41 asked 108 students whether their biorhythms, which he calculated for them on a particular day, were valid. The majority said yes. Unknown to them, however, he had determined their values by flipping a coin. Hines42 subsequently reviewed more than 20 years’ worth of studies and found no evidence to support the claims of biorhythm theory. The human body has real, objectively measurable biologic rhythms that have nothing to do with the aforementioned “biorhythms.” Growth hormone and cholesterol production, for example, tend to peak while people are asleep at night. The science of repetitive and cyclic biologic rhythms is called chronobiology.

Chapter Two Separating Fact from Fiction 21

enforcing this policy.46 As a result, chelation therapy, bogus anti-aging practices, homeopathy, and many of the other dubious methods mentioned throughout this book are promoted through organizations that the ACCME accredits.

Print and Electronic Media Max Gunther47 has succinctly described the role of the media in disseminating health information:

The media have four main functions: to entertain, to inform, to carry advertisements, and to make money for their stockhold- ers. Because of the ways in which these functions are carried out, and the peculiar and intricate ways in which they are connected, an appalling amount of misinformation—ranging from the faintly biased to the downright wrong—is fed every day to an unfortunately gullible public. Hardly anywhere is this more evident than in the fields of medicine and its unwanted cousin, medical quackery.

Publicity is obviously a major factor in the success of quackery. Controversy often works to the advantage of quacks. During the mid-1970s Laetrile (amygdalin) promoters skillfully orchestrated publicity to increase their public following. Court cases of children whose parents wished to withhold conventional therapy

became a rallying point. Laetrile supporters who sin- cerely believed it had saved their lives gained access to national television, where they appeared quite credible.48 During the past several years chiropractic, homeopathy, and other “alternative” methods have received consider- able publicity in mainstream publications with little or no attempt to examine their shortcomings. When the media attempt to present health informa- tion, problems are often evident: (a) coverage of a subject is inadequate because of the limited time allotment; (b) selection or screening of speakers or subject areas is poor; (c) pseudoscientific claims often are presented without rebuttal from qualified experts; (d) attempts are made to sensationalize and overdramatize preliminary or new findings, especially about cancer, heart disease, arthritis, or alleged environmental dangers (Figure 2-1); and (e) attempts are made to attract large audiences with claims that “alternative” methods are effective. Koren and Klein49 have noted that the media have a natural tendency to report more on positive medical findings than on negative ones. This tendency contributes to the difficulty laypersons have in placing medical news in perspective. Barrett and Herbert50 note additional factors in the spread of misinformation by the media:

• Magical claims about health methods tend to be regarded as more newsworthy than established facts. Nationally tele- vised talk shows provide enormous publicity for promoters of quackery.

• Time works to quackery’s advantage. It is much easier to report a lie as a straight news event than to investigate it.

• Some journalists who have been misled by false ideas can- not write accurate reports.

• Most promoters of health misinformation are regarded as underdogs in a struggle against the establishment. As such, they tend to be treated with undeserved sympathy. Most editors insist that articles that attack false ideas be balanced so that the apparent “underdog” gets a fair hearing. Even science editors rarely feel a duty to issue effective public warnings against misinformation.

• Many more people are actively promoting misinformation than are actively opposing it. The sheer force of numbers works against the truth.

• Publications that accept ads for food supplements may be unwilling to risk offending their advertisers. For example, when Self magazine published an article by a freelance writer listing money-saving tips from the 1980 edition of this book, a tip about spending less money on vitamins was deleted from the writer’s manuscript by the magazine’s editors.

• Many editors fear that attacks on nutrition quackery will stir up controversy from readers who regard nutrition as their religion.

Figure 2-1. Magazine cover, 1992. Sales for this issue topped all others during the first half of the year. The six- page story, which speculated about antioxidant vitamins, was hailed by the health-food industry as a “watershed” event. In 1996, after studies refuting these speculations were published, Time covered the subject only briefly.

Part One Dynamics of the Health Marketplace22

• Many editors fear that attacking the credibility of a quackery promoter will result in a libel suit.

Although libel suits related to health issues are rare, other forms of economic reprisal are not. Some manufac- turers cancel or threaten to cancel ads when magazines run articles that criticize their products, and “alternative” practitioners often initiate letter-writing campaigns or cancel their subscriptions when publications criticize their methods. After publication of the third and fourth editions of Consumer Health, chiropractors attempted to execute a boycott52 and bring other pressure on the publisher to make the book’s discussion of chiropractic more favorable. Many publications use sensational claims to generate sales. Tabloids and women’s magazines, for example, frequently carry articles on “quickie” reducing diets or “superfoods.” Marilynn Larkin,53 a freelance writer in New York City, has noted that topic selection is com- monly based on sales appeal rather than scientific merit. Even a well-written article may be accompanied by a sensational headline that contradicts the article itself.

Newspaper headlines are often composed by an editor who did not write the article and is not well-versed in the subject matter. Paul Offit, M.D., chief of infectious diseases at Chil- dren’s Hospital of Philadelphia, has noted that counter- ing misinformation—even with a mountain of evidence available—can be a challenge. Referring primarily to the spread of false claims that vaccines are dangerous, he said, “It’s very easy to scare people; it’s very hard to unscare them.”54

Lack of peer review. Scientists are generally eager to point out the deficiencies in each other’s theories and experimental techniques. Journalists, however, almost never publicly criticize each other’s coverage of the news. This is particularly true when health topics are involved. Stories about “alterna- tive” methods rarely enable readers to judge whether proponents’ claims are true. Skeptical Inquirer, Skeptic, and the antiquackery Web sites are among the very few that publish unrestrained criticisms of poor reporting. The National News Council was founded in 1973 “to serve the public interest by . . . advancing accurate and fair reporting of news.” It investigated complaints alleging unfairness, inaccuracy, or breaches of ethical standards by wire services, newspapers, news syndicates, news magazines, and television and radio networks and stations. The Council exerted some pressure on media outlets, but its findings were not widely publicized. It ceased operation in 1984, citing lack of media support as the primary reason. Some media outlets have referees (ombudsmen)55 to whom complaints can be made, but misleading health reports are rarely investigated.

Advertisements. Many periodicals contain ads encouraging their readers to buy vitamins and minerals, herbs, wrinkle remov- ers, weight reducers, headache-relief drugs, pep pills, and various other health-related products. Advertising, however, is frequently misleading—often deliberately so. Advertising claims often have multiple meanings, one or more of which may be false. Many ads describe a product in terms of a mystical ingredient rather than specific contents or values. Advertising dollars can also affect what gets pub- lished. Gunther47 has observed: “Fear of losing good advertisers is one of the common reasons why worthless medicines and gadgets and treatment methods get free plugs and why you do not see honest medical rebuttals printed as often as could be wished.” Chapter 4 discusses this subject further.

Personal Glimpse

Pseudo-Balance It isn’t just the shiny magazines that give unproven medicines such an easy ride. What is the attraction of unproven medicines for the weightier news publications. . . . Surprising angles, new scoops, wonder cures and personal accounts are all a lot more interesting to most readers than a bunch of hard statistics, and unproven remedies tend to be strong on personal anecdotes (and, of course, the one thing that unproven remedies can’t provide is decent data!) Journalists also need to give more than one opinion. In many health features and interviews, unproven alternative therapy can often seem like the perfect antidote to a dry medical expert. “Traditional” therapies versus “modern medicine,” or “natural” versus “pharmaceutical,” or “herbal” versus “drug”-- the contrasts make for a compelling feature story. But the trouble is, the two “sides” may not be as equal as they seem. . . . Better investigative features do more than hang an argument between opposing views. They consider the ordering of these views carefully, and seek to position and frame information so that readers can understand the merit of each viewpoint. Clare Bowerman51

Chapter Two Separating Fact from Fiction 23

Newspapers. Many newspapers use overdramatization of incidents, inaccurate or exaggerated reports, quotations from unreliable sources, and misleading headlines to attract reader interest and attention. The weekly tabloids are notorious for this. HealthNewsReview.Org, a project of the Founda- tion for Informed Medical Decision Making, provides independent expert reviews of news stories. Among other things, its reviews look for adequate analysis of the qual- ity of the evidence and whether new ideas are compared with existing options.56 In 2010, after reviewing more than 1000 stories by more than 70 news organizations, the organization reported that about 70% of stories overemphasized benefits, minimized harms, and failed to adequately discuss costs.57 Consumers should be wary of reports indicating that studies were completed on small numbers of subjects, done in foreign countries (evidence of accuracy is more

difficult to ascertain), or based on animal studies alone. Preliminary findings can be important, but they do not become established as facts unless additional studies support them.

Magazines and Newsletters. Magazines and newsletters differ widely in the accu- racy of the information they publish. In 2006, experts associated with the American Council on Science and Health59 evaluated the nutrition information in 22 popular magazines from 2004 through 2005. Up to 10 articles from each magazine were examined for accuracy, readability, substantiation of contents, and reliability of recommendations. Consumer Reports scored highest, followed closely by Glamour, Ladies Home Journal, and Shape. The worst were Cosmopolitan, Muscle & Fitness, and Men’s Fitness. Although Consumer Reports’ coverage of health topics is generally reliable, it has virtually ignored the dubious practices described in Chapter 8 of this book. In 2011, for example, it reported the results of a survey of readers who were asked about their experiences with acupuncturists, chiropractors, and massage therapists. The article stated that the survey data might not represent the experiences of the general population and should not be compared to the results of clinical trials. However, in- stead of warning about the risks of consulting such these practitioners, the article recommended using proponent organizations to help find them.60 The major news magazines, Time, Newsweek, and U.S. News & World Report, are good sources of news on general health topics. Their articles are usually timely, well-written, and based on interviews with recognized experts. However, all three of these magazines have publicized news about “alternative” health methods without appropriate critical analysis.61 Newsweek has also published several unduly alarmist articles about environmental factors and co-sponsored the 1996 Las Vegas Health Show, a large exposition at which many speakers and exhibitors promoted unscientific methods. Many periodicals specialize in health-related infor- mation. Dr. Barrett, who monitors many of them, has summarized his ratings in Table 2-2.

Books and other Literature. Thousands of health-related books, booklets, and pam- phlets are published each year. The First Amendment of the Constitution protects free speech and thus, un- fortunately, permits authors to publish inaccurate and misleading health information as long as it is not directly tied to the sale of products.