Practitioners of "complementary and alternative medicine" (CAM) have a love-hate relationship with randomized clinical trials (RCTs). Actually, it's mostly hate, but they do crave the validation that only randomized clinical trials can provide within the paradigm of evidence-based medicine (EBM). Yes, I intentionally said EBM, rather than science-based medicine (SBM), because, as I've described so many times before, the two are not the same thing. EBM fetishizes clinical trials, a fixation that I sometimes call "methodolatry," defined by a blog bud of mine from long ago as the "profane worship of the randomized clinical trial as the only valid method of investigation." Of course, as I've also explained many times that SBM is needed is because EBM mostly ignores prior plausibility and basic science in favor of clinical trials. The EBM "pyramid" of evidence begins with basic science at the very bottom of the pyramid, which, as one climbs the pyramid, progresses through case reports, case series, case control studies, and cohort studies, progressing to RCTs and then systematic reviews and meta-analyses. If you look at a typical EBM pyramid, you'll see that animal research and in vitro research are ranked below even "ideas, editorials, opinions." That's how CAM research infiltrated EBM. Modalities that can be dismissed as highly improbable or even impossible on basic science considerations alone, such as homeopathy or reiki, are not considered "impossible" for purposes of EBM because basic science is so low on the EBM pyramid. SBM is intended to try to correct this oversight.
The reason for this oversight is that there is an implicit assumption underlying EBM, and that's that RCTs are not performed on a new treatment until it has "climbed the pyramid," going through stages of preclinical basic science that supports it, through less rigorous preliminary study designs, and finally to RCTs before it's considered validated and can become a standard of care. In other words, none of the shortcomings of EBM should be construed as meaning that RCTs don't remain at the apex of clinical evidence for a treatment or drug. They do. It's just that for modalities with very low prior plausibility, the "noise" of RCTs can lead to a lot of false-positives. As I've said before, it's not plausibility bias that leads me to these conclusions. It's reality bias. That's the reason why CAM advocates try very, very hard to do what I like to call the CAM "appeal to other ways of knowing." Specifically, that's why they try to discount the value of RCTs and argue that we should use other methods to prove that their woo works. I've seen it time and time again.
And I've seen it again just this week, not once but twice.
The first example comes from that citadel of quackademic medicine, that blight on the National Institutes of Health (NIH). I'm referring, of course, to the National Center for Complementary and Alternative Medicine (NCCAM). It's right there on the director's blog, where Dr. Josephine Briggs speculates on When to Get Pragmatic. It is, unsurprisingly, an argument for applying pragmatic trials to CAM interventions, and it's full of the same fallacies CAM advocates use to argue for "other ways of knowing" about CAM that don't involve rigorous RCTs. I normally expect better from Dr. Briggs, as I've felt a bit sorry for her. She's an actual scientist overseeing a Center that by its very nature can never by scientific, which is why I sympathized with her effort in the NCCAM five year plan, which I referred to as "let's do some real science for a change." This argument for pragmatic trials, however, is just sad:
Many complementary approaches are readily available in the marketplace. As a consequence, NCCAM sits at the crossroads between research and real-world consumer use. The general public wants to know what works and what doesn’t, and increasingly health care providers also want reliable information. Complementary health approaches are being integrated into the care offered in many nursing homes, hospices, and hospitals, and these health care organizations want good information to drive decisions about which therapies to provide or recommend. NCCAM wants to take on the challenge of meeting this need, but by and large we do not have the kind of rigorous, high-quality data that would help answer these questions.
None of this is a valid argument for decreasing the rigor of clinical trials. Rather, it is an argument for either doing the rigorous clinical trials that would be necessary to "answer these questions," as Dr. Briggs put it, or to filter what we already know through the Bayesian lens of prior plausibility based on scientific knowledge. But that's not what NCCAM is about, its protestations otherwise notwithstanding. It thinks that that's what it's about, and it even walks the walk when it comes to pure methodology. What the leadership of NCCAM can't seem to understand is that, when it comes to hardcore CAM modalities, what it is doing is "tooth fairy science," as Harriet Hall calls it. As she points out, we can study the amount of money left by the Tooth Fairy in different settings, but since we haven’t determined that there is really a Tooth Fairy, any conclusions we reach will be falsely attributed to an imaginary being rather than to the real cause (parental behavior). As for other modalities that have fallen under the rubric of CAM, such as dietary interventions, lifestyle, and exercise, these are nothing more than science-based modalities magically "rebranded" as CAM.
So what are "pragmatic" trials? They're basically an attempt to determine whether treatments validated in RCTs work under "real world" conditions. RCTs are intentionally designed to make the population studied as homogeneous as possible, both to minimize differences between the control group and the experimental groups and to decrease variability within groups, the better to isolate the signal from the difference between treatment and control. However, once a treatment gets out into the community, it becomes more widely used, and the rigid inclusion and exclusion criteria used to select subjects for clinical trials fly out the window. The patients upon whom the treatment is used become much less homogeneous, and differences between academic medical centers and the community can change how the treatment is delivered. So "pragmatic" trials seek to determine effectiveness in the real world, which is a different thing than the efficacy determined in the rarified, tightly controlled world of RCTs. Here's the problem. Pragmatic trials in CAM are putting the cart before the horse. You need to demonstrate efficacy in RCTs before it's appropriate to consider doing pragmatic trials to determine real world effectiveness.
None of this stops Dr. Briggs from writing:
Two of the Collaboratory studies will address pain management. The LIRE study, a partnership with the National Institute of Arthritis and Musculoskeletal and Skin Diseases and a number of Health Maintenance Organizations, looks at the impact of more detailed radiology reports for back pain imaging studies on subsequent use of resources. The second partnership, a study called PPACT, which involves a number of Kaiser health systems, with oversight from the National Institute on Drug Abuse and the National Institute of Neurological Disorders and Stroke, will examine the impact of an integrated pain management strategy implemented in primary care practices.
Notice that neither of these studies involve CAM. The LIRE study involves looking at more detailed radiology reports and whether they are useful for targeting pain management. Neither does the other study, PPACT, involve CAM. It's yet another example of how CAM appropriates and "rebrands" science-based therapies as somehow being "alternative." These trials are not inappropriate, but no doubt NCCAM will be funding trials that are, such as "pragmatic" trials of acupuncture and various other forms of placebo medicine.
As bad as what Dr. Briggs argues is, at least she still respects the importance of RCTs and clinical trials, whether they be tightly controlled efficacy trials or "pragmatic" effectiveness trials. Dean Ornish, on the other hand, was asked what scientific idea is ready for retirement. Guess what scientific idea he picked? You guessed it: The randomized clinical trial:
It is a commonly held but erroneous belief that a larger study is always more rigorous or definitive than a smaller one, and a randomized controlled trial is always the gold standard . However, there is a growing awareness that size does not always matter and a randomized controlled trial may introduce its own biases. We need more creative experimental designs.
None of this is anything that clinical trialists don't already know and recognized. Does Ornish think that clinical trialists are unaware of the perils and pitfalls of RCTs? Seriously? So contemptuous is he of clinical trialists that he presumes to lecture on what, exactly, statistical significance in a clinical trial means and what a p-value less than 0.05 means. Thanks a lot Dean. I never would have figured that out myself. Seriously. Thanks for that and for pointing out that variables are not necessarily independent and that their lack of independence can, if not adjusted for, result in confounding factors. Clinical trialists never would have thought of that! No, it's not as though there aren't all sorts of methodologies to try to prevent such biases and to account for the ones that can't be eliminated.
It doesn't take Ornish long to reveal what his real agenda is about, though. Basically, what he is saying is nothing more than the old, tried-and-not-so-true trope of CAM advocates everywhere that "your randomized trials are not up to proving that my woo works." Or, as I like to put it, I reject your reality and substitute my own because I know my woo works. RCTs can't persuade me otherwise. I'll show you what I mean:
For example, a RCT may be designed to determine if dietary changes may prevent heart disease and cancer. Investigators identify patients who meet certain selection criteria, e.g., that they have heart disease. When they meet with prospective study participants, investigators describe the study in great detail and ask, "If you are randomly-assigned to the experimental group, would you be willing to change your lifestyle?" In order to be eligible for the study, the patient needs to answer, "Yes."
However, if that patient is subsequently randomly-assigned to the control group, it is likely that this patient may begin to make lifestyle changes on their own, since they have already been told in detail what these lifestyle changes are. If they're studying a new drug that only is available to the experimental group, then it is less of an issue. But in the case of behavioral interventions, those who are randomly-assigned to the control group are likely to make at least some of these changes because they believe that the investigators must think that these lifestyle changes are worth doing or they wouldn't be studying them.
Or, they may be disappointed that they were randomly-assigned to the control group, and so they are more likely to drop out of the study, creating selection bias.
Thank you, Dr. Ornish. Thank you so much. None of us poor, benighted clinical investigators would have ever figured out that these problems with RCTs exist were it not for your fantastic wisdom in pointing it out to us! OK, OK, I know I'm being snarky. Ornish is writing for a general audience, but that doesn't excuse him from making it sound as though these problems are insurmountable defects in RCTs that doom them to extinction as no longer useful in this brave new genomic world.
In all seriousness, though, does Dr. Ornish really think that clinical trialists are unaware of these particular pitfalls of clinical trials of dietary or lifestyle interventions? Does he seriously argue that they haven't developed methods to compensate for them? To correct for them? One might think that Ornish thinks that clinical trialists have never thought of these issues or considered these problems. Or maybe—just maybe—he thinks that clinical trialists have never come up with methodology that could correct for these biases, shortcomings, and difficulties in making sure there are adequate controls. True, RCTs are not perfect, but no one is more aware of that than the people who actually design them and carry them out. Particularly hilarious is the part where Ornish points out that small trials "may be more likely to show significant differences between groups than a large one." Well, duh. Double "Well, duh!" when it comes to Ornish's conclusion:
We need new, more thoughtful experimental designs and systems approaches that take into account these issues. Also, new genomic insights will make it possible to better understand individual variations to treatment rather than hoping that this variability will be "averaged out" by randomly-assigning patients.
One wonders if Ornish means something like the I-SPY 2 trial, where the trial design evolves based on the previous results? Would that do it? Or would any of the other many innovations in RCT design developed over the last several years be enough for Dr. Ornish?
One example that Ornish uses as an example of the "failure" of clinical trials is the Women's Health Initiative. He's unhappy because the study reported that the dietary interventions tested (reduction of dietary fat, an increase in the amount of fruits, vegetables, and whole grains in the diet) didn't protect against heart disease or cancer:
However, the experimental group participants did not reduce their dietary fat as recommended—over 29 percent of their diet was comprised of fat, not the study's goal of less than 20 percent. Also, they did not increase their consumption of fruits and vegetables very much. In contrast, the control group reduced its consumption of fat almost as much and increased its consumption of fruits and vegetables, diluting the between-group differences to the point that they were not statistically significant. The investigators reported that these dietary changes did not protect against heart disease or cancer when the hypothesis was not really tested.
Dr. Ornish overstates his case a bit. Here are the three papers (1, 2, 3) reporting the results Dr. Ornish cites. The results are actually nicely summarized in this NIH press release. While it's true that the women didn't reach the goal of 20% of their calories, it's a bit of an exaggeration to say that the control group decreased its intake of total fat by as much. For instance, at year one, the experimental group reduced their percentage from 37.8% to 24.3%, and the difference between the groups remained 8.1% at 6 years. That's not perfect, but it's pretty good. What it indicates to me more than anything else is that dietary interventions are hard. Very hard. It's very difficult to change one's diet over the long term. I think that what Ornish is actually complaining about but wasn't specific about, was that the differences in specific kinds of fat intake were much lower; for example, the decrease in intake of saturated fats was only 2.9%. So, while Ornish has a point to some extent, he uses that point to drive straight off the cliff.
He also neglects to mention some rather important findings. For example, there was a trend towards a decrease in breast cancer risk noted; the 9% difference reported just didn't achieve statistical significance at followup available (8.1 years on average). If the results were to be reported now, given the trend, it's quite possible, in line with other studies, that the decrease in breast cancer risk would be statistically significant. Cancer takes decades to develop; it's unreasonable to expect that decreased risk from cancer from a dietary intervention will become apparent in much less time. Ditto the risk of colorectal cancer, which was also decreased but the difference hadn't achieved statistical significance as of 2006. In fact, this brings up an unspoken assumption on Ornish's part, which is embodied in this paragraph by him:
Paradoxically, a small study may be more likely to show significant differences between groups than a large one. The Women's Health Initiative study cost almost a billion dollars yet did not adequately test the hypotheses. A smaller study provides more resources per patient to enhance adherence at lower cost.
Did you figure out what the unspoken assumption is? It's this: That the effect of dietary and lifestyle interventions will be so large that they will be detectable in much smaller studies in which the dietary interventions are more rigorously enforced. There's a reason why the Women's Health Initiative dietary intervention study involves nearly 50,000 women. It's because the differences were not expected to be really dramatic, and they weren't. Even if future reports show a statistically (and clinically) significant difference, as of eight years they hadn't. Doing smaller studies, as Ornish advocates, would be more likely to result in a bunch of equivocal or negative studies because they wouldn't have the statistical power to detect the differences. Maybe that's what Ornish wants.
Of course, Ornish is no different than CAM advocates in that he's unhappy that the clinical trials being done on "alternative" interventions have been so unremarkable in their results, with either no effect above placebo for the hard core alternative interventions or generally at best modest effects on SBM that's been "rebranded" as CAM, such as diet and lifestyle interventions. RCTs are not showing what they had hoped for their favorite CAM or rebranded CAM; so they try special pleading, declaring that RCTs are not up to studying their woo or, as Ornish declares, that the very concept of the large RCT needs to be "retired." It's quite a convenient argument if RCTs don't show what you want them to show about your favorite woo.
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The fundamental problem is that CAM advocates and SBM proponents see two different purposes for clinincal trials. The SBM crowd sees the trial as a tool to determine if something works or not while the CAM cohort see it as a way to prove to doubters that what they already know works actually works. so if a trial proves something doesn't work SBM accepts it's done its job, while CAM believes it's failed to do its job and we'll just have to keep trying until it does (ie gives up the outcome we're looking to.)
Dr Ornish's research institute is located in Sausalito**.......
So what do you expect?
Reality?
I remember walking off of the ferry onto the shore of that blessed realm myself- awash in the golden light we sat transplendently upon the green grass, surrounded by undying blossoms, feeling the cool and sparkling waters of the ancient fountain transported by the mild breezes, gazing upwards towards the villas decorously clinging to the cliffside, their reflections sparkling upon the pristine bay...
Where was I?
** which means 'little willow' in Spanish I believe.
-btw- the wikipedia article on him is FAR too glowing, friends, colleagues and minions...
There are two meanings to "creative".
I readily accept that Dean Ornish meant it as thinking outside the box, but I have seen enough people trying to spin mediocre results into good ones to be wary of a willingness to be "creative". At best, it's a good way to increase the risk to fool oneself (been there, done that...); at worst, it's an outright foray into dishonesty (no comment).
tl;dr: Most of these pro-CAM arguments boil down to "screw the rules, I know better". Not a surprise since mainstream scientists suffer from the same temptations.
Paradoxically, a small study may be more likely to show significant differences between groups than a large one.
This appears to be a syntactically valid English sentence, but it includes several different words which I don't think mean what Ormish thinks they mean.
Start with the obvious: If the dominant source of uncertainty in your results is due to counting statistics (not necessarily true of all RCTs, but I suspect many RCTs have this limitation), then you need four times as many subjects to reduce your uncertainty by a factor of two.
There are probably cases where the dominant error is systematic, i.e., won't get smaller if you make the study bigger. When this is true, then it makes sense to see how to make the error smaller, and in those cases you may get better significance with a smaller sample. But systematic errors are notoriously difficult to deal with in experimental physics, and probably even harder to deal with in clinical trials (at least in the lab you might be able to find the loose cable). So I don't think there would be many situations where Ormish's strategy would actually work. Unless, of course, you redefine certain terms, as Ormish et al. seem to do from time to time.
Denice @2: I've been to Sausalito myself, and got the impression of a town that's gone way too chi-chi for its own good. If you like living in a town full of art galleries, high-end boutiques, and quaint coffee shops, and you have the considerable wealth necessary to afford a Bay Area house with a water view, then Sausalito might be your kind of town. As is apparently true of Ormish, and likely true of several of his clients. But Sausalito looked like a facade to me--I prefer a town that is less obvious about catering to well-heeled tourists.
Eric, I think that we just found the perfect place for our pharma shill convention.
Oooo! I've never been to California before. Another reason to pencil in that date?
I can attest from experience how hard it is to stick to extreme diet changes. When Mr Woo had his stroke last March we lasted about six months eating mostly lean meat and raw vegetables, cutting out sugar (he refused to part with his artificial sweeteners; with his love of woo that always confuses me), refined flour, etc. However, slowly but surely it just got old. Then we started just having a "little" of the old stuff, and over the course of another three months completely reverted back to our old eating habits.
Trying to get back on the wagon again, but pretty sure it won't stick. For one, Mr Woo and J have decided that I am the only human being capable of making salads or cooking meat, and I get sick of spending so much time cooking and serving them.
Large differences? Yes. Significant differences? No. At least, not mathematically.
Consider if you suspect that a coin is biased toward heads. So you flip it to find out. If you flip it 4 times, there is a 25% chance that you will get heads 75% of the time.
Now flip it 100 times. The chance that you get 75 heads for a fair coin is miniscule.
See? You have a better chance of getting a large effect in the smaller dataset.
It's not significant in the least, of course.
Is it just me, or does the "they didn't stick to the diet as much as they hoped" line sound a lot like "They didn't pray hard enough"?
In order to show whether the amount of prayer makes a difference, don't you have to show that it makes any difference at all?
A smaller study provides more resources per patient to enhance adherence at lower cost.
With sufficient resources per subject, you could no doubt keep them kidnapped and locked in cages and kept rigidly on the experimental diet or the control diet. Trouble is that the results would not extrapolate to the real world.
If the hypothesis is that "a special diet can reduce cancer X" then you need to test it as people actually follow the diet (i.e. imperfectly).
I was looking at that Edge list of "scientific ideas which need to be retired", and there are way too many nimrods, numpties, eedjits and pundits on the list of luminaries.
We need more creative experimental designs.
There was a time when I would hear the word "creative" and understand that it was code for "make it work and don't get caught."
Is it just me, or does the “they didn’t stick to the diet as much as they hoped” line sound a lot like “They didn’t pray hard enough”?
It's not just you. Many adherents seem to take the view that CAM can't fail, it can only be failed. Likewise with certain religions and certain political philosophies.
There was a time when I would hear the word “creative” and understand that it was code for “make it work and don’t get caught.”
In some contexts, that's still true for me. For example, "creative accounting".
Aw, I got married in Sausalito - it's not all bad... although the Indian restaurant where we had our atheist ceremony closed down less than a year later. :(
And yes, I don't know if Ornish is being ignorant or condescending - or both - but the shortcomings of RCTs are endlessly discussed and endlessly worked on. At least where I work. We're probably trying for the opposite outcome of his, though - we think minimizing placebo response is a good thing...
@ Mrs Woo:
FYI:
It's a facsimile south of France jammed into a square mile without French people. I understand that it used to be a boatyard. There are houseboats- some more 'house' than 'boat'. You might want to look at the images for the town via google- it's next to the nearly conically shaped Angel Island.
In all seriousness, I took photos and people always go-"Oooooooh!" when they see them- esp at the one of a blond male creature languishing on the grass beneath the aforementioned blossoms and archaic fountain.
I hate to say what an ice tea and a Belgian beer cost. Nevermind the crab salad.Yiiiii!
Some of the alt media woo I survey similarly advocates for diets that are nearly impossible to maintain for any lengthy period:
( PRN, Natural News) vegan or nearly so, mostly raw,10% fat, organic, GMO free,high fibre, no caffeine/alcohol, juices, dried, powdered vegetables/ fruits, superfoods etc etc etc.
Who can live like this? I eat reasonably well but I am not a monk/ nun and even they drank. Life shouldn't be a chore and eating a duty. Everyday life has to require some pleasure, no?
-btw- Null has done 40+ life style change "clinical" studies wherein the victims/ subjects must maintain an arduous diet/ exercise regime which leads to (supposedly) incredible results-which are mostly based on SELF reports.
I hereby rest my case.
@ Roadstergal:
I also love the place but you know what I mean.
The Women’s Health Initiative study cost almost a billion dollars yet did not adequately test the hypotheses.
By "did not adequately test the hypotheses", Ornish seems to mean "tested the hypotheses but did not provide the desired answer". RCTs are a Bad Idea because they sometimes give negative results.
I’d like to see if Ornish can document how many people have followed his diet to the letter for any significant length of time. I follow the general principles (which are not exclusive to his program), but honestly, you can’t even have a walnut on his program! There could be no joy at all in strictly adhering to something so restrictive.
I’m sticking with Michael Pollan. Eat good food, not too much--mostly plants. (And I will enjoy my occasional grass-fed bison steak, topped off with the most decadent flourless chocolate cake I can find, ending with a nice glass of port.)
Is there a mass-market book in that?
Denice @15
In other words, an extremely unnatural diet.
@Dorothy
Food of the gods even if it won't make you immortal.
Does anybody finish bison on grain? (Run-of-mill cattle are also grass-fed before finishing.)
I know where Ornish is coming from. Reality let me down the other day. I knew that I was a rich man on his own Caribbean island surrounded by hot babes, and reality said I was at work...working. Bastards.
Denice, the people that follow the latest fad diets don't have any problem sticking with them, because the latest fad diet changes every four months or so. All they've got to do is keep following whichever miracle diet pops up next and they get all the variety they need. But during those four months, you better believe that anyone not following that diet is about to keel over at any moment in the most painful way possible, and you're a fool for not following it.
Now that I think about it, fad diets are the new chain letters. Do what they say and warn the others and you'll be safe. Otherwise...doom.
FTFY
* In fairness, I don't recall Feniger & Millikan from the first edition, but I'm not going looking for it. Keller was the only edible contribution of the lot.
Doctor Biobrain, may I borrow the chain letter line--its perfect!
mho, I am always quotable. Just as long as you're thinking of me when you do so.
Narad, we definitely have different ideas of paradise. I'll eat frozen burritos for the rest of my life as long as the girls serving them are dark skinned, Asian, and curvy. Or perhaps it's because I know how to cook, yet have been single for much too long.
grass-fed bison
Mention 'bison' and 'grass', and straightaway I think of vodka. Such are the workings of the mind.
@ Doc Biobrain
I prefer the babes in my paradise to be intelligent, interested in music, art, books and science, preferably the music and books I like as well. Of course they need to be against quackery and be rational. And I want good food, meat, fish, crustacea and shellfish. I know I ask a lot, but hey, it has to be paradise.
Renate, you forgot beer.
@ Doctor Biobrain:
But you know there will always be Orthorectics in each of these charlantans' audiences and they'll follow the programming to the letter. Null's bs has only changed glacially over the years I've surveyed him: it's always been vegan, organic pure foods-
concepts like GMO-free and high ORAC have been added as they crop up. Also he and Mike keep adding arcane superfoods to the list- acai, goji, quinoa, cacao, coconut oils- all the buzz word foods.
What's my idea of paradise?
I need to have nice clothes and NOT be sick, be cold or have a non-functioning car. And that the economy isn't in a tailspin wiping out my investments. Also having a decent place to live in an area not invested with crime.
It's also necessary to have work and things to do and friends and male creatures around. Also a cat. Although I then have to take care of them- which is something to do.
Oh sh!t, I'm in paradise.
That was a stickpoke at the cast of characters in Eat More, Weigh Less. (The stuff was by and large inedible.)
Narad:
That stuff is horrible.
I do know HOWEVER of a relatively functional eating plan that sounds like a kinder, gentler Paleo :
you limit highly processed foods. I know a tennis instructor about my age: he lives on grilled poultry and fish, salads, plain vegetables/ fruits, little breads and hardly any cheeses for 2 months or so and then is more lax.
"Lax" includes Scotch and vodka. But only posh brands.
Here's his big secret :
he has money, lives alone and can afford to go to the chi-chi natural foods supermarket and buy ready-made foods.
Apparently I'm not keeping up - I thought coconut fat was supposed to be exceptionally bad for you?
he has money, lives alone and can afford to go to the chi-chi natural foods supermarket and buy ready-made foods.
It's "funny" how many of these fad diets tend to have gobs of disposable income as a prerequisite....
@ Denice Walter
My cat's defenitly belong in paradise as well. They are angels, well, not always, but still, a paradise without my cat's wouldn't be paradise.
It’s “funny” how many of these fad diets tend to have gobs of disposable income as a prerequisite….
It seems there are two ways of making a small fortune with fad diets. One is to be the person who sells them. The other is to follow them rigorously. Of course, to do the latter requires that you start with a large fortune.
Heh. I promptly abandoned this line of enquiry with a former close in-law after about 90 seconds.
(Strangely, a reliance on Thai curries for a while out of just plain easy cooking led to my putting on pounds, so I must have been doing something wrong.)
My wife rejects my suggestions about cutting out cookies and ice cream from our shopping list, but she wants to start a new strict high protein low starch diet. *sigh*
Speaking of odd, I noticed that my comment to the CCAM blog did not get passed through by the moderator. I didn't use the words quack or scam even once!
Right, the woo-meisters are cuckoo for coconut.
I like Thai green curry myself but I don't overdo it.
Mercola has written a lot about its benefits ( on his own site and Huff Po, Feb 2011)- for weight loss, heart health, thyroid, for 'energy'- its lauric acid has anti-viral, anti-bacterial qualities. It's fabulous for skin, teeth and hair. He follows Weston Price's ideas about its miraculous powers ( see Pacific Islanders) ALSO neurological benefits for Alzheimer's and autism ( see also TMR et al).
Adams and Null sell coconut based products(e.g for smoothies or in "Coco-Magic Bars", respectively- not that I respect them).
SBM's qualms about saturated fat are ridiculous, they say.
It is Mother Nature's MagicElixir (tm) growing on trees in Paradise!
A newer trend is pink Himalayan salt. Another exotic locale, another exotic product that you truly need, they say.
One of my gentlemen has bought into Celtic sea salt woo of late. But he's a Celt- that's his excuse.
Oh, I think that's older than the coconut-oil craze. I saw somebody report three or four years ago on MDC that she had managed to give her kid a goiter though an insistence upon it (which I presume was also accompanied by other weird dietary restrictions).
Yah, at least since 2006. Hilariously, the antifluoride brigade sounded the alarm over a decade ago.
The "Himalayan salt detox patches" (for the feet, of course) are a new one on me, though.
I once opened Dean Ornish's cookbook. Upon seeing a recipe for split-pea guacamole, I quickly reshelved it.
Even if he's correct, I'd rather die.
Green split peas make a perfectly decent pate/spread. Esselstyn at least has the sense to do this. It appears that Ornish's appears to call for fresh or frozen whole peas (and lemon rather than lime). Purée de petit pois is one thing, but Gerbemole is just wrong.
Denice,
I think I may have mentioned before that pink Himalayan salt is known as Kala Namak or Black Salt in South Asia - the seeming contradiction is because it looks black in larger lumps, and pink when powdered. It is always chemically refined, and most it is actually made from sodium chloride, "admixed with smaller quantities of sodium sulphate, sodium bisulphate and ferric sulphate, which is then chemically reduced with charcoal in a furnace" in factories, for example this one in Kanpur*. This slightly brimstone-odored stuff is most definitely not the natural and pure substance it is portrayed as - it contains hydrogen sulphide which is quite poisonous, though it is only present in small amounts.
* An irrelevant aside: I spent a few days in Kanpur back in the late 80s, staying in a 'railway retiring room', a sort of cheap hotel room you can find in many Indian railway stations. The room was furnished with beautiful Victorian English furniture with the exception of one 60s psychedelically decorated plastic bucket seat - the sort of weird but charming juxtaposition that is so common in India.
Lucas Beauchamp,
Mushy peas, made from dried and reconstituted marrowfat peas (i.e. allowed to mature and dry in the pod), is a Northern English and Scottish delicacy, just another form of hummus if you think about it. I like it, occasionally.
Lucas is correct:
health food cookbooks can be quite unappealing. Various alt med and anti-vax folk have published/ distributed their arcane culinary secrets.
Such as:
-"spaghetti and meatballs" raw w/o meat, pasta or cheese
- avocado ( real ones) chocolate smoothies
- raw, vegan desserts
- soy 'cheese' 'cake'
- anti-vax autism mothers concoct "birthday" "cakes"that are gluten-free, caseine-free, sugar-free as well as snacks and sweets- just what kids want.
Mike Adams has a few videos of how to make smoothies with superfoods @ NaturalNews.
Strangely, a reliance on Thai curries for a while out of just plain easy cooking led to my putting on pounds, so I must have been doing something wrong
Obviously, because everyone knows that Eastern diets are so much better for you than Western ones.
At the risk of sounding prejudiced, Krebiozen, "Scottish" and "delicacy" are two words that I would never use together, but perhaps that's because I'm married to an Ulster Scot.
I got my flu shot today! Strangely, I have an open-minded (but I still love him) primary care provider. He told me that if I chose to avoid the flu shot I could always use nasal irrigation to reduce my exposure to flu and said that there are studies that show a reduced chance of flu with regular neti pot usage (I don't really like the neti pot anyhow). I assured him that was all well and good, but really I wanted to be sure I could visit a friend who has stage IV cancer and is having chemo without worrying that I might expose them to flu when I don't have symptoms yet.
Wow Denice! I'll have to do that in a bit. I was a few places during a stint in the Navy, but haven't been out of Missouri since moving here in '02. My life is now full of things like demanding guinea fowl and a horse who spends as much time as possible looking for parts of me he can grab without getting caught (tonight it was my braid). I'm beginning to worry that Mr Woo is right and he will be untrainable. He is an ornery guy - loves to play jokes on other creatures in the barn yard, etc.
I'm not so sure about that. The kala namak I used to have was grayish and very sulfurous. I doubt there'd be much of a market for it as an actual salt replacement. Cf. the corresponding entry for the Himalayan stuff.
Denice Walter wrote:
Is it the salt or the woo that's Celtic? If the former, how does one determine the cultural or linguistic affiliation of salt?
Sel gris comes from Brittany. Thus, it must be Celtic.
Strangely, although it's just evaporated seawater, "drinking Celtic salt water does not make you thirsty, only dead table salt makes you thirsty. Celtic salt is live food, and is nourishing to your body." (Here.)
So all the other mineral-traces make the NaCl less harmfull?
I don't buy it.
Why don't people at sea just drink seawater? Because it is not really healthy and it makes you thirsty. But if you take sea-salt, made by evaporate seawater and dissolve it in water, the seawater you create has changed, so it is better for your thirst. How is it possible, people believe this?
Narad,
Yes, I think you're probably right from the look of it. Selling kala namak to CAMsters might be tricky, but I bet I could do it - after all the modern diet is deficient in organic sulfur which is an essential part of glutathione, the detoxifying enzyme par excellence, what better way to replenish our sulfur stores than with a Himalayan product buzzing with life energy etc. etc.. Add a couple of testimonials and there you go.
Shay,
I use the word "delicacy" a little ironically; I would use it to describe a deep fried Mars bar, or deep fried butter balls for example (a recipe devised by a chef from Harvey Nichols no less).
I wonder if the Health Rangers Manglers realise Himalayan Sea Salt contains mercury, uranium and plutonium as well as iron oxide.
How could a mineral which was never alive to begin with could be "live food"? Or, for that matter, if by some standard some form of mined salt is considered "alive", how could seasalt (aka regular table salt) be considered "dead"? Seawater is considerably -and sometimes uncomfortably - more alive than a piece of rock buried underground for some millenia.
I think I get it: "Celtic" means it was made out of Celtic people.
I suppose alive means something like natural, not messed with by humans. And natural is everything that exists in nature and to stay natural it only has to be harvested, or mined, without further human intervention. And of course it can only be touched by natural substances.
Helianthus - you mean that soylent - er - Celtic salt is PEOPLE?
Renate,
I'm reminded of an old cartoon showing a conveyor belt in a factory putting foodstuffs into bags, which bore the proud slogan "Untouched by human hands". The food was being put into the bags by chimpanzees, of course.
Some woosters believe in 'ormus', a form of gold and other elements with electrons orbitally rearranged, which acts very much like the alleged life-force. One rich source of 'ormus' is sea salt, especially Dead Sea salt. Some of them claim that the 'ormus' is trapped in clathrate cages made from water molecules, which makes me wonder what happens when it dries out.
You can extract 'ormus' from sea water by adding sodium hydroxide, which makes it precipitate out at a specific pH. It is then consumed, though you have to be careful or you might start suddenly manifesting every thought immediately, and then where would you be? (I'm not joking, there is a tale in circulation of a man who suffered just such a fate)
Skeptics might point out that any magnesium chloride in the sea water will react with sodium hydroxide to form almost insoluble magnesium hydroxide, which precipitates out, and sodium chloride, which doesn't. I strongly suspect that most of the 'ormus' these people consume and sell is little more than unflavored Milk of Magnesia. It's a fascinating area of pseudoscience, if you like that sort of thing.
My point is that there is a belief that natural salt still contains 'ormus', while processed salt does not, having driven it off or destroyed it somehow. Natural News has a page on 'ormus', so my hypothesis seems plausible.
I am utterly fascinated by the ability of the woo-entranced ( both sellers and buyers) to take a simple foodstuff and -probably, because of whatever intrinsic symbolism is associated with it- declare it infused with mana or magic.
Salt has been viewed as being protective against witchcraft and other malfeasance and IS actually necessary for life. Wooist ad-writers just tart up both the realistic and fantasy-based qualities: they might present it as a cure-all and protectant against various ills. When people are low on sodium, they feel a particular way- usually weak- thus the opposite of this state, exaggerated, becomes part of the product's mystique. High sodium is another issue of which consumers are aware of in recent times.
Sea salt is *lower* in sodium- so it helps CV health they say but keeps you from being deficient in sodium and other ESSENTIAL minerals. The ads for this product stress how 'natural' it is.( see Celtic seasalt/ Selina)
The Celtic salt partisan started using it several years ago- being evil, I remarked, " Isn't that about when you hair started going quite grey?...Just a coincidence, I suppose".
Another creature vouches for flax seeds - tons of woo about that- to which I remark to him," Isn't that estrogenic? " Heh.
Fortunately, their woo ends with one product each.
Amongst foodstuff idolators, a few products loom large:
Asian mushrooms, berries, nuts ( esp almonds), green tea ( which I actually drink- not believing in its magic though), sea vegetables, algae, kelp, cruciferous vegetables et al.
Why is there no mana-infused liquor?
Reminds of what a guitarmanufacturer, I think it was Peavey, once said. "Handmade often only means, it isn't made by feet." Or something simular.
Some woosters believe in ‘ormus’, a form of gold and other elements with electrons orbitally rearranged, which acts very much like the alleged life-force. One rich source of ‘ormus’ is sea salt, especially Dead Sea salt. Some of them claim that the ‘ormus’ is trapped in clathrate cages made from water molecules, which makes me wonder what happens when it dries out.
The originator of that line of bullsh1t (white monoatomic gold with nuclei in an excited elliptical state) called it ORMES. I am disappointed for the unconcern for accuracy or IP within the scamosphere!
According to that originator, ORMEs have a special kind of superconductivity. This is why normal chemical tests can't detect *any gold at all* in the product -- its presence is *drowned out* by any impurity, which propagates through the sample in a distributed quantum state. Same for his monoatomic rhodium and monoatomic iridium products.
it is all conncted, somehow, with the Jesus Bloodline. And with lizardoids. I am not making this up.
And the current discussion is why I love reading this blog.
@ Mrs Woo:
Believe it or not, I was waiting for a film to start last night and my companion invited me to step into what is probably the most-woo infested single location I have ever frequented- it was a natural foods/products shop and most likely about 5000 sq feet of woo-driven merchandise. I really need to go back with a notebook so I can list what is available: some of it was hilarious altho' unintentionally so.
Not only was it overflowing with woo but it had a balcony above where you could sit and drink your free-trade organic coffee or superfood juice and was decorated with heroic murals of simple farm folk enjoying the fruits of the earth- the artwork looked vaguely like socialist realism from Israel or eastern Europe,c. 1960s.
The customers- aged 20s to 80s- walked around carefully reading product labels with nervous looks on their faces:
" Is it truly 100% gluten free?"-" Is there any paraben in this skin cream?"- "Do you have chemical- free soaps?"
And there were more powdered-dried greens and vegan proteins than you could shake a stick at. 50 types of salt.
The staff appeared as if supplied by Central Casting to include a youthful diversity of ethnicities to cheerfully scan your purchases.
The place is a goldmine for its proprietors..
perhaps I should say 'ormus mine'. I'm sure they have some if you look closely.
Slightly off topic - but I've just found that in one of Nigella Lawson's cookbooks she suggests swallowing a tablespoon of baking soda diluted in water as a treatment for cystitis (for until you get to see a doctor). Thought it was a really odd thing to include in a cookbook. Does anyone know whether this is plausible, or whether this is alkaline-diet based woo?
Liz,
I think it's plausible, as most of any bicarbonate ingested will be surplus to requirements and will be excreted in the urine, making it more alkaline and perhaps soothing the inflamed areas to some extent. I think E. Coli prefer an acid environment too, so it might also reduce the infection. The other thing often recommended for cystitis is mannose, which is also excreted in the urine and may interfere with bacterial adhesion to the urinary tract. I have some tucked away in case of emergencies, anecdotally, it does appear to work for the females I have given it to to reduce symptoms before they were able to see a doctor.
Of course it's always possible that Nigella may have mixed up her white powders and was referring to the local anesthetic properties of cocaine.
Liz -- due to a urinary diverticulum, I've had reason to get very familiar with UTIs. ;-) I'll make it easy: it won't do a damn thing. It'll help with heartburn, but that's it. It's almost certainly alkaline-diet based woo.
Even cranberry, which has some prior plausibility, doesn't really help either. Cranberry may possibly provide a small help* in *preventing* UTIs by disrupting the bacterium's ability to form a plaque, but once the colony is established, the cows have left the barn on that option. And you'd need to consume a LOT of cranberry. I like cranberry (and blueberry and lingonberry...) but even I can't take *that* much. Especially since it triggers my heartburn, so I guess maybe the baking soda would help at that point. :-D
If you suspect you have a UTI, call a doctor or nurse practitioner or go to an urgent care. They may even be willing to prescribe on symptoms alone, though personally, I like to get a culture done, since I have run into problems with resistant bacteria before. (Very annoying to take a drug for a week while the infection gets worse, only to then have to take a *different* drug to kill the little buggers.)
Phenazopyradine is a gift from the heavens in terms of controlling symptoms, and it's available over the counter. I understand it has some bad side-effects if used long-term, though, and you should not be used in pregnancy. Also, use pantyliners; the stuff has an amazingly strong pigment that yes, does go through the system. I like to wait until after seeing the doctor to start on that, but they can still do a urinalysis while you're on it.
There is a lot of woo about UTIs, partly because there are so many things that can mimic the symptoms but which resolve on their own. Some pre-menstrual symptoms mimic a UTI, and only last a few days. Some foods are more irritating to the bladder (and some people are more sensitive to these than others), so you can get symptoms from those which resolve on their own once the chemicals have cleared. Caffeine is a common offender. And yeast infections can seem like a bladder infection, and sometimes do clear up on their own. So people will get something like this going on, take some natural remedy, and then assume the remedy cleared up their problem. I've had enough things that *felt* like infections that now I won't see the doctor without at least three UTI symptoms. ;-)
* Cranberry has been disappointing in well-designed studies. If it has an effect, it's pretty small. Not worth it, IMHO. Better things for prevention are hygiene related.
Kreb -- I doubt the mannose is actually helping your patients. Studies with cranberry (similar proposed mechanism) suggest that once the infection is established, it's too late for that to be helpful. And are you sure 1 Tbsp of baking soda is enough to significantly alter the pH of the bladder? I'd think all it would really accomplish is to slightly increase the pH of the stomach.
al kimea:
I think you are misreading that link. I think <.001 means undetectable. Note that Plutonium is not a natural element, it is only produced in reactors. While it is possible that the salt was contaminated by fallout, *anything* could be contaminated by fallout.
Re bladder infections, I was interested in Calli's point, that not all lower urinary tract symptoms [LUTS] mean bacterial cystitis. I have seen women with burning, urgency etc., but no pus cells or bugs found in the urine sample. I wonder about a link with anxiety disorder--which seems to be common in folks with LUTS, including men, who may end up without their prostate, and still not get better! Anxiety disorder, which affects 32% of Americans [Dr K Merikangas, NIH], has now been traced to fatty maternal diet, in animal studies. Such a diet inflames the placenta, inhibiting an enzymatic barrier to maternal cortisol [stress hormone], which therefore leaks across and programmes lasting anxiety in the foetal brain. The cortisol also hyperactivates a key developmental enzyme, called GSK3beta, that may disturb both renal tract and gut development. GSK inhibits a key transcription factor, SKN-1/Nrf-2, that evolved in ancient times to protect the gut from toxins and infections--but which later got co-opted into driving gut [and urogenital tract] development. This is really weird, because I have seen families where Mom has definitely had a fatty diet in her pregnancies, and the invariably anxious children have irritable bowel symptoms, and even vesico-ureteric reflux [leading to serious kidney infections], plus slight loss of bladder control. I wonder whether anxious folks are prone, though this maldevelopment of the "endomesodermal" embryonic tissues, to weak sphincters [including heartburn and reflux], impaired enteric and renal tract neuromuscular function, and possible leaky gut and bladder mucosa. Of course, ongoing anxiety postnatally means chronic overactive sympathetic nerves, which alone will promote sphincter opening, from oesophagus to bladder and [rarely] rectum. Local enteric nerve scientist Dr Kulmira Nurgali, from Mongolia-->Moscow Uni-->Melb Uni PhD under Prof John
Furness, hopes to get funding to feed fat to pregnant mouse dams, and examine gut function in the pups, in great detail. As for treatment, I use myo-inositol to reverse anxiety [see INOSITOL ANXIETY, or INOSITOL LEVINE]. This serotonin 2A receptor inhibitor blocks the cortisol and sympathetic nerve arms of the anxiety response. My patients report calmness , surprising energy, better libido and immunity, faster hair and nail growth, reduced reflux and IBS symptoms, and less bladder irritation and incontinence. This deserves a proper
clinical trial. Inositol also suppresses the insulin-like signalling pathway, an action known to be both anti-cancer and anti-ageing. The activated anti-ageing genes include genes for antioxidant enzymes, glutathione synthesis [promotes mucosal integrity and microbe resistance], and a range of "antibiotic" genes, that code for antimicrobial peptides, lysozyme [bug-destroyer], defensin peptides etc.. Foods high in inositol are grains, nuts, legumes and citrus. If a higher dose is needed, for more complete anxiety control, one can buy powder supplement, and take 5 gm/day.
Re bladder infections, I was interested in Calli's point, that not all lower urinary tract symptoms [LUTS] mean bacterial cystitis. I have seen women with burning, urgency etc., but no pus cells or bugs found in the urine sample. I wonder about a link with anxiety disorder--which seems to be common in folks with LUTS, including men, who may end up without their prostate, and still not get better! Anxiety disorder, which affects 32% of Americans [Dr K Merikangas, NIH], has now been traced to fatty maternal diet, in animal studies. Such a diet inflames the placenta, inhibiting an enzymatic barrier to maternal cortisol [stress hormone], which therefore leaks across and programmes lasting anxiety in the foetal brain. The cortisol also hyperactivates a key developmental enzyme, called GSK3beta, that may disturb both renal tract and gut development. GSK inhibits a key transcription factor, SKN-1/Nrf-2, that evolved in ancient times to protect the gut from toxins and infections--but which later got co-opted into driving gut [and urogenital tract] development. This is really weird, because I have seen families where Mom has definitely had a fatty diet in her pregnancies, and the invariably anxious children have irritable bowel symptoms, and even vesico-ureteric reflux [leading to serious kidney infections], plus slight loss of bladder control. I wonder whether anxious folks are prone, though this maldevelopment of the "endomesodermal" embryonic tissues, to weak sphincters [including heartburn and reflux], impaired enteric and renal tract neuromuscular function, and possible leaky gut and bladder mucosa. Of course, ongoing anxiety postnatally means chronic overactive sympathetic nerves, which alone will promote sphincter opening, from oesophagus to bladder and [rarely] rectum. Local enteric nerve scientist Dr Kulmira Nurgali, from Mongolia-->Moscow Uni-->Melb Uni PhD under Prof John
Furness, hopes to get funding to feed fat to pregnant mouse dams, and examine gut function in the pups, in great detail. As for treatment, I use myo-inositol to reverse anxiety [see INOSITOL ANXIETY, or INOSITOL LEVINE]. This serotonin 2A receptor inhibitor blocks the cortisol and sympathetic nerve arms of the anxiety response. My patients report calmness , surprising energy, better libido and immunity, faster hair and nail growth, reduced reflux and IBS symptoms, and less bladder irritation and incontinence. This deserves a proper
clinical trial. Inositol also suppresses the insulin-like signalling pathway, an action known to be both anti-cancer and anti-ageing. The activated anti-ageing genes include genes for antioxidant enzymes, glutathione synthesis [promotes mucosal integrity and microbe resistance], and a range of "antibiotic" genes, that code for antimicrobial peptides, lysozyme [bug-destroyer], defensin peptides etc.. Foods high in inositol are grains, nuts, legumes and citrus. If a higher dose is needed, for more complete anxiety control, one can buy powder supplement, and take 5 gm/day.
Since I started using alternatives, Acupuncture and hands-on techniques, in my office 15 yrs ago I have discovered there is an inherent “truth” to some of the disciplines. When I finished 30 years ago I wished that I was introduced way back then. A lot of enigmas and conundrums would have been easily addressed with this insight. These truths must be teased out of the mechanism of actions so we can really begin to redesign our present failing healthcare system. Especially as it relates to pain and pain therapy. No matter how vigorously we debate the merits of CAMs, a truth is forever.
Another discovery is the “words” we use to describe pain and dysfunctions. Some of these words need to be clarified for the benefit of patients, the general medical communities, the legal and business aspects of society. As an example if a patient comes in with “pain in the shoulder” it is assumed that the patient has “pain in the shoulder” and a sequence of events follows based on expediency and the high-technology of modern medicine. Time, money and resources will be wasted and the patient will not have an answer to his original complaint.
In the CAM world and the paradigm shift, hands-on will answer all of the questions so a therapy can be implemented in the office setting. The CAM provider would make the diagnosis with the history, physical exam and in office simple therapies designed to uncover the source of the pain. Therapy implemented and the patient is treated without delays, exposure to radiation and caustic medications.
In my journey there are 2 major barriers, Dogmatic Science and lack of insight into the world of Myofascial Pain and Dysfunction. These 2 issues are costing and displacing billions of dollars and lots of patient are suffering in pain and misery.
@SSR - you are like a plague - spreading from SBM to here...please go away...CAM that works is called "medicine" not the crap you are peddling.
Ooooh, diy acupuncture for trigeminal nerve disorders:
http://www.youtube.com/watch?v=aQaIHrQD6mU
LOL you guys are in a vacuum and have no idea how to treat complex pain patients. As I stated there is an inherent truth the many of these CAM especially needles and hands-on.
So lilady and lawrence ... what would you manage a patient who has facial pain be it TN or ON and they are till in pain levels> 5 and they have tried all the meds, anti seizures and opiate? or for that matter they have failed back or shoulder surgery? or can't walk because there feet are numb?
Please if you are an "Avatar" there is no need to comment. At least you have done a work following the links.
Hmmm, let me think this out. Got it!
If I had trigeminal neuralgia, I would expect that my (non quack) Family Practice physician would evaluate my pain, do a physical examination, question me about "triggers", dental treatments history, etc., to rule out known causes of trigeminal neurolagia.....then send me to a specialist (neurologist) for further evaluation....not send me to a quack acupuncturist.
http://www.ninds.nih.gov/disorders/trigeminal_neuralgia/detail_trigemin…
Tsk, Tsk Dr. Rodrigues....You've already posted your inanities on the SBM blog....and you had the derision, you so richly deserve, heaped upon you:
http://www.sciencebasedmedicine.org/osteopathy-in-the-nicu-false-claims…
Such as "Why do the French only have one egg for breakfast?"
lilaly, With your logic it would mean that the medical community have an exact cause and an exact treatment for TN. So why are some many still suffering in pain. Why do people still want to commit suicide?
@narad So you have an answer as to why we have an epidemic of pain, opiate use and abuse?
Find the links that answers those questions!
Naysaying is an easy past-time and requires no critical thinking or imagination.
Dr. Rodrigues: Time now, for you to put up or shut up, by linking to studies that prove acupuncture has any place within modern medical practice.
There's an epidemic of pain now? I could observe that rises in opiate prescribing correlate quite well with the rise in the popularity of acupuncture. Maybe it's the fault of acupuncturists making false promises* and driving disillusioned people to seek the effective treatments that became available.
Beg pardon? I was merely pointing out that, like "avatar," you don't know what "conundrum" means. There's no need to further emphasize your (to put it mildly) idiosyncratic grasp of English.
* BTW, how does this happen? "When doctors use [acupuncture needles] as a diagnostic tool, it works better than any MRI." Did you run that claim past the TMB?
Why is the study of potential health benefits using plant based diets with minimal intake of added fats for conditions known to be significantly effected by diet (CAD, CVD, cancers, autoimmune disorders) linked to "high" dietary consumption of animal based products and added fats automatically "lowly" CAM pseudoscience?
Ornish has good point with inherent problem of finding suitable vegan controls with fat intake below 10% of total calories.
Dietary intake of fats and protein in Havard "Carniverous" Nurses study much higher than subjects in whom prevalence of above "western diseases" very low. I acknowledge one has to start somewhere; however, is it possible to find 25,000 true vegans adhering to a very low fat (≤ 10% total calories) for a prospective case:control study?
No way in hell you could double blind this!