Monthly Archives: February 2014

HRT optimization, using transdermal estradiol plus micronized progesterone, a safer HRT.

Women at menopause have a number of options – do nothing and put up with the symptoms of menopause, take HRT or use the Bioidentical(natural) HRT. This article gives further proof of the better safety and effectiveness of the BHRT vs the synthetic form. After all the evidence, I still get doctors trying to defend the use of synthetic HRT, especially HRT in a pill form.
Climacteric. 2013 Aug;16 Suppl 1:44-53. doi: 10.3109/13697137.2013.808563.

HRT optimization, using transdermal estradiol plus micronized progesterone, a safer HRT.


Obstetrics and Gynecology Department, Centre Hospitalo-Universitaire Brugmann, Université Libre de Bruxelles , Bruxelles , Belgium.


ABSTRACT Hormone replacement therapy (HRT) remains the gold standard for treatment of climacteric symptoms in menopausal women; it is relatively safe in healthy subjects for at least 5 years, provided it had been initiated before the age of 60 years and/or within 10 years from menopause. Estrogen probably adds some cardioprotection, that can, however, be obscured by progestogens, especially medroxyprogesterone acetate (MPA). Oral HRT is associated with an increased risk of venous thromboembolism (VTE), gallbladder disease and possibly stroke. The increased occurrence of all these events can be prevented by the use of the transdermal route of estradiol administration; this route seems also advantageous for women with diabetes, hypertension and other cardiovascular risk factors, and also especially with advancing age. Endometrial protection by any progestogen is insufficient in the mid to long term when cyclical, sequential regimens are used; full protection can be secured only by continuous combined estrogen + progestogen. Natural, ‘body-identical’ progesterone, devoid of any androgenic as well as glucocorticoid activities but being slightly hypotensive due to its antimineralocorticoid activity, appears to be the optimal progestogen in terms of cardiovascular effects, blood pressure, VTE, probably stroke and even breast cancer (contrary to synthetic progestogens and particularly MPA, which appear to be mitogenic on breast cells, in synergism with estrogen). HRT optimization can thus be achieved by combining low doses of estrogen given transdermally with micronized oral progesterone; such optimized HRT will allow us to treat symptomatic women for as long as required. Asymptomatic women at risk of (osteoporotic) fractures can also be treated with this optimized HRT as long as their individual risk/benefit ratio remains favorable (thanks to the absence of increased risks of VTE, stroke and breast cancer).

Breast Cancer: Good Foods

Breast Cancer: Good Foods
Published: 10/7/2013


Diet and nutrition can play a significant role in the chances of developing breast cancer, especially if you have a family history of the disease. The following foods may help to prevent or lessen the risks – Dr. Weil encourages all women to give them a try:

  1. Use healthy fats: Monounsaturated fats found in a high quality, extra virgin olive oil, and polyunsaturated omega-3 fats from freshly ground flaxseed and oily fish such as wild Alaskan salmon and sardines may help reduce your risk of developing breast cancer.
  2. Include whole soy products in your diet. Soy foods contain many cancer-protective substances, including isoflavones. Try to eat one to two servings of whole soy-based foods a day.
  3. Eat more fruits and vegetables! Especially cruciferous vegetables such as broccoli, bok choy and cauliflower, which contain many different cancer-protective phytonutrients.

Walking does not protect bones

The best protection against osteoporosis is oestrogen. (see under “osteoporosis: on this website”) Weight bearing exercise also helps, as well as Vit D and calcium – not as a pill, but in  food. Search “harm from calcium” on this web-site for the potential dangers of calcium tablets.
Menopause. 2013 Nov;20(11):1216-26. doi: 10.1097/GME.0000000000000100.

Effects of walking on the preservation of bone mineral density in perimenopausal and postmenopausal women: a systematic review and meta-analysis.


From the Schools of 1Nursing and 2Continuing Education, Peking Union Medical College, Chinese Academy of Medical Science, Beijing, PR China.



This study aims to critically evaluate the effects of a walking intervention on bone mineral density (BMD) in perimenopausal and postmenopausal women and to identify the optimal duration of this walking exercise intervention.


Two independent reviewers assessed for eligibility randomized and nonrandomized controlled trials evaluating the effects of walking on BMD in perimenopausal and postmenopausal women. Heterogeneity, potential publication bias, and the quality of the included trials were assessed.


Ten trials were eligible for inclusion. A meta-analysis of trials assessing lumbar spine BMD showed no significant effects (weighted mean difference [WMD] [fixed effects], 0.01 g/cm; 95% CI, -0.00 to 0.02; P = 0.05) regardless of the length of the intervention duration. BMD at the femoral neck increased after long intervention durations (6 mo to 1-2 y), although no significant effect could be seen when all trials assessing femoral neck BMD were taken into account (WMD [fixed effects], 0.01 g/cm; 95% CI, -0.00 to 0.01; P = 0.07). The effects of walking on the radius and whole body were not significant (WMD [random effects], -0.01 g/cm; 95% CI, -0.06 to 0.04; P = 0.71; and WMD [fixed effects], 0.04 g/cm; 95% CI, -0.00 to 0.08; P = 0.06, respectively).


Walking as a singular exercise therapy has no significant effects on BMD at the lumbar spine, at the radius, or for the whole body in perimenopausal and postmenopausal women, although significant and positive effects on femoral neck BMD in this population are evident with interventions more than 6 months in duration.

Five Reasons Why ‘Food’ Is A Massive Global Health Issue

Health beyond the horizon

Alessandro R Demaio

Australian Medical Doctor; Postdoctoral Fellow in Global Health & NCDs at Harvard University

17 December 2013, 8.03am AEST

Five Reasons Why ‘Food’ Is A Massive Global Health Issue

Last week in Stockholm, Sweden, I was asked to present an insight into the links between food and global health to the Swedish Medical Society Conference; a brief outline on the parallels and overlap between what we eat, the systems that produce and support that consumption, and the health of our populations.

Now this is no easy task – and not because the overlaps are limited – quite the opposite – but because I had only 10 minutes to do it in!

With this in mind, I proposed just 5 of the reasons why food is, and must be, a Global Health Issue.

Reason number one, we are what we eat.

Put simply, globally, locally and individually – we are what we eat. Improvements in nutrition may have given us enormous health benefits this last century, but food-related disease, including obesity, has now become our greatest health challenge for the current century.

Flickr / Kyle Taylor, Dream It. Do It.

In addition to half a billion people still undernourished worldwide – today diabetes, heart disease, cancers and lung disease, are the leading cause of global deaths. In China, a nation rapidly undergoing nutritional and epidemiological transition, one in two or 500 million people are thought to be prediabetic or diabetic.Diseases which are both caused and solved, in part, by food.

In Europe, the USA and Australia, obesity rates range from the low teens to mid thirty percent, and obesity-related disease is already crippling populations, health systems and national budgets – concurrently under strain from the economic crisis.

Now this is not to suggest that it is simply a question of calories in versus calories out, but the food we eat, can afford and have access to – and how this is marketed, packaged and served – is a large dictator of our health.

Reason number two: Poverty is not a protector from food-related disease, but a risk factor for it.

Flickr / DFAT photo library

In the 20th century, the global health scourges were more likely resulting from under-nutrition. This is no longer. Today – our leading global health challenge results from over-nutrition related malnutrition, with 80% of this disease burden occurring in the world’s low and middle income nations.The commonly spouted theory that malnutrition resulting from overconsumption is a rich-person’s problem is a dangerous myth.

Risk factors such as obesity and poor diet – as well as diseases such as diabetes, heart disease, lung diseases, cancers and mental illness – are linked with poverty, not affluence. Diseases deeply linked with the quality and quantity of our diets, these are all linked with social and economic derivation.

Reason three: Dietary risks represent profound health opportunities.

The 2010 Global Burden of Disease Study ranked the top causes of global disability and deaths. It is no surprise to many of us, that diet-related diseases topped the charts. But what can surprise some, is that diet itself was named the number one risk factor for morbidity and mortality globally.

The good news though, is that this is a risk factor. This is a disease modifier and amplifier, but if addressed, it is also a disease minimiser and an opportunity for prevention. The quality and quantity of our diets may be an enormous threat to current global health, but inversely it can also become an enormous opportunity for creating a healthier future – if managed appropriately.

The fourth reason: Big Food is a complex, heterogenous and prickly beast.

In 2013, top food companies have more power than some governments, but are unelected and have very different incentives – we must understand this.

The world’s biggest food company alone employs 330,000 people and has an annual revenue of almost 100 billion US dollars – two-thirds the GDP of New Zealand and twice the GDP of Croatia. This company also produces 1 billion products each and every day.

Flickr / Keoni Cabral

In short, some of these companies have more economic power than some national governments and probably more global political influence than many national governments. Yet, the leaders of these companies are unelected and their driving incentives are market-based and focused on profit, not development, environmental sustainability, social justice or health.This is a challenge – a huge challenge – and currently there is no clear consensus on how to manage this risk.

Do we work with them? Do we shut the door? Do we regulate or let them regulate? Can they really be trusted to fund governments and elections?

These companies exert an enormous influence on population health and I categorise their behaviours into three groups. The good, the bad and the ugly.

The good companies – those which supply food staples, share the need to create healthy populations and sustainable practices – must be engaged and led by government, but in an independent, mature, arms-length and transparent way.

The bad must be recognised, called out, improved and, when necessary, regulated.

The ugly is the most dangerous. We must recognise that selfish and deliberate decisions by food multi-nationals have caused enormous public health costs in the past decades. These Big Food corporations and their practices must be controlled, even limited – this is essential for global health.

The final reason, there is a growing disconnect between food, cooking and people.

Food is essential to global health, right down to the individual level. As food systems become more processed, supply-chains become longer, and our diets are characterised by a long list of chemicals rather than ingredients – we are losing our personal connection to food. Our understanding of how to choose it, cook it and consume it. And this is occurring almost ubiquitously.

Flickr /

Understanding food and where it comes from, is an essential knowledge nugget for a healthy society – and crucial for those working in health. As the Journal of the American Medical Association recently published, the old medical adage of “see one, do one, teach one” must also become “see one, taste one, cook one, teach one”.Engaging with the education and political sectors to ensure this is understood, would be time and energy well spent for any global health enthusiast or doctor. Food must become a more accepted part of the clinical mandate.

Looking Forward.

To conclude, Food is an essential part of health and wellbeing – chosen, prepared, cooked and consumed correctly, food is medicine – it can and has been an enormous catalyst to gains in life expectancy and quality of life to populations around the globe.

Flickr / FlyingSinger

But – and this is an important ‘but’ – mismanaged, unregulated, recklessly advertised, poorly produced and over consumed, food can have dire public health consequences. And those consequences are currently playing out around the world.Food companies, governments, the medical community, the food supply, what we eat, how we eat, food policies and what we subsidise, how much we eat and what we waste will all dictate whether, in the next century, food can once again be a catalyst of health – or continues as a risk to it.

One thing is clear – food is, and must be, a Global Health Issue.

Trust your Gut feeling

I take probiotics on a daily basis, as I am aware of the value of our billions of passengers in our body. Also, I am loathe to take antibiotics (or my family to take them) for the damage they do to these free-loaders of ours. Also, excessive cleanliness and avoidance of germs, especially to infants, does more harm than good.
27 November 2013, 6.07am AEST

Navel gazing: healthy gut bacteria can help you stress less

Striking new evidence indicates that the gut microbiome, the ecological community of microorganisms that share our body, has a huge effect on brain function – much larger than we thought. It has long been established that our gut acts as a second nervous system and is capable of functioning without…

The trillions of bacteria in your gut can affect your brain – psychologically and physically. Helga Weber

Striking new evidence indicates that the gut microbiome, the ecological community of microorganisms that share our body, has a huge effect on brain function – much larger than we thought.

It has long been established that our gut acts as a second nervous system and is capable of functioning without input from the brain.

Nevertheless, the brain and gut are still intimately connected through a process called “the gut-brain axis”, and changes to either system can have dramatic effects on the other.

The guts of both vertebrate and invertebrate animals are home to trillions of microorganisms, which primarily consist of mutualistic bacteria.

These resident bacteria play an essential role in many of our biological processes, such as supplying important nutrients, breaking down indigestible compounds and defending against other pathogenic microbes.

Bacterial composition has recently been correlated with several neurological disorders, especially those relating to anxiety. While the exact way gut microbes affect the nervous system is unfortunately not yet entirely understood, scientists are working to answer this question by exploring brain function at the molecular level.

How do gut microbes affect the brain?

Two research teams headed by Rochellys Diaz Heijtz and Thomas Neufeld recently discovered that completely eliminating gut bacteria from mice had surprising effects on the animals’ anxiety levels.

Aaron Logan

When tested under conditions that would normally induce stress, bacteria-free mice were found to have significantly less anxiety and anxiety-associated behaviours than the mice with normal intestinal microbes. This was one of the first instances showing that the gut microbes may play a role in mental disorders.

To investigate why removing the gut microbiome correlated with reduced anxiety, both teams explored the possibility that gut bacteria may influence the activation of genes important for brain function.

Specifically, the activity of genes involved in regulating neuron survival and signalling — along with genes that encode for receptors that bind important neurotransmitters – were changed. For instance, several neurotransmitters, including serotonin, were altered within regions of the brain associated with motor control and anxiety-like behaviour in bacteria-free mice.

This hints that intestinal bacteria have some level of influence on DNA transcription – especially on genes that are essential for brain function.

Gut flora may also alter the way the brain changes during the earliest stages of life. Young, microbe-free mice were reconstituted with normal levels of intestinal flora to examine how these bacteria affects neurogenesis, the process where neurons are generated from stem cells and progenitor cells during pre-natal development.

As a result of these tests, activation of genes responsible for the maturation of neurons was found to be increased. This demonstrates that gut flora may be essential for proper brain development during the foetal stage.

Gut bacteria, therefore, seems to play an essential role in neuronal growth. As bacteria colonise the gut in the days following birth – a sensitive period for brain development – poor establishment of the microbiome may potentially lend to the occurrence of anxiety-based disorders.

The key players: identifying important bacteria

While these studies have revealed that removing our gut microbes has serious effects on the brain, it begs the questions of whether specific types of bacteria are more important for neural function than others. This is becoming clear as scientists explore brain changes associated with some of our most common species.

Lactobacillus bacteria. AJ Cann

For instance, in 2011, researchers in Ireland discovered that mice treated with the common probiotic bacterium Lactobacillus rhamnosus had reduced stress hormone and anxiety related behaviours.

L. rhamnosus was later found to influence gamma-Aminobutyric acid (GABA), the primary central nervous system inhibitory neurotransmitter involved in regulating countless processes.

GABA or GABA receptors are associated with the development of anxiety and depression, suggesting that this particular probiotic helps to normalise GABA in the brain and consequently reduce stress.

Microbes as a treatment option

Together, these recent findings highlight the important role of bacteria in the communication between the gut and the brain. Our increasing knowledge of how human mental illnesses – such as autism, anxiety, and depression – are linked to gut flora may lead to future treatments of mental illness.

This could include administration of probiotics or faecal transplant procedures that would modify gut flora community structures. Already, studies doing exactly this through clinical trials show promising results, with many patients reporting improved mental health after high-dose treatments.

Our knowledge of this specific area of neuroscience is expanding quickly, but in order to advance this emerging field of medical research, we will require experimental approaches that more accurately describe the microbial community of the gut and identify other behaviour-modifying species.

In addition, experiments that seek to either alter microbial communities or the molecular signals employed by microbes will be critical to the development of new therapeutics.

These continuing discoveries may finally prove once and for all that our fears and anxieties are not actually all in our head. We should attempt to rely more on our gut.

Health Check: should we aim for daily bowel movements?

4 November 2013, 2.43pm AEST

Health Check: should we aim for daily bowel movements?

When I was in my teens, I watched the comedy Crazy People, starring Dudley Moore and Daryl Hannah. Moore plays a burnt-out advertising executive who creates (hilarious) “honest” ads. One of the ads is for the fibre supplement Metamucil which claims: It helps you go to the toilet. If you don’t use it…

When it comes to passing stools, ‘normal’ ranges from three times a week, to three times a day. Image from

When I was in my teens, I watched the comedy Crazy People, starring Dudley Moore and Daryl Hannah. Moore plays a burnt-out advertising executive who creates (hilarious) “honest” ads. One of the ads is for the fibre supplement Metamucil which claims:

It helps you go to the toilet. If you don’t use it, you’ll get cancer and die.

Don’t worry, constipation doesn’t cause bowel cancer.

Perhaps this is a testament to the power of advertising, but this fake advertisement, inside a movie, had a long lasting effect on me. In fact, constipation is not associated with the development of bowel cancer. But I didn’t learn this until well into my medical studies!

What is constipation?

Constipation is the passing of hard, dry bowel motions (stools), which can cause straining and pain. Other common symptoms include passing stools less often, a sense of incomplete emptying after going to the toilet, and abdominal bloating and cramps.

The Bristol stool chart is used to classify faeces, and types one and two can indicate constipation.

Kyle Thompson
Click to enlarge

From a medical perspective, the Rome Foundation publishes the diagnostic criteria for chronic constipation. I’m fond of this particularly apt mnemonic to remember:

Straining for at least 25% of the times

Hard stools at least 25% of the times

Incomplete evacuation sensation at least 25% of the times

Two times or less bowel movements a week.

Constipation is common. Around one in six to one in eight adults suffer from it, so most of us have probably experienced constipation at some stage in our lives.

Although there are many medical diseases that can lead to constipation, such as Parkinson’s disease, hypothyroidism, and hernias, these “organic” causes are by far the minority.

Most episodes of constipation are without structural underlying causes. More commonly, lifestyle and constitutional factors, often in combination, increase the risk of constipation:

  • Dietary habits – particularly a change in diet, reduction in water intake, or a diet low in fibre
Older people are more likely to suffer from constipation. Image from
  • Physical inactivity – for instance, a reduction in regular exercise, or a sedentary lifestyle
  • Mood – anxiety and depression are associated with a number of gastrointestinal symptoms, including constipation
  • Drugs – many medications are known to increase the likelihood of constipation (such as opioid analgesics, antidepressants, iron supplements, some blood pressure medicines)
  • Age – older people are more likely to suffer from constipation, though mostly from the above factors.

So, how often should I go?

When my patients use the term “regular bowel movement”, they typically interpret it as meaning opening one’s bowels at approximately the same time, on a daily basis. Interestingly, only about one third of adults pass stools in such a pattern, making the conventional “normal bowel habit” not terribly “normal”!

There is considerable variation between individuals. The claim that stool frequency in well people ranges from three times a week, to three times a day, is quite old – it comes from a British study from 50 years ago. Nevertheless, it remains a relatively useful rule of thumb.

When should I be worried?

Simple constipation will generally resolve by addressing the aforementioned lifestyle factors. Your local community pharmacist will be able to give advice on the use of fibre supplements and over-the-counter laxatives if they are required.

Longer-term use of laxatives can be safe – but it depends on the medication and the clinical situation. This shouldn’t be a decision made without medical advice.

Although more serious causes of constipation are uncommon, they do occur. Should you experience any of the following, you should seek the advice of your regular general practitioner:

  • having to use laxatives regularly to open bowels
  • rectal bleeding
  • mucous (slimy material) in the stool
  • a change in bowel habit for no obvious reason
  • alternating diarrhoea and constipation
  • persistent pain with passing motions.

There is no pressing health need to aim for once-daily bowel motions for its own sake, if that isn’t “normal” for the individual. That being said, there are unambiguous health benefits from having sufficient fibre and water in the diet, and being physically active.

An obvious reason to manage constipation well, and aim to avoid it altogether, is – quite simply – that it’s unpleasant.

Herbal Supplements Are Often Not What They Seem

Americans spend an estimated $5 billion a year on unproven herbal supplements that promise everything from fighting off colds to curbing hot flashes and boosting memory. But now there is a new reason for supplement buyers to beware: DNA tests show that many pills labeled as healing herbs are little more than powdered rice and weeds.

Using a test called DNA barcoding, a kind of genetic fingerprinting that has also been used to help uncover labeling fraud in the commercial seafood industry, Canadian researchers tested 44 bottles of popular supplements sold by 12 companies. They found that many were not what they claimed to be, and that pills labeled as popular herbs were often diluted — or replaced entirely — by cheap fillers like soybean, wheat and rice.

Consumer advocates and scientists say the research provides more evidence that the herbal supplement industry is riddled with questionable practices. Industry representatives argue that any problems are not widespread.

For the study, the researchers selected popular medicinal herbs, and then randomly bought different brands of those products from stores and outlets in Canada and the United States. To avoid singling out any company, they did not disclose any product names.

Among their findings were bottles of echinacea supplements, used by millions of Americans to prevent and treat colds, that contained ground up bitter weed, Parthenium hysterophorus, an invasive plant found in India and Australia that has been linked to rashes, nausea and flatulence.

Two bottles labeled as St. John’s wort, which studies have shown may treat mild depression, contained none of the medicinal herb. Instead, the pills in one bottle were made of nothing but rice, and another bottle contained only Alexandrian senna, an Egyptian yellow shrub that is a powerful laxative. Gingko biloba supplements, promoted as memory enhancers, were mixed with fillers and black walnut, a potentially deadly hazard for people with nut allergies.

Of 44 herbal supplements tested, one-third showed outright substitution, meaning there was no trace of the plant advertised on the bottle — only another plant in its place.

Many were adulterated with ingredients not listed on the label, like rice, soybean and wheat, which are used as fillers.

In some cases, these fillers were the only plant detected in the bottle — a health concern for people with allergies or those seeking gluten-free products, said the study’s lead author, Steven G. Newmaster, a biology professor and botanical director of the Biodiversity Institute of Ontario at the University of Guelph.

The findings, published in the journal BMC Medicine, follow a number of smaller studies conducted in recent years that have suggested a sizable percentage of herbal products are not what they purport to be. But because the latest findings are backed by DNA testing, they offer perhaps the most credible evidence to date of adulteration, contamination and mislabeling in the medicinal supplement industry, a rapidly growing area of alternative medicine that includes an estimated 29,000 herbal products and substances sold throughout North America.

“This suggests that the problems are widespread and that quality control for many companies, whether through ignorance, incompetence or dishonesty, is unacceptable,” said David Schardt, a senior nutritionist at the Center for Science in the Public Interest, an advocacy group. “Given these results, it’s hard to recommend any herbal supplements to consumers.”

Representatives of the supplement industry said that while mislabeling of supplements was a legitimate concern, they did not believe it reached the extent suggested by the new research.

Stefan Gafner, the chief science officer at the American Botanical Council, a nonprofit group that promotes the use of herbal supplements, said the study was flawed, in part because the bar-coding technology it used could not always identify herbs that have been purified and highly processed.

“Over all, I would agree that quality control is an issue in the herbal industry,” Dr. Gafner said. “But I think that what’s represented here is overblown. I don’t think it’s as bad as it looks according to this study.”

The Food and Drug Administration has used bar-coding technology to warn and in some cases prosecute sellers of seafood found to be “misbranded.” The DNA technique has also been used in studies of herbal teas, which showed that a significant percentage contain herbs and ingredients that are not listed on their labels.

But policing the supplement industry is a special challenge. The F.D.A. requires that companies test the products they sell to make sure that they are safe. But the system essentially operates on the honor code. Unlike prescription drugs, supplements are generally considered safe until proved otherwise.

Under a 1994 law, they can be sold and marketed with little regulatory oversight, and they are pulled from shelves generally only after complaints of serious injury. The F.D.A. audits a small number of companies, but even industry representatives say more oversight is needed.

“The regulations are very appropriate and rigorous,” said Duffy MacKay of the Council for Responsible Nutrition, a supplement industry trade group. “But we need a strong regulator enforcing the full force of the law. F.D.A. resources are limited, and therefore enforcement has not historically been as rigorous as it could be.”

Shelly Burgess, a spokeswoman for the F.D.A., said that companies were required to adhere to a set of good manufacturing practices designed to prevent adulteration, but that many were ignoring the rules.

“Unfortunately, we are seeing a very high percentage — approximately 70 percent — of firms’ noncompliance,” she said, “and we are very active in taking enforcement actions against such violations.”

DNA bar coding was developed about a decade ago at the University of Guelph. Instead of sequencing entire genomes, scientists realized that they could examine genes from a standardized region of every genome to identify species of plants and animals. These short sequences can be quickly analyzed — much like the bar codes on the items at a supermarket — and compared with others in an electronic database. An electronic reference library at Guelph, called the International Barcode of Life Project, contains over 2.6 million bar code records for almost 200,000 species of plants and animals.

The testing technique is not foolproof. It can identify the substances in a supplement, but it cannot determine their potency. And because the technology relies on the detection of DNA, it may not be able to identify concentrated chemical extracts that do not contain genetic material, or products in which the material has been destroyed by heat and processing.

But Dr. Newmaster emphasized that only powders and pills were used in the new research, not extracts. In addition, the DNA testing nearly always detected some plant material in the samples — just not always the plant or herb named on the label.

Some of the adulteration problems may be inadvertent. Cross-contamination can occur in fields where different plants are grown side by side and picked at the same time, or in factories where the herbs are packaged. Dr. Gafner of the American Botanical Council said that rice, starch and other compounds were sometimes added during processing to keep powdered herbs from clumping, just as kernels of rice are added to salt shakers.

But that does not explain many of the DNA results. For instance, the study found that one product advertised as black cohosh — a North American plant and popular remedy for hot flashes and other menopause symptoms — actually contained a related Asian plant, Actaea asiatica, that can be toxic to humans.

Those findings mirror a similar study of black cohosh supplements conducted at Stony Brook University medical center last year. Dr. David A. Baker, a professor of obstetrics, gynecology and reproductive medicine, bought 36 black cohosh supplements from online and chain stores. Bar coding tests showed that a quarter of them were not black cohosh, but instead contained an ornamental plant from China.

Dr. Baker called the state of supplement regulation “the Wild West,” and said most consumers had no idea how few safeguards were in place. “If you had a child who was sick and three out of 10 penicillin pills were fake, everybody would be up in arms,” Dr. Baker said. “But it’s O.K. to buy a supplement where three out of 10 pills are fake. I don’t understand it. Why does this industry get away with that?”

A version of this article appears in print on November 5, 2013, on page D1 of the New York edition with the headline: Pills That Aren’t What They Seem.

Readers Comments:

    • Millicent
    • Lagrange, IL
    NYT Pick

    What in the world was the point of doing this study and NOT publishing company names? They “didn’t want to single anyone out”? Why in the world not? I don’t buy herbal supplements often – hardly at all, really – but it’s ludicrous that these researchers wouldn’t offer concrete, useful information.

    • Mark Neuman.
    • Lakewood, CA
    NYT Pick

    They get away with it because Senator Orin Hatch of Utah defanged FDA oversight of this industry in 1994. And guess where most of these companies are located? Yup. Utah. Figures. Thanks, Senator Hatch, for putting industry profits ahead of consumer safety and ensuring efficacy of what is sold to consumers.

    • WWR
    • Toronto, Ontario
    NYT Pick

    I heard one of the people responsible for this report summarize its results five weeks ago. The only rule of thumb he could give was that smaller (Canadian) companies were more reliable than larger multinational ones. As to why they didn’t name names – I doubt that this organization has a legal budget large enough to fend off these multinationals. This organization has developed a programme to certify that (based on a sampling process) the product is genetically identical to what is shown on the label of its package.

    • PBeeee
    • Montana
    NYT Pick

    This is a message I have tried to tell people for many years. Someone can literally go out into the back yard, scoop dirt into a capsule and sell it to you as any herbal supplement they want. And then there is the fact that so many of these products come from China or India where pesticides like DDT and worse are in wide use. There is simply no oversight at any level. I don’t touch the stuff, it is a waste of money and definitive proof of the placebo effect.

    • RSC
    • Nyack, NY
    NYT Pick

    I observed a packaging operation on a line that produces herbal and vitamin tables and capsules.

    The labeling machine dispensed three types of labels: generic label, fancy label, and store brand label.

    All the pills of a certain type came down the same line, and were filled into the three differently-labeled bottles.

    The bottle that was sold for $5 contained the same pills as the ones in the $10 bottle, and in the $15 bottle. “Good, better and best” were actually “same, same and same.”

    Likewise, the various “doses” of the material in the pills and capsules were the same in any labeled dosage. The 500 mg tablet or capsule contained the same quantity of materials as the 1000 mg, and the 1500 mg capsules and tablets.

    As to what materials were in the tablets and capsules, I couldn’t say. The lettering on the bulk packaging was not in English.

    • BH
    • MD
    NYT Pick

    When I was in college, I was taking some vitamin supplements. The supplement came in a capsule formulation. Out of curiosity, I opened a capsule and emptied its contents into a bottle of water. Well, the most remarkable observation was a tiny fly flew out of the content and just escaped into the environment. I was baffled to say the list. To be clear, that vitamin supplement contained a tiny fly within the capsule!

Why I Never Got a Mammogram

Op-Ed Contributor

Why I Never Got a Mammogram


I HAVE never had a mammogram. I’m almost 50 — nearly a decade into the age when the screening is recommended by the American Cancer Society. I’m college educated, adequately insured. And I am the bane of my health care providers. Once, my midwife went so far as to request that I never speak of my decision in any space where other patients might hear.

This week, I was vindicated. On Tuesday, a Canadian study, one of the largest ever done on mammograms, was published in the British Medical Journal. The study found that mammograms did not reduce breast cancer deaths in women around my age compared to physical exams, and that one in five women screened was overdiagnosed, possibly leading to unnecessary surgery or radiation.

It seems astonishing, but it reinforced what smaller studies had told me, as someone with no family history of breast cancer: that getting a mammogram was unlikely to affect my chances of dying from the disease. What it would do is increase the probability of my mistakenly becoming a breast-cancer patient.

When I was in my late 30s, my midwife suggested I get a baseline mammogram, followed by annual screenings. I was ready to do it. I assumed my research into it would be mere due diligence.

This kind of research was a new habit of mine, born of necessity. When our son was 18 months old, he developed a devastating tumor on his spinal cord. We waited for the doctors to tell us what to do, but the diagnoses and suggestions were scattered — it’s cancer, it’s not cancer, it’s half cancerous, we need radiation, we don’t need radiation, it’s life-threatening, it’s benign. We opted for surgery, and it was deemed a success. Doctors waved us out of the hospital with balloons. But a few weeks later, we were urgently summoned back. The oncologists had decided that he needed another operation to make sure they had removed all of the tumor.

It made me realize that, despite the surety with which the medical professionals had presented things, it was all a best guess based on the available information. So I started doing my own research, to try to make the best decisions for our baby. I soon began to wonder why I didn’t study my own health care decisions as thoroughly as I did his.

So I started looking into mammograms. The more I found, the more I doubted. I was stunned by a 2001 Cochrane review — considered to be the gold standard for evidence-based studies — that concluded, “The currently available reliable evidence has not shown a survival benefit of mass screening for breast cancer.” Everywhere, I saw pink ribbons and the message that mammograms save lives. But no matter how many times I read the numbers, I wasn’t convinced that I should get one.

Over the years, my choice has spurred concern from health care practitioners as well as the person who is most worried about my health: my mother, who, in her 80s, is still a religious mammogrammer. She has described how nerve-racking the post-procedure waiting room is — you shiver in the cooled air until you’re sent home or get the ominous “The doctor needs to talk to you.” One day a few years ago, she was the one called to stay. They had found something “suspicious,” and she felt her world falling apart.

When my mother told me this, the first thing I thought of was the high rates of over- and misdiagnoses, and I told her so. But she still spent over a month in a panic — waiting for the follow-up, which then was somehow done incorrectly and had to be repeated one more time. Finally, multiple painful mammograms later, they concluded it had all been a mistake. And oddly, the false urgency has continued: She has been getting notices reminding her to make an appointment for another mammogram in six months because she is now “high-risk.”

Patients want reassurances. We feel we have to test, so we can find out if we’re sick. We rarely consider that the test itself might make us sick — perhaps through repeated exposure to radiation — or that there are health advantages for the nontester like me, who gains time, sheds stress and potentially dodges the harm of a false positive or unnecessary treatment.

This isn’t the answer for everyone. But as parents and patients, we have no choice but to try to become conversant in medicine, even if it makes some doctors bristle. Our medical experts are an invaluable resource, but in the end, it’s up to each of us how we want to proceed.

I now have a new primary care physician who still refers me to the mammography center, but when he hands me the slip, he smiles and says, “But I suspect you won’t do it,” and I get the feeling he respects my reasons. I wonder if, some day in the not too distant future, he’ll say, “This test actually seems to have more risks than rewards,” and stop handing out that slip at all.

Marie Myung-Ok Lee teaches writing at Columbia and is working on a novel about the future of medicine.

How fluoride in water helps prevent tooth decay

12 November 2012, 8.12am AEST

How fluoride in water helps prevent tooth decay

The most effective way to prevent tooth decay is delivered to most Australian homes every day through their water pipes. It is, of course, fluoride distributed via the water supply. Dental decay occurs when acid destroys or demineralises the outer surface of the tooth – the enamel. Bacteria in the mouth…

Fluoridated water protects against the tooth decay from acid produced by bacteria in the mouth. T. Faltings

The most effective way to prevent tooth decay is delivered to most Australian homes every day through their water pipes. It is, of course, fluoride distributed via the water supply.

Dental decay occurs when acid destroys or demineralises the outer surface of the tooth – the enamel. Bacteria in the mouth from food and drinks containing sugar produces acid and fluoride repairs demineralisation before it becomes permanent. It does this by encouraging remineralisation or repair of the enamel surface. Fluoride also helps strengthen the mineral structure of developing teeth.

Fluoride is a naturally occurring compound found in plants and rocks and, in very low levels, in almost all fresh water. Sometimes, fluoride is found naturally in the water supplies of Australian communities at exactly the level recommended to reduce dental decay, but this is rare and happens by chance.

Community water fluoridation is the adjustment of fluoride in drinking water to a level that helps protect teeth against decay. Drinking water in many parts of Australia has been fluoridated since the early 1960s.

Fluoride helps strengthen the mineral structure of developing teeth. Jens Gyldenkærne Clausen

Although widely accepted and applauded as a crucial public health policy, fluoridation has attracted some vocal critics. Fluoridation opponents over the years have claimed that putting fluoride in water causes health problems, is too expensive and is a form of mass medication. Some go as far as to suggest that fluoridation is a communist plot and affects children’s IQ.

Despite these claims, fluoridation is supported by many national and international organisations including the World Health Organization, World Health Assembly, World Dental Federation, Australia’s National Health and Medical Research Council (NHMRC), Australian Dental Association and the Public Health Association of Australia.

In 2006, the WHO and the International Dental Federation and the International Association for Dental Research, released a statement endorsing community water fluoridation.

And the Centers for Disease Control and Prevention (CDC) in the United States includes water fluoridation in its list of the top ten health initiatives of the twentieth century, alongside immunisation, compulsory seat belt wearing and smoking bans.

In November 2007, the NHMRC completed a review of the latest scientific evidence in relation to fluoride and health. Based on this review, the NHMRC recommended community water fluoridation programs as the most effective and socially equitable community measure for protecting the population from tooth decay. The scientific and medical support for the benefits of fluoridation certainly outweighs the claims of the vocal minority against it.

Luc De Leeuw

The recommended level varies around Australia and depends on the annual average maximum daytime temperature. In Victoria, for instance, the maximum level of fluoride added to drinking water is one milligram per litre or one part per million as recommended by the World Health Organization.

In hotter climates where people drink more, the recommended level can drop to around 0.7 parts per million. As a comparison, the amount of fluoride in children’s toothpaste is 400 to 500 parts per million. In regular toothpaste, it’s 1,000 parts per million.

We’ve known about the role of fluoride in reducing dental decay since the early part of the twentieth century and some countries, such as the United States, have been adding it to water and toothpastes since the 1950s.

Canberra was the first Australian capital city to be fluoridated – back in 1964. Melbourne has had community water fluoridation since 1977. And other parts of Australia have had fluoridated drinking water for more than 50 years.

Joost Nelissen

Some communities in regional and rural Australia, previously without optimal water fluoridation, have recently started to receive fluoride through their drinking water as part of a program to prevent tooth decay and improve oral health. Australia has now achieved overall population coverage of 90%.

But tooth decay remains significant problem. In Victoria, for instance, more than 4,400 children under 10, including 197 two-year-olds and 828 four-year-olds, required general anaesthetic in hospital for the treatment of dental decay during 2009-10. Indeed, 95% of all preventable dental admissions to hospital for children up to nine years old in Victoria are due to dental decay.

Children under ten in non-optimally fluoridated areas are twice as likely to require a general anaesthetic for treatment of dental decay as children in optimally fluoridated areas.

Community water fluoridation remains a vital public health activity and has a key role to play in preventing dental decay and improving oral health for all Australians. The provision of drinking water through our pipes was never more important.

Fluorinated water – good or bad.

I know that many of my patients are anti-fluoride believers, so this post will upset many. I post this because I am a believer in following the evidence, and as nearly all dentists believe in fluoridation of water, and they should be in the best position to make this judgment, I will go along with it.

Anti-fluoride activists should put their tinfoil hat theories to rest

Believing the ‘fluoride is an industrial poison’ meme requires you to deny decades of evidence that fluoride at low concentrations has no ill effects on our healthinShare0

Andrex: Girl brushing teeth
‘Fluoride is not medication. If anything, it’s a supplement‘. Photograph: Laura Doss/Plainpicture

Politics and religion are the classic topics to avoid if you want to enjoy a dinner party. In Australia, you can now add water fluoridation to that list.

It’s hard to understand what could lead to a respected senior public servant being heckled and bizarrely threatened at a public meeting after she gave a submission to a city council on the benefits of fluoride, but it helps if you realise that a lot is at stake for anti-fluoride activists. They have dedicated their whole world view to perhaps the most embarrassingly sketchy conspiracy theory of them all.

In a nutshell, anti-fluoride campaigners believe different versions of a few basic memes. The first is that fluoride in drinking water is harmful because it alters your brain in some way. The genesis of the “fluoride is a mind-altering chemical” trope goes back to post-war Europe and the breakup of German chemical company IG Farben. The company was at one point the fourth largest company in the world, and manufactured the dyes and industrial chemicals which were fundamental to German industrial might. Due to its close involvement with the Hitler regime and its atrocities (the company provided Zyklon B for gas chambers), it was broken up after the war, and many of its executives were put on trial for war crimes.

The tinfoil hat crowd makes the leap to believing that IG Farben had developed plans during the war to fluoridate occupied countries because they had found that fluoridation caused “slight damage to a specific part of the brain” (usually cited as the pineal gland), which would make the population either more docile or dumber, depending on your pet theory.

Even if it’s true that IG Farben had those plans, they wouldn’t have worked. The pineal gland has nothing to do with obedience, or defending the organism’s freedom from governmental interference. There’s no credible science proving that the tiny deposits of calcium and fluoride which accumulate in the pineal gland would affect its function at all. Here is the entire PubMed literature on the subject – the texts which refer to it are almost entirely obscure rat studies. Nothing there about behavioural changes, or lowering of IQ.

Others believe that water fluoridation was invented by chemical companies to allow them to simultaneously raise money for their lawsuits and dump their industrial by-products by concocting fake science to show that it helps tooth decay rates. While it is true that much of the fluoride added to water supplies is cheaply sourced from industry, that’s about as far as it goes. The massive flaw in this reasoning is that there is simply no evidence of harm coming to anyone from water fluoridation. Where is the damage? Where is the generation of disabled children that was promised by anti-fluoride activists? Why does nothing happen to towns, regions or even countries that fluoridate water supplies, apart from having fewer fillings?

Believing that fluoride is an industrial poison requires you to deny decades of evidence that fluoride at low concentrations has no ill effects. Oh, and you also have to believe that the “industry” is paying the “government” to keep quiet while industrial dumping of chemical waste into public water supplies is going on, and that municipal water engineers are either on the take, or sunk in fluoride-induced slavery to their unseen masters.

The other main line of argument is the “mass medication” belief. You can see how it would appeal to a certain type of citizen believing that the government shouldn’t force people to take “medication”, even for their own good. In the US, courts have repeatedly upheld the right of the state to fluoridate for the good of its people given the lack of harm and the overwhelming evidence of cost-effective benefit. Both sides have repeatedly made their best arguments before judges, and the anti-fluoride side has never won. Fluoride is not medication. If anything, it’s a supplement. Many anti-fluoride campaigners take all sorts of exotic supplements to “detoxify” from fluoride exposure, but seem unaware of the irony.

It’s true not every country fluoridates their water. Some jurisdictions have bought into the anti-fluoride hype, including in continental Europe. For some it is an economic decision – their decentralised water supplies mean the cost of fluoridation is very high. In Australia, we can and should make the effort, because the risks associated with children having to undergo general anaesthesia to remove teeth is orders of magnitude higher than the nonexistent risks of water fluoridation.

A summary of the economic and public health benefits of fluoridation can be found here. Anti-fluoride activists may keep on coming back like zombies, but their line of argument remains brain-dead.