Credibility of consumer health digest

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

BARATZ

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.

1 2 3 4 5 6 7 8 9 0 QDB/QDB 1 0 9 8 7 6 5 4 3 2

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