Dr David Grimes: challenge claims and stand up for science

As in other “policing” areas this is a question of scale – imagine the number of adverts and then the number of experts, bodies and beaurocracy needed to adjudicate. I do not think it feasible.

I would rely on people in general and expert organisations reporting blatant advertising misrepresentation and requiring supporting evidence form the advertiser to support their claim. The cost of investigation should be paid by the advertiser, refunded only if the claims were true. If untrue, the company should be fined and, if fraudulent, criminal proceedings take. Is Trading Standards the starting point – if only we had a well-funded national organisation.

We do have to learn how to deal with persuasive adverts that are not untrue but appeal to our emotions. Every organisation that sells products or services wants to persuade you to buy, so will miss out the negatives. Is that misrepresentation?

How would MPs survive in this scenario?

Ask for the Evidence I am proud to say I used a few days ago querying the lifetime use claims on electrical drills.

However the problem remains that unless there are penalties for making unverified or unverifiable claims we are not much further forward in preventing them. The interesting case of Cokes Vitaminwater where its US counsel argued that a normal person would not believe that it contained vitamins is on record and googleable.

What’s the relevance of that piece? Cancer diagnosis has been rising for decades and will continue to rise as the population ages. You have to die of something, and the more you don’t die of injury, infection or heart disease, the more you’re likely to die of cancer.

Homeopathy has no supporting evidence so, on this basis, should be banned. However the NHS has some Homeopathic hospitals and some GPs practise it. Presumably these are scientifically-trained logical people. Just to illustrate the difficulty.

Is it just is important to disprove something as it is to prove it? On the one hand homeopathy may work, or the thought it will work might be sufficient to help some people; against that, using homeopathy instead of a mainstream treatment might be damaging or fatal.

I think Malcolm a lot more research is needed in the field of homeopathy and the placebo effect.
Each and everyone reacts differently to a variety of remedies which is evidence of our uniqueness. Tighter regulation is essential to prevent charlatans from profiteering from other people’s misery. The National Institute for Clinical Excellence (NICE) is the official governmental body appointed to approve and regulate malpractice and misrepresentation.

All the research so far has shown no demonstrable effect. So far. As you say, maybe more is needed. I think we may share a view in principle. However, my point was where do you penalise advertisers when proof for and against can be vague? And, as you say, at what point does misrepresentation become an issue? Do we all need multivitamins?

Charles, being given a treatment you believe can help you, even if it has (to others) no proven beneficial effect, is surely good enough for it to be classed as a placebo? And if that belief works, then surely that is good? I have not a clue whether placebos can be beneficial. Do we have any research to demonstrate any effect?

I’m almost sorry I introduced homeopathy. As an engineer I do not see how it can work, and I see proponents of it but not evidence to support it. Lack of evidence is good enough for me to discount it for my own use. But – evidence is not always easy to find, even though we believe some things work. I’m sure it is a myth but I remember being told that by the laws of aerodynamics a bumble bee cannot fly, yet it does. Some believe in dark matter but, as yet, I don’t know whether we have found any, have we? Hypotheses are used to help explain situations when proof is scarce.

The key in this conversation is critical thinking – keep an open mind and look at available facts. Then make your best judgment. You might make the right choice.

Malcolm, “more research is needed” is the endless mantra of those who promote quackery. Sometimes no more research is needed.

Homeopathy is, by now, solidly shown to be worthless, but they still want “more research” because every now and then chance will throw up a positive result they can use to keep the flame alive.

It is ethically indefensible to conduct any further human studies on homeopathy until the following conditions are met:

1. Proof that like cures like as a general or useful principle. It’s based on a single speculation by Samuel Hahnemann over 200 years ago, that cinchona bark cures malaria because cinchonism is “like” malaria. Actually it cures malaria because it contains quinine which kills plasmodium falciparum, the parasite that causes malaria. There is absolutely no reason to believe homeopathy should work in the absence of a robust proof that like cures like, and that symptomatic similarity has any role in the treatment of disease.

2. Proof that dilution increases potency. Thus far not one study has decisively answered the question of how many shakes are required, how many strikes of what force, or whether the shaking and striking is even necessary, and no test, however sensitive, can tell the difference between two similarly prepared remedies at normal potency.

3. A credible – or even remotely plausible – mechanism of action. Homeopaths focus on bits of research showing apparently anomalous effects in water, but in reality even if water did have a memory and it was persistent and somehow related to the magical property involved in symptomatic similarity, the bioavailability in a remedy as normally presented would be zero. It’s very common for drugs to fail to make it to market because it’s simply not possible to deliver them to the affected organ in a meaningful dose without unacceptable side effects. The human body has a superb engine for preventing things we consume form making it into the bloodstream without being broken down into the usable parts.

Of course homeopaths will arm-wave about “energy”, but they are never able to specify what form of energy or how much. Energy is measured in Joules and is physically measurable, it’s not a synonym for magic.

Charles: Looking at it from a psychological point of view my research has come up with the best and most interesting study I think on http://www.psychologytoday…/exploringtheplaceboeffect/11nov2012. Dr Novella explains how endorphins in the brain contribute to and people with high levels of dopamine are more likely to experience placebo effects. Fascinating stuff!

And I’m not picking on you, it’s just that homeopathy is a particularly unambiguous example. Acupuncture is an interesting one – it has by now been convincingly demonstrated that it doesn’t matter where you put the needles, so meridians and qi are out (as expected, given their inconsistency across traditions and lack of empirical evidence of their existence). Recent experiments also cast serious doubt on whether it actually matters if the needles are even inserted, so it’s very likely that acupuncture is purely a theatrical placebo – a small amount of research may be justifiable, but there are risks associated with the practice so careful attention is required to the ethics of any trials.

Interestingly, the US National Center for Complementary and Alternative Medicine (NCCAM) has spent about two billion dollars on trials of various CAM practices, and failed, thus far, to validate a single one. It’s my strong belief that anything still in the “alternative” bucket is, by now, not worth looking at, and that’s doubly true for those which have become alternative only after being refuted scientifically – HCG for weight loss, chelation therapy for heart disease and autism and so on.

Minchin’s Law applies.

Guy, as I said I do not believe in the principle – so I agree with your comments. However I also believe in the freedom of people to carry out research into whatever they choose – but to present those results for peer review and not launch them on the unsuspecting as proof of their belief (or opinion). MMR vaccine acceptablilty was damaged by, I believe, lack of a proper approach, wasn’t it, and that was by supposedly reputable people. People whose views we would normally respect.

But, we make little progress if we stifle free thinking – even from cranks. Our belief and opinion might just turn out to be wrong.

Sure, people should have freedom to investigate anything, scientifically, but there are ethical considerations too. The rules for conduct of human studies are set out in the Declaration of Helskinki and they require that there should be evidence that the experimental population be likely to benefit from the outcome of the research. This is a very hard sell with homeopathy. While there’s undoubtedly a strong case to be made that there would be benefit from withdrawal of homeopathic nostrums as purported treatment and/or prevention of serious disease, there’s compelling evidence that no negative study outcome is likely to influence the practice of homeopaths. The Society of Homeopaths has publicly stated that homeopathy should not be promoted for prevention or treatment of serious disease, but in submissions to the House of Commons on antimicrobial resistance and homeopathy generally they have pretty much stated the opposite.

The problem with treatments not anchored in reality is that they have no system for self-correction. The entire purpose of medical research is precisely that: self-correction. Marshall and Warren corrected centuries of incorrect practice by demonstrating that duodenal ulcers can be caused by infection with helicobacter pylori, and that changed the standard of care very quickly. I have never seen any evidence of any alternative practitioner amending their practice in response to a study that finds any part of their beliefs to be incorrect.

I suggest we turn our attentions from homeopathy to some of the dodgy claims currently used in advertising. Any reasonable person will understand the scientific explanation why homeopathy cannot work, so that puts homeopathy in the category of belief – like religion. Both are interesting to explore but extended debate achieves little.

David’s article in Focus on Alternative and Complementary Therapies uses the solar system to help visualise the dilution involved in homeopathy. This is a useful approach for anyone who finds it difficult to comprehend very large/small numbers. I don’t believe the full text is freely available.

I very much agree that we need to raise awareness of false product claims and to have suitable penalties in place, but the problem with this approach is that companies are likely to have a period in which they can profit by the sales of these products and some of the customers will be miffed when they are withdrawn. One thing we don’t want to encourage is public distrust of science.

As I suggested above, product information and advertising claims need to be scrutinised before products are put on sale, and this will have to be funded by the companies. Companies can save costs by not constantly changing their products and marketing. Since that would apply to all companies, it’s an even-handed approach.

Thanks for the reminder about the AllTrials campaign, Dieseltaylor. I signed up during an earlier Conversation.

Accounts auditing is funded by the companies – look how well that works (Tesco??). It would have to be independent and expert – where are all those resources? I’d rather see them deployed doing something more constructive. Instead, respond to significant reports of advertising malpractice with a properly funded body – Trading Standards? Ensure that adequate penalties are in place for misleading, deceptive or untrue claims to make it commercially not worthwhile; we want to prevent it, not just catch culprits.

Malcolm – I agree that claims would have to be vetted independently and experts. That would have to be funded by the companies wanting to market their products. If no claims are made then there are no claims to be tested.

Trading Standards is not coping at present and there is no indication that this will change soon. Even if more money was available, the current remit of TS is to investigate reported problems. What I am suggesting is to vet claims before products go on sale. In many cases it has been established what product claims are permissible for ingredients used in foods, so other producers of similar foodstuffs can make the same claim.

Introducing a novel claim will be what costs money, but a company should be prepared to provide good evidence to support their claim and pay for this to be independently vetted. What I am suggesting is that claims are scrutinised before the product goes on sale instead of waiting until the Advertising Standards Authority has received a bunch of complaints.

wavechange, I understand what you are proposing, but simply believe that there are too many new claims for it to be practical to vet every one – good, bad or indifferent – before they are marketed.

If there are many new claims (I was not aware of this) then all the more reason for having these vetted before products go on sale. If these claims are just new to a product but acceptable for similar products, there may be no reason for investigation or delaying the launch of a new product.

I don’t see that it is impractical to vet new claims before products go on sale.

It won’t happen because the supplement industry won’t allow it to happen. We’re not quite as bad as the US, where supplement industry stakeholders in government pushed through the DHSEA, an Act that effectively prevents the FDA from even looking at a supplement unless people are clearly being harmed by it, but we’re not far off.

It’s interesting to see the fallacies used by the supplement industry when Europe looked at restricting maximum vitamin doses on sale (i.e. pushing back against vitamin megadose quackery) – they presented this as Europe wanting to take away your vitamins. This claim was of course entirely false.

I appreciate that the supplement industry is a big problem, Guy, but that should not stop us making inroads elsewhere.

I agree, but I don’t think you’d ever be able to have a system where all marketing claims are subject to prior approval – that would be a bureaucratic nightmare. The ASA do a pretty good job, I think the only thing that needs to change is that there should be an offence of false advertising, and it should be possible for courts to issue injunctions forbidding people form repeating advertisements that have been adjudicated as false.

It’s the difference between moderation and retromoderation, in online discussion terms. Moderation is a guard, a deterrent, and means that only the most motivated even participate, whereas retromoderation is a traffic policeman, keeping people’s minds on the consequences of stepping outside the boundaries.

I totally agree. I think critical thinking should be a core curriculum subject in schools, but I suspect that no politician in the world would risk giving rise to a generation capable of analysing their claims rationally.

I agree with you. Handwash has become a ‘lifestyle’ product promoted in fancy bottles with alluring names, pretty colours and beguiling fragrances. This is marketing, and more or less what i would expect. What annoys me is that this stuff is given added currency by the editorial content of ‘lifestyle’ magazines and other media that probably knows better but is frightened of losing valuable advertising. The hygiene-in-the-home scare has even reached the point where manufacturers have come up with battery-powered no-touch dispensers of hand cleansers. No doubt automatic sterile latex glove applicators will be next [put your hands in the pod and they come out ready-wrapped for household chores]. This is another area where sensible education would make a difference.

One of the issues I see with the widespread use of alcohol hand disinfectants is that poeple stop looking at the wider picture.
We are encourgaed or even mandated to use these when visiting hospitals, dentists, blood donor sessions , but no attempt is made to stop almost instant recontamination by everything we then touch which has not been cleaned. i.e. seats contaminated by clothes, forms or leaflets handed out.

I can see the value of alcohol-based disinfectant where there is a risk of transmission of an infection from a sick person or where someone is very ill in hospital and at risk of infection. I see no reason for using antibacterial handwash in the home, when ordinary hand washing does an adequate job.

What concerns me is that the manufacturers are implying that we need these products in the home.

Exactly. I am not aware of any credible evidence that the antibacterial products confer any benefit over good old fashioned soap, when used correctly, and I seem to remember a publication showing precisely the opposite, but I can’t find it now.

Soap, hot water, a decent nailbrush, and none of your microbeads thanks all the same.

Beryl – You have asked for the reason that homeopathy does not work. The reason is that the extent of dilution is huge and any active component will no longer be present. A disproportionate amount of time and effort has been put into investigations of homeopathy already. We need to move on, but I don’t know how that can be achieved.

wavechange, I belive that as well. However clearly some people do not – including people within the NHS. Just because we hold a particular opinion – even when quite well founded – it does not mean we should be dismissive of contrary views. If someone wants to continue investigating an apparantly dead-in-the-water topic, that is their affair – providing public money is only used for more promising projects.

What we need to do is first, educate people not to take everything at face value, second to do some basic research – internet and books – and third to use critical thinking and common sense to reach their own conclusion. May get it wrong, may get it right, but at least they have made their own judgment.

Malcolm – I’m normally very guarded but I put homeopathy firmly in the same category as perpetual motion machines. We have a well respected explanation – the placebo effect – of why homeopathy appears to work. I hope that the NHS will discontinue involvement with homeopathy but maybe not until we have a Health Secretary who does not support the approach.

Critical evaluation helps only where you have gained enough experience. It will not help if you encounter a product that claims to be beneficial to the health of your heart, for example. My advice is to be very wary about what is published on most websites.

Guy, I couldn’t agree more. All of which takes place in the mind or the brain whichever you feel comfortable with. One day this will all be measureable, I hope I will still be around to witness it!!!

Beryl – I’m sure we will continue to learn more about the placebo effect and maybe even use it to our benefit. A personal example is that I find pink ibuprofen tablets more effective than white ones. As a scientist I’m uncertain about whether to be embarrassed to admit this or simply to accept it as an interesting phenomenon. On the NHS page about the placebo effect, there is a short video in which Ben Goldacre mentions this aspect of the placebo effect. I have know about this for many years but only relatively recently have I been aware how much I am affected.

Like you, I have never considered using homeopathy. It concerns me that there are people pretending that it is effective and consigning its funding by the NHS is my top priority.

Wavechange: Coincidentally I have recently researched the phenomenon of different coloured pills and their psychological effect so you have no reason to feel embarrassed at all. Apparently Red (or pink in your case) are mostly the preferred colour for painkillers and blue is for anti-depressants. I cant remember what yellow pills were for but I think it was the preferred colour for stomach complaints. There is definitely a psychological hidden message behind it all. Interesting nevertheless.

I should look out for red ibuprofen because they might be even more effective than the pink ones. 🙂

“Ibuprofen may cause an increased risk of serious and sometimes fatal stomach ulcers and bleeding. Elderly patients may be at greater risk. This may occur without warning signs.”

Not for the elderly wavechange !!

Actually, Beryl, most of it doesn’t take place in the mind. The largest single cause of falsely attributing “cure” to bogus remedies is the symptoms simply getting better – either through immune response or because they are naturally cyclic.

Dieseltaylor – I’m one of these people who reads about side-effects and contraindications before taking any unfamiliar pill. I also know that ibuprofen, like aspirin, can be a problem for asthmatics like me, but I’m one of those who is not affected. A pack of 16 pills lasts a month, so hopefully I’m not at great risk.

It does surprise me that ibuprofen is on the supermarket shelves (albeit with sale restricted to two packs of 16 x 200mg pills), usually with the important information in tiny print. The ibuprofen tablets sold by Tesco have the main points on the packaging, whereas other generic versions do not.

Guy: The immune system is controlled through the CNS. Ref: sciencedailycom. ‘How the Immune System and Brain Communicate to Control Disease.’

Beryl: That does not make immune response conscious, and in fact I don’t think that’s a particularly meaningful way of looking at it anyway. The immune system includes a lot of largely autonomous closed-loop processes, like those in the gut wall.

However, that’s arguing about angels dancing on the head of a pin. The point at issue is that cranks, quacks and charlatans have no special access to the immune system – and in my view it’s just as well that the claims to “boost the immune system” are b******t given that an overactive immune response is responsible for so many disorders.

The majority of cases where the patient recovers with quack treatments, are because the patient simply gets better, exactly as they would have done with no treatment. Since “The Powerful Placebo” a lot of work has been done that tries to unpick the actual effects from the cognitive biases, and the consensus seems to me right now to be that placebo response, as in, actual physiological effects from placebo, is very weak, transient and not at all dependable, see “Is the Placebo Powerless? — An Analysis of Clinical Trials Comparing Placebo with No Treatment” (A. Hróbjartsson, P. C. Gøtzsche, N Engl J Med 2001; 344:1594-1602May 24, 2001 DOI: 10.1056/NEJM200105243442106).

I don’t think we disagree fundamentally on this though, the pathological search for supportive findings from refuted, nonsensical or wildly implausible treatments is unhelpful to anybody especially the experimental subjects.

Yes, Kaputchuk’s experiment is very subtle and really rather clever. This is one of those papers like Ioannidis and Dunning-Kruger that every student of bogus medical claims should read.

Nobody dismisses the placebo effect, but as noted above the current state of knowledge shows that the actual physiological effects are essentially negligible; most of what is reported as placebo effect is basically the patient telling the researcher what they think they want to hear, and the symptoms getting better because they were going to anyway.

There is no “mind over matter” or “pure placebo” effect worth testing. Experiments since the early publications on placebo effects have (as is the case with virtually every highly cited finding) dramatically reduced the estimates of effect.

That is what open-minded scientists find. There exists also a cadre of people who for one reason or another have some emotionally or financially vested interest in there being a large placebo effect which is somehow “real”. They do indeed need to develop a more open mind. However, many of them are members of the SCAM community, and that is, sadly, a community in which the mind is permanently closed to dissenting opinion.

” AUTHORS’ CONCLUSIONS:
We did not find that placebo interventions have important clinical effects in general. However, in certain settings placebo interventions can influence patient-reported outcomes, especially pain and nausea, though it is difficult to distinguish patient-reported effects of placebo from biased reporting. The effect on pain varied, even among trials with low risk of bias, from negligible to clinically important. Variations in the effect of placebo were partly explained by variations in how trials were conducted and how patients were informed.”
http://www.ncbi.nlm.nih.gov/pubmed/20091554

Lets see “clinically important” ” variations partly explained” all seems a little less cut and dried than some would be suggesting. I get the impression that some people get rightly excited about extravagant claims for placebo and then use phrases such as ” dramatically reduced the estimates of the effects”.

I am unaware what the original claims were so to be told they are dramatically resuced does not actually mean, to me, that there is no placebo effect. Just that it is less than some people have claimed.

I believe in Ben Goldacres first book it mentions people who were given the correct medicine for their complaint but not told it was such. AFAIR the medicine had no effect. Being Ben Goldacre I am sure it would be a pukka experiment.

This from another work:
” Placebos have been reported to produce some rather startling effects on skin conditions. The most impressive of these reports involves the suggestion-related production and inhibition of contact dermatitis (6). Contact dermatitis is a skin condition produced by chemical substances to which people have become sensitized. In the study reported by Ikemi and Nakagawa, 13 students were touched on one arm with leaves from a harmless tree, but were told that the leaves were from a lacquer or wax tree (Japanese trees that produce effects similar to poison ivy and to which the boys had reported being hypersensitive). On the other arm, the subjects were touched with poisonous leaves, which they were led to believe were from a harmless tree. All 13 subjects displayed a skin reaction to the harmless leaves (the placebo), but only two reacted to the poisonous leaves.”
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2582668/

It could be regarded as a party trick but I think to most people it and another case quoted shows the mind has powerful mojo.

As I pointed out above, the idea that there is some mystical placebo-based mind-over-matter effect, is considered refuted. The original claims in the 70s were striking, and as with most striking and highly cited results, they turned out to be overstated. There are some effects such as you describe, but they are weak, unreliable and transient. In the majority of cases the purported placebo response turns out to be either the patient telling the practitioner what they want to hear, or the patient simply getting better anyway.

This peer-reviewed publication is, I think, more reliable and comprehensive than the source you prefer: http://www.nejm.org/doi/full/10.1056/NEJM200105243442106

“In the majority of cases the purported placebo response turns out to be either the patient telling the practitioner what they want to hear, or the patient simply getting better anyway.” This is purely a biased assumption and is not based on any credible evidence.

Ref: Ongoing studies in Sweden at the Karolinska Institute & Harvard Medical School “Placebo can be activated unconsciously.” Updated on 2014-06-17. Further investigations to take place using neuro-imaging.

I think we have long moved away from mystics and magic Guy. In the real world scientific research will continue as long as positive results prevail over negative and I believe I have provided enough evidence to back up my assertions. I will now respectfully bow out and refrain
from any further comment on this particular subject.

I’m not saying that the narrative around placebos is wrong, only that I am wary of it, due to past history of special pleading by quacks and charlatans. Neurologist Dr. Steven Novella sums this up much better than I can: http://www.sciencebasedmedicine.org/the-placebo-narrative/

And here’s the kind of dangerous nonsense that is generated fomr that kind of thinking: http://www.sciencebasedmedicine.org/eminent-harvard-psychologist-mother-of-positive-psychology-new-age-quack/ – that is why I am very suspicious of anything that looks like advocacy of “mind over matter”, aka wishful thinking, because that has been well tested and it simply does not work.

Careful testing shows that mental attitude has no effect on organic disease (e.g. summary here http://www.cancer.org/treatment/treatmentsandsideeffects/emotionalsideeffects/attitudes-and-cancer). And it’s been shown in several studies that while self-reported pain is reduced in patients undergoing placebo therapy for nociceptive pain, their use of pain medication does not actually reduce. That casts serious doubt on the idea that placebo effects are “real”.

It’s certainly not a straightforward question and I don’t think we have the final answer yet by a long way, but it is very clear that the boldest and most striking claims for placebo effects are at best overstated if not completely wrong.

@Beryl specifically: “I think we have long moved away from mystics and magic Guy” – I wish this were true. We (that is, you and I) may well have done but a flip through the pages of What Doctors Don’t Tell You shows that mystics and magic are alive and well.

I should add perhaps that Mauna Kea is 13,800ft high and temperatures there dips below freezing every month of the year. So whilst the report may be true but it is entirely misleading, in my view, to imply that Hawaii the state, is suffering anything freakish.

Currently on Mauna Kea according to Accuweather in C
Hi / Lo
Previous 6 Hours 28° 25°
Previous 12 Hours 29° 23°
Previous 24 Hours 29° 21°

Incidentally the sentence itself seems:
“Temperatures across all 50 US states plummeted to freezing, and there were snow-related fatalities elsewhere.” BBC
seems nonsensical.

Rather suddenly I was thinking of another thread and feeling sympathy for her. : )