Thursday, May 28, 2015
Twisters, teapots and the land of (Doctor) Oz
Mehmet Oz and I have long been friends. This is because I actually know the man, not because I am an ardent fan of daytime television.
Rather the contrary, to be honest. I think television in general, daytime television in particular, and perhaps health-related programming above all, inevitably caters to the quick-fix, silver bullet, active ingredient mentality that prevails in our society. What actually ails us is generally much bigger than a sound bite or segment, as are what's needed to fix it, and how best to get there from here.
I understand the demands of television, however, knowing firsthand the prodding of producers to generate maximal tease and titillation, even when the professed intent is education. The balance struck involves compromise and results not in pure education, but in edutainment. The tone is showy, the language provocative. It's television.
When I have appeared on the Dr. Oz Show, as I have a number of times, I have inevitably been bombarded with emails afterwards from those inclined to think that whatever I talked about was “the thing“ they needed to turn their health around and wanting confirmation. Some such exchanges involved specific medical issues, and those are all confidential. In all other instances, however, my standard response has been: Stop watching daytime television! Get up and go for a walk instead.
It has been a tempestuous week in the land of Dr. Oz. And because we are friends, it has been a rather tempestuous week in my world, too, involving the customary vituperations of social media that ensue these days when people don't like something you've said. On close inspection, though, the source of these travails proves to be a far more twisting plot than first meets the eye, and something of a tempest in a teapot.
I suppose the story begins with green coffee bean extract.
The FTC sued a manufacturer of this weight loss supplement after the company in question generated some hyperbolic marketing claims following a segment on the Dr. Oz Show. The company has since settled with the FTC.
Dr. Oz was never a party to the litigation. He opined, of course, about green coffee bean extract on air, but did so as an uninvolved commentator. He has no financial stake in this product, nor any other discussed on the show, and could not, even if he wanted to, which he does not. There are rather strict stipulations in place about any such potential conflict.
But, Mehmet did put his toes over the line by using words like “magic” and “miracle” when talking about this, and perhaps other, products. Of course, he did not say it was magical or miraculous; rather, he said that “some have called it ...” But that is still a claim by proxy, and untoward. When I have expressed my view to Mehmet that “magic” and “miracles” have no place in the medical lexicon, his only response has ever been: Agreed, mea culpa.
That was his response, too, when Sen. Claire McCaskill delivered a public rebuke for his alleged peddling of what was referred to routinely in the media as a “weight loss scam.”
Superficially, this might be wholesome, consumer protection, and appropriately spearheaded by Sen. McCaskill, who chairs the subcommittee on consumer protection. But there are a couple of considerations that suggest it may be something else.
For one thing, green coffee bean extract for weight loss is not a scam. It's certainly not magical or miraculous, nor a panacea, but the weight of evidence suggests it works.* The citations below include studies showing both promising effects in people and mechanisms of action in animal research. I am by no means suggesting that this bibliography establishes the utility of the product, but at a minimum, it indicates the product is the subject of genuine scientific inquiry. It also indicates that a fair amount of reading is required before presuming to opine.
While green coffee bean extract is certainly not the answer to epidemic obesity, it's clearly not a “scam” either. In fact, it is almost certainly safer, and apparently nearly as effective, as the dugs approved for weight loss by the FDA, all of which are quite lousy. I have no financial stake in either, and would certainly recommend a patient of mine try GCBE before any of the drugs now on the market.
Then, there is the concern raised in several media outlets that Sen. McCaskill's ire directed at Dr. Oz may have had less to do with GCBE, weight loss, or the customary penchant for titillation and hyperbole on TV, and more than meets the eye to do with his advocacy for GMO labeling. According to Sourcewatch.org, Sen. McCaskill is among the prominent recipients of campaign finance support from Monsanto. That may not be directly relevant to this plot, but wherever you examine the Oz story, from root to leaf, the name that comes up even more often than Mehmet's is: Monsanto.
This isn't really the time to go too far into the weedy issue of genetic modification of crops. I will say that from my perspective, the notion that GMOs are always good and safe is shockingly dismissive of the law of unintended consequences, and the innumerable unintended follies of history. I will also say that the notion that GMOs are inevitably bad is at least comparably fatuous. It's a method, and the results can be good or unintentionally bad. The arguments in question, however, have nothing to do with use of the method, and pertain only to disclosure. Even on the issue of labeling, there are arguments going both ways. But I think we must concede that withholding information from consumers on the basis that they won't know what to do with it is a rather significant foray into Nanny-state ideology. Rather shocking to find Monsanto in the position of “nanny,” with an entourage of the very republican support that generally assaults any such proposition, but it is what it is.
The timing of all this does not appear to be happenstance. A bill is currently being advanced in Congress that would prohibit any states from requiring GMO labels. Given the usual devotion of republicans to state autonomy, let alone opposition to nanny-ing, republican sponsorship of this bill borders on the surreal. But apparently, what Monsanto wants, Monsanto gets. And all this fuss, by the way, not over some radical, uniquely American fastidiousness, but over labeling and disclosure that most developed countries around the world already require.
As it turns out, we can't avoid the weeds entirely, because going into the weeds is directly relevant to Monsanto's fingerprints all over this tale. The real concern about Monsanto among those well informed on the topic is not the GMO crops, per say, but the glyphosate-containing herbicide, Roundup, sprayed on them. Crops have been genetically modified specifically to tolerate high exposure to Roundup, so that high doses may be used to kill all of the competing “weeds.”
I leave for you to chew as the cud moves you on the financial advantages of selling both the seed crops designed to tolerate a potent herbicide, and the potent herbicide the crops are designed to tolerate. I have to presume whoever cooked up that business model got one helluva Christmas bonus.
Speaking of Christmas, it was in the Christmas issue of 2014 that the British Medical Journal added wind to this incipient cyclone by publishing a paper challenging the substantiation of claims made on medical TV shows, the Dr. Oz Show notable among them. This engendered allegations of charlatanism among those apparently eager to see their mightily celebrated colleague fallen, but the “truth” was quite another story.
Writing on the BMJ website, the authors acknowledged that the recommendations on TV were substantiated by randomized trials almost exactly as often as prevailing recommendations in clinical practice; and slightly more often than guidance in position statements. They also disclosed that the kind of “recommendation” they found to be unsubstantiated with RCTs included: cover your nose and mouth when you sneeze; don't buy products out of vending machines oozing goo; and confer with your own doctor before acting on the advice of a doctor you saw on TV.
So, yes, it's true, there are apparently no RCTs to show better outcomes when people confer with their own doctors before acting on medical advice. There are, to my knowledge, no RCTs to indicate it's better to treat bullet holes through the chest with emergency surgery rather than watching them bleed, either, but I'm OK with it, in both cases. As noted, tempest in a teapot.
Now, back to the bigger issue: Is Roundup safe? I don't know. Argentina doesn't seem to think so.
Studies have suggested that glyphosate, alone, is acceptably safe at the levels routinely encountered. But Roundup is not just glyphosate, and independent scientists reporting in the peer-reviewed literature have raised concerns that the whole herbicide may be toxic in ways greater than the component parts. Subsequent reports of potential Roundup toxicities have been published by the same group again, and again, and again. I would gladly defer to an unaffiliated toxicologist to say how concerning this literature is, but my own training certainly allows me to say that reports of “no cause for concern” are premature, and unjustified. The shadow of legitimate doubt has been cast.
What, then, of Monsanto in the Oz-related turbulence of late? I have absolutely no idea if Monsanto-related provocations had anything to do with Sen. McCaskill's rebuke. But I must say that a highly publicized reprimand from a sitting U.S. Senator for a television segment about a weight loss supplement that is probably both safe and somewhat effective seems a remarkable instance of aiming an RPG at a gnat.
Monsanto's involvement in the latest twist of the story, however, seems all but certain, according to sources that include Al Jazeera America, and for those who prefer only truly erudite journalism, People Magazine. The initial headlines, and echoes in cyberspace, all contended that “prominent physicians” were requesting the ouster of Dr. Oz from the Columbia University faculty. The reality is that a group of 5 physicians with ties to Monsanto apparently invited along 5 friends to make, a minion? And then masquerade as the voice of the impartially prestigious, and righteous.
That such echoes in cyberspace were propagated by, among others, those professing to defend science and evidence, who apparently didn't bother to check the evidence underlying the claims in, or about, the already infamous letter, can be a story for another day. Suffice to say now that claims of defending the public from the hypothetical harms of medicine-on-television by use of evidence should, really, provide some evidence of ever having defended the public from any actual harm. Otherwise, evidence is espoused, but propaganda is dispensed. It may be some such groups are simply the extended phenotype of an Internet troll, not really concerned with defending anyone from anything -- and simply committed to trolling for their own notoriety. As noted, that can be a story for another column, and another day.
None of this is to suggest that medical advice on television has been entirely vindicated. As noted, I have long had my own concerns about it. The legitimate practice of medicine is full of uncertainties and delays; doubts, and disappointments.
Television, in contrast, needs to be much about drama, and titillation, and perennially perky. When I worked on-air for Good Morning America (which, by the way, has also addressed the letter-of-righteous-indignation story, reaffirming not only the conflicted interests of the letter writers, but also the felony and prison term of one of their august number), I found the reconciliation of the 2 a challenge. I suspect Mehmet does as well at times. The rest of us have cause to recognize the tensions that govern any attempt at “education” on television. We also have cause to wonder what is wrong with the modern practice of medicine, when so many find the understanding, empathy, and empowerment they hope to get from their own doctor, only from a doctor they see on TV.
So we come to the end of this rendition of a tale with more twists than the cyclone that lifted Dorothy's house off its foundation. We are, I think, invited to reach the same conclusion imparted to Dorothy when she landed. If what is supposed to be a story about the distortions born of TV medicine is actually much about the profit-driven machinations of a global agri-business, and the dubious self-promotions of the self-serving and flagrantly conflicted, then things may not be as they seem. We are someplace other than where we started, whether over the rainbow or otherwise. We are, as the saying goes, not in Kansas anymore.
*Selective bibliography for green coffee bean extract:
1) Marcason W. What Is Green Coffee Extract? Journal of the Academy of Nutrition and Dietetics. 2013;113(2):364.
2) Clifford MN. Chlorogenic acids and other cinnamates - nature, occurrence, dietary burden, absorption and metabolism. Journal of the Science of Food and Agriculture.2000;80(7):1033-1043.
3) Shimoda H, Seki E, Aitani M. Inhibitory effect of green coffee bean extract on fat accumulation and body weight gain in mice. BMC Complement Altern Med.2006;6:9.
4) Naczk M, Shahidi F. Phenolic compounds in plant foods: chemistry and health benefits. Nutraceuticals and Food. 2003;8(2):200-218.
5) Clifford MN. Chlorogenic acids and other cinnamates - nature, occurrence and dietary burden. Journal of the Science of Food and Agriculture. 1999;79(3):362-372.
6) Olthof MR, Hollman PC, Katan MB. Chlorogenic acid and caffeic acid are absorbed in humans. J Nutr. Jan 2001;131(1):66-71.
7) Henry-Vitrac C, Ibarra A, Roller M, Merillon JM, Vitrac X. Contribution of chlorogenic acids to the inhibition of human hepatic glucose-6-phosphatase activity in vitro by Svetol, a standardized decaffeinated green coffee extract. J Agric Food Chem. Apr 14 2010;58(7):4141-4144.
8) Ho L, Varghese M, Wang J, et al. Dietary supplementation with decaffeinated green coffee improves diet-induced insulin resistance and brain energy metabolism in mice. Nutr Neurosci. Jan 2012;15(1):37-45.
9) Hemmerle H, Burger HJ, Below P, et al. Chlorogenic acid and synthetic chlorogenic acid derivatives: novel inhibitors of hepatic glucose-6-phosphate translocase. J Med Chem. Jan 17 1997;40(2):137-145.
10) Laranjinha JA, Almeida LM, Madeira VM. Reactivity of dietary phenolic acids with peroxyl radicals: antioxidant activity upon low density lipoprotein peroxidation.Biochem Pharmacol. Aug 3 1994;48(3):487-494.
11) Nardini M, D’Aquino M, Tomassi G, Gentili V, Di Felice M, Scaccini C. Inhibition of human low-density lipoprotein oxidation by caffeic acid and other hydroxycinnamic acid derivatives. Free Radic Biol Med. Nov 1995;19(5):541-552.
12) Tanaka K, Nishizono S, Tamaru S, et al. Anti-Obesity and Hypotriglyceridemic Properties of Coffee Bean Extract in SD Rats. Food Sci Technol Res. 2009;15(2):147 - 152.
13) Cho AS, Jeon SM, Kim MJ, et al. Chlorogenic acid exhibits anti-obesity property and improves lipid metabolism in high-fat diet-induced-obese mice. Food Chem Toxicol. Mar 2010;48(3):937-943.
14) Thom E. The effect of chlorogenic acid enriched coffee on glucose absorption in healthy volunteers and its effect on body mass when used long-term in overweight and obese people. J Int Med Res. Nov-Dec 2007;35(6):900-908.
15) Welsch CA, Lachance PA, Wasserman BP. Dietary phenolic compounds: inhibition of Na+-dependent D-glucose uptake in rat intestinal brush border membrane vesicles. J Nutr. Nov 1989;119(11):1698-1704.
16) Suzuki A, Yamamoto N, Jokura H, et al. Chlorogenic acid attenuates hypertension and improves endothelial function in spontaneously hypertensive rats. J Hypertens. Jun 2006;24(6):1065-1073.
17) Bugianesi R, Salucci M, Leonardi C, et al. Effect of domestic cooking on human bioavailability of naringenin, chlorogenic acid, lycopene and beta-carotene in cherry tomatoes. Eur J Nutr. Dec 2004;43(6):360-366.
18) Plumb GW, Garcia-Conesa MT, Kroon PA, Rhodes M, Ridley S, Williamson G. Metabolism of chlorogenic acid by human plasma, liver, intestine and gut microflora.Journal of the Science of Food and Agriculture. 1999;79(3):390-392.
19) van Dijk AE, Olthof MR, Meeuse JC, Seebus E, Heine RJ, van Dam RM. Acute effects of decaffeinated coffee and the major coffee components chlorogenic acid and trigonelline on glucose tolerance. Diabetes Care. Jun 2009;32(6):1023-1025.
20) Ota N, Soga S, Murase T, Shimotoyodome A, Hase T. Consumption of Coffee Polyphenols Increases Fat Utilization in Humans. Journal of Health Science (Japan).2010;56(6):745-751.
21) Watanabe T, Arai Y, Mitsui Y, et al. The blood pressure-lowering effect and safety of chlorogenic acid from green coffee bean extract in essential hypertension. Clin Exp Hypertens. Jul 2006;28(5):439-449.
22) Monteiro M, Farah A, Perrone D, Trugo LC, Donangelo C. Chlorogenic acid compounds from coffee are differentially absorbed and metabolized in humans. J Nutr. Oct 2007;137(10):2196-2201.
23) Zhao Y, Wang J, Ballevre O, Luo H, Zhang W. Antihypertensive effects and mechanisms of chlorogenic acids. Hypertens Res. Apr 2012;35(4):370-374.
24) Dellalibera O, Lemaire B, Lafay S. Svetol green coffee extract induces weight loss and increases the lean to fat mass ratio in volunteers with overweight problem.Phytotherapie. 2006;4(4):194-197.
25) Ayton Global Research. The Effect of Chlorogenic Acid Enriched Coffee (Coffee Shape) on Weight When Used in Overweight People. 2009.
26) Vinson JA, Burnham BR, Nagendran MV. Randomized, double-blind, placebo-controlled, linear dose, crossover study to evaluate the efficacy and safety of a green coffee bean extract in overweight subjects. Diabetes Metab Syndr Obes. 2012;5:21-27.
27) Onakpoya I, Terry R, Ernst E. The use of green coffee extract as a weight loss supplement: a systematic review and meta-analysis of randomised clinical trials.Gastroenterol Res Pract. 2011;2011.
28) Heckman MA, Weil J, Gonzalez de Mejia E. Caffeine (1, 3, 7-trimethylxanthine) in foods: a comprehensive review on consumption, functionality, safety, and regulatory matters. J Food Sci. Apr 2010;75(3):R77-87.
29) Therapeutic Research Faculty. Green Coffee. Natural Medicines Comprehensive Database. 2013.
David L. Katz, MD, FACP, MPH, FACPM, is an internationally renowned authority on nutrition, weight management, and the prevention of chronic disease, and an internationally recognized leader in integrative medicine and patient-centered care. He is a board certified specialist in both Internal Medicine, and Preventive Medicine/Public Health, and Associate Professor (adjunct) in Public Health Practice at the Yale University School of Medicine. He is the Director and founder (1998) of Yale University's Prevention Research Center; Director and founder of the Integrative Medicine Center at Griffin Hospital (2000) in Derby, Conn.; founder and president of the non-profit Turn the Tide Foundation; and formerly the Director of Medical Studies in Public Health at the Yale School of Medicine for eight years. This post originally appeared on his blog at The Huffington Post.
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