Archive for the ‘In the news’ category

What is “Natural”, anyway? FDA edition

November 19, 2015

The Pediatric Insider

© 2015 Roy Benaroch, MD

You frequently see the word “Natural” on food packaging, but what does it mean? Probably not what you think it does. And the FDA has decided it’s time—maybe—to legally define the term, and enforce rules about when food manufacturers can use the word. I agree that words have meanings, and that consumers ought to be able to know what they’re buying. But “Natural” is a slippery term, and more regulations about its use might not clarify much of anything.

Natural, one would think, means “from nature” or “occurring in nature.” But plenty of things you might think of as “unnatural” are very much from nature. Like ionizing radiation, which you’re being bathed in right now (from cosmic rays from above, and radioactive elements from below. Hello, radon!) Or toxins like those made by pufferfish or chrysanthemums (the active ingredient in many lice preparations). Living organisms like vegetables are loaded with toxic compounds including pesticides that are just as harmful as anything man-made.

Pyrethrin - natural!

Pyrethrin – natural!

Likewise, some things you might think of as “natural” are not, in fact, from nature at all. Homeopathy is touted as “natural”, when it in fact relies on a completely magical, imaginary mechanism of action that can’t be observed and isn’t in any way a part of the natural world. Diluting a chemical until it doesn’t exist any more doesn’t make it magically more powerful. Homeopathy is “supernatural”, meaning that it relies on magic, not nature.

The FDA has known that it would be difficult to pin down what’s meant by “natural”, and had previously said it has no interest in formally defining the term. Their current policy is that it’s OK to use the word on foods that don’t have any added color, synthetic substances, or synthetic flavors. Their policy doesn’t consider how a product is made—so synthetic pesticides are OK, as is irradiation, as are genetically modified organisms (GMOs.) Currently, these are all fair to label as “natural”.

Several citizen’s groups have petitioned the FDA to define “natural”, tightening up their policy to exclude more things. The FDA is now soliciting comments from the public on exactly how to do that, and based on the comments I’m reading this isn’t going to be easy. Here are the current top two comments:


“Natural should mean nothing in it but food grown without chemicals…”

That makes no sense. Water is a chemical, manure is loaded with chemicals, and, well, everything is a chemical. I think what this person meant was food grown without pesticides or fertilizers—but, again, plenty of those are natural too, and current regulations for organic farmers include long lists of scary, chemically-sounding compounds that they’re allowed to use because they’re “natural.” Food can’t be grown without chemicals, and life can’t occur without chemicals, and what the chemical names are (or how “scary” they look) have nothing to do with whether they’ll hurt you or not, or now “natural” they might be.


Natural should be an ingredient that has not been boiled, microwaved, or in anyway (sic) tampered by chemical process.”

 Cooking food (boiling, baking, using a George Foreman Grill) is a chemical process—you add heat to facilitate chemical reactions. That liberates more-accessible energy, and often makes food tasty. Humans have been cooking food, in nature, for thousands of years. Does it make any sense that a food is only natural until you cook it, or that cooking makes something un-natural? Really?


The FDA, I’m sure, would like to come up with a definition that’s clear and enforceable, but in common usage the word “natural” isn’t so easily pinned down. It’s reminiscent of the supreme court’s 1964 attempt to define pornography: “I can’t say what natural is, but I know it when I see it”. Meanwhile, food-scare opportunists are making a fortune selling a fear of “un-natural” foods.

Until we come up with a way to define the word “Natural” in a way that we can all understand, I suggest you ignore it on food labels. It doesn’t mean anything—not anything more than any other marketing words, like “fresh” or “delicious”. Buy a variety of foods that your family enjoys eating, especially fresh fruits and vegetables, and cook and eat together as a family. Forget the fear, and ignore the labels.

Measles vaccine: A real immunity super-booster

October 29, 2015

The Pediatric Insider

© 2015 Roy Benaroch, MD

What if there was an intervention that could reduce a child’s risk of death from infection—from any infection—by half? And that one intervention’s immune-boosting power lasted 2 or 3 years. It’s also very safe, with a very small risk of any serious side effects.

Pat yourself on the back. Your child has probably already had it, and your entire community is getting benefit from fewer circulating infections.

A recent study published in Science looked at long-term changes in immunity following measles vaccination in populations worldwide. It’s known that measles infection put people at risk for other infections for several weeks or months afterwards – natural infection seemed to suppress the immune system. Using data correlating vaccinations, measles cases, and infectious disease deaths, the authors found that the immune suppression had a much more serious and lasting impact than had been thought. For two to three years after natural measles, the all-cause infectious mortality spiked upwards. Measles vaccination, in other words, doesn’t just prevent measles deaths—it prevents deaths from any infection. For years.

The effect is striking in its intensity. Overall, when measles was common years ago, it accounted for about half of all deaths from infection (combining the direct effect of measles infection itself with the immune suppressive effect.) In some of the most resource-poor countries, it probably accounted for up to 90% of all infectious deaths. Think about that. One vaccine, preventing all of those deaths. The authors only looked at mortality—if you consider other morbidity, hospitalizations, costs, and misery, the positive effect of measles vaccinations would be much, much higher.

Boosting immunity doesn’t just help the individual child. The entire community is protected when the risks of infection drop, including the risk to newborns and elderly people, or people who are already sick.

Don’t be fooled by the fake immune-boosters—the colon cleanses, the “Airborne”, the pills and potions pushed by the multi-billion dollar supplement industry. Real immune boosting does not rely on magic. Get enough quality sleep, eat a healthy diet, get some exercise, and take reasonable precautions like washing your hands and avoiding sick people. And, please, make sure you and your children have received all of the recommended vaccines. Protect yourself, protect your kids, protect your communities. Vaccinate!

Mammography isn’t always a good idea

July 13, 2015

The Pediatric Insider

© 2015 Roy Benaroch, MD

Draft guidelines from the US Preventative Services Task Force (USPSTF) are concerning to some breast cancer advocates. The suggested guidelines no longer recommend routine mammography for women of average risk until age 50. For women from 40-49 years of age, the task force recommends an individualized assessment rather than screening all women.

These recommendations can have great economic weight. Under the Affordable Care Act, preventative services recommended by the USPSTF must be covered by health insurance with no cost-sharing. In other words, they’re not part of a deductible, and you’ll seem to get it for “free”. If these new draft recommendations stick, women in their 40’s will not have automatic free coverage for their yearly mammos (they could still get coverage if they’re in a special risk category.)

How’s this news going over in the breast cancer advocacy community? Not well. Full page ads ran last week, including on the back of the A section of the Washington Post, urging people sign a petition to get the US House of Representatives to step into the fight.

The petition starts:

Early detection saves lives. With one in eight women developing breast cancer during her lifetime, the earlier we can detect breast cancer, the better. After all, these are our mothers, daughters, grandmothers, wives, sisters, and friends, the people we care about most.

How can you argue with that? Where to these USPSTF numbskulls get off, letting more women die of cancer?

With the best intentions, the petitioners and many in the Breast Cancer advocacy community are getting it wrong. They say “Early detection saves lives”. But in this case, it’s not actually true.

Several good studies have shown that screening women in their 40s for breast cancer with mammography does not in fact save lives. In 2014, Canadian researchers did a randomized, controlled study– following over 50,000 women, half of whom were assigned to annual mammos, and half to no mammos from age 40-49. These women were then followed until age 60 to see how many died of breast cancer. In the mammo group, 134 died; in the non-mammo group, 122 died. That’s right, more women died who got mammos then women who did not (the difference was not statistically significant.) Screening mammos in this large, well designed clinical trial did not save lives.

Another study, from Great Britain, randomized about 160,000 women, starting at age 39. Again, those randomly assigned to get annual mammography were not less likely to die of breast cancer. It didn’t matter– whether or not yearly screening mammos were done, the death rates were the same. Screening mammos, again, didn’t save lives.

How could this be? Don’t we know that the earlier you detect cancer, the easier it is to treat? Unfortunately, medicine isn’t so simple. It turns out that many early breast cancers will regress (go away on their own), or grow so slowly that they never cause health problems. Of course, other breast cancers are aggressive and deadly– and women with those kinds of cancer benefit from treatment. But that has to be balanced against the genuine harm from therapy for breast cancer in many women who never needed treatment at all. And that therapy—it’s far from benign. Some women will die of complications caused by breast cancer therapy.

I’ve had two women very close to me killed by breast cancer, and I do not want to see more women suffer. But catchphrases — “Early screening saves lives”– are more to help fundraising than to guide policy. We need to figure out which women need earlier diagnosis and therapy, and how to best use mammography and other tools to help find women at-risk. But what we’re doing now, screening all women with mammos starting at 40, isn’t helping. It’s time to admit that, and move on.

Do-it-yourself lab tests aren’t always a good idea

April 27, 2015

The Pediatric Insider

© 2015 Roy Benaroch, MD

Labcorp, one of the largest outpatient lab providers in the USA, is soon going to let you skip the tedium of a doctor’s visit to get lab work done. Want some tests? Come on down!

I’ve got mixed feelings about this. While there are some tests that seem reasonable for people to do on their own—pregnancy and HIV tests come to mind—others may lead to problems. The bottom line: people imagine tests are simple things that give you a reliable, yes or no answer. In reality, many tests are far from perfect. And their results might be more misleading than accurate.

First, the good tests. A urine pregnancy test is safe and easy to do, and very accurate. If you’re more than a few days late for your period, and your pregnancy test is positive, it’s time to think about buying little booties. Likewise, even the (relatively) cheap drug store saliva HIV tests are really quite accurate, almost all of the time—though even then, the test doesn’t become accurate until several weeks after HIV infection. A drug store test done a few days after a potential exposure tells you nothing.

But many other tests are far more complicated. There are all sorts of “thyroid tests” that can be done, but (for example) thyroid antibodies are often positive in people who don’t actually have thyroid disease. Likewise, antinuclear antiobodies (ANA), which you’ll find on the internet is a “lupus test”, are very often positive in people without lupus.

Allergy blood tests are even more problematic. A recent study showed that even among those with a positive food allergy blood test, only 2.2% actually had a food allergy. If you do big panels of food allergy tests, at least some of them are going to be positive in anyone—that’s just the nature of that kind of test. That’s why allergy testing is such a bad idea, unless there’s a specific clinical indication.

Many tests are for screening, rather than diagnosis—and I think that’s going to lead to misunderstandings, too. The “prostate specific antigen” test can be used to screen for prostate cancer—but many men with a positive test don’t actually have cancer. To complicate things further: many men who do have prostate cancer will not be affected by it—they’ll die of something else long before the prostate cancer causes mischief. Prostate cancer can be a terrible problem, especially in younger men, but appropriate screening for it involves more than just getting a blood test.

Celiac disease affects about 1 in 100 people, but testing for it can be complicated. The genetic test for the two celiac-associated haplotypes is almost always positive in people with celiac disease… but most of the people who test positive for that will never develop celiac. In other words, a negative tells you something (you’re unlikely to ever get celiac), but a positive tells you nothing (you may or may not currently have celiac, and you may or may not ever develop it.)

Tests for Epstein-Barr virus and Lyme disease–these have been misunderstood by doctors and laymen for years. Is Labcorp going to explain what the results mean in a way that their customers understand?

I’m also troubled by the marketing of these tests by a for-profit company. Traditionally, doctors who order tests don’t make any money off of them—there’s no conflict of interest. Once Labcorp is profiting off more and more tests, won’t the logical next step be to market them more heavily? It’s already happening, in my neighborhood, especially with allergy testing—Labcorp really wants me to order more. What happens when they skip me and market straight to you?

We’ll see soon enough. According to the story, Labcorp sees big growth in direct-to-consumer labs. They say this will help people stay healthier and more well-informed. It’s certainly profitable for them. With the internet, as we all know, everyone is an expert, so it’s logical to figure that people who order tests on themselves know what they’re doing. Right?

Have no fear- your vegetables are loaded with toxins

March 30, 2015

The Pediatric Insider

© 2015 Roy Benaroch, MD

There’s so much fear and uncertainty out there. If you pay any attention to Facebook and Teh Interwebs, the air is killing is, the water is killing us, and, worst of all, our food is killing us. Chemicals!

Let’s straighten out some simple misperceptions. I promise, this won’t hurt.

Truth 1: Your food is loaded with chemicals.

It’s true. A chemical is just a compound or a substance that can be isolated or identified. Water is a chemical, salt is a chemical. Ethyl butanoate, phenylalanine, and aspartic acid are all chemicals, too, and they’re all a natural part of what makes a banana. Some chemical names look scary – like 3-methylbut-1-YL-ethanoate, another banana constituent. Others look friendly, like “ricin.” But ricin isn’t a natural part of rice (it actually comes from the castor bean.) It’s a deadly poison, and just one milligram of it can kill you.


So: all food is all chemicals, and whether or not the name of the chemical is scary has nothing to do with how much or how little it might harm you.


 Truth 2: Your food is loaded with pesticides, too.

OK, I get it—“chemical” is just shorthand for “bad chemical”. And by “bad chemicals”, we mean pesticides and preservatives and toxins.

By that definition, your fruits and veggies are loaded with “bad chemicals”, too. They’re put there by nature. Plants are not just happy organisms that are here to feed us. They’ve evolved, too, in a natural world filled with plant parasites, plant predators, and other plants that want to steal their nutrients and sunshine. So plants have developed plenty of chemicals themselves that act as “natural” toxins to give them a competitive advantage over other organisms. Plants make all sorts of toxins and chemicals specifically to prevent fungal and parasitic attacks, to make them taste less appealing when fruit is unripe, and to make them taste more appealing when fruits ripen.

A classic study, from 1990, illustrated this well. Dr, Bruce Ames and colleagues found that 99.99% by weight of the “pesticides”—the chemicals that kill pests—that they found in foods were made by the foods themselves. For instance, cabbage, good old cabbage, contains terpenes (isomenthol, carvone), cyanides (1-cyano-2,3-epithiopropane), and phenols (3-cafffoylquinic acid.) Tasty! All of these, and far more (listed in table 1 of that link and pasted below), are naturally made by cabbage. So the cabbage can survive.

from Ames, et al 1990

from Ames, et al 1990

Adding up the measured quantities of residual synthetic pesticides and related chemicals, Dr. Ames’ team found that the quantity of naturally-occurring pesticides outweighed those added by farmers by 10,000 times. Yes, your veggies are loaded with pesticides. Nature put them there.

By the way—Dr. Bruce Ames is no gadfly. He developed the “Ames test” that remains in wide use to determine if a chemical is a mutagen (a potential carcinogen.)  He is a real scientist who cut his teeth long before we decided anyone can “do the research” with Google.


Truth 3. Natural pesticides are just as harmful as synthetic ones.

We have this romantic, idealized view of nature—it’s nice and filled with bluebirds. In truth, nature is a fearless, relentless monster that can kill you five times before you hit the ground. Every organism competes with every other organism for survival, using claws and teeth and toxins and poisons. Small pox is natural, and it wants to kill you (or wanted to kill you, until we killed it first). Lightning is natural, and volcanoes, and frostbite and starvation and tapeworms and malaria. The natural world and natural things have killed far more organisms than humans ever have or ever will.

But what about those man-made, synthetic chemicals—they’re not “natural”, so maybe they’re more harmful. Let’s ask Dr. Ames. From that same study, in 1990, he showed that of 52 of the natural pesticides he had found in natural food, 27 of them were documented carcinogens. Half of them. Ironically, the proportion of synthetic chemicals that he had found were mutagenic was also about half. In Ames’ study, he said:

We conclude that natural and synthetic chemicals are equally likely to be positive in animal cancer tests. We also conclude that at the low doses of most human exposures the comparative hazards of synthetic pesticide residues are insignificant.

That makes sense, actually—when you let go of that odd romantic view of nature, and realize that natural organisms evolve to compete, it makes sense that natural chemical defenses will be harmful, too. That’s why they exist. Organisms need chemicals to protect them from pests, and there’s no particular reason to think that the chemicals they invent are any more or less harmful than the chemicals we invent.


Truth 4. “Organic foods” have plenty of added pesticides and chemicals.

OK, you might say. But organic foods have no added pesticides or chemicals! Even if the added amount with conventional foods is tiny, why not avoid that tiny added potential risk?

Because organic foods do have added pesticides and chemicals. Plenty of them. Here’s a link from the US government to approved lists of allowed substances, things that can be added to foods that are labeled organic. It includes sub-lists, including “synthetic substances allowed for use in organic crop production”—tasties like copper oxychloride, lignin sulfonate, and sucrose octanoate esters. You may also enjoy browsing the section on “Non agricultural (nonorganic) substances allowed as ingredients in or on processed products labeled as ‘organic’ or ‘made with organic (specified ingredients for food groups)’.” I could list many more scary chemicals (diethylaminoethanol! octadecylamine!) and unpleasant-sounding food additives (catalase from bovine liver!)—but you get the point. Organic, inorganic, natural, synthetic—it’s all chemicals. Organic is not added-pesticide free, not even close.


So: despite what the self-appointed internet experts are telling you, chemicals cannot be avoided—and natural foods contain far more harmful and natural preservatives, pesticides, and “toxins” than we add ourselves. Let’s keep this whole “chemicals in food” scare in perspective. There’s no need to fear what you eat.

What your kids do affects how their brains grow

March 2, 2015

The Pediatric Insider

© 2015 Roy Benaroch, MD

A short study to review today—from Pediatrics, November 2014, “Cortical thickness maturation and duration of music training: Health-promoting activities shape brain development.” Researchers looked at MRIs scans of healthy children that were being obtained as part of a larger study of normal brain development, correlating the development of several brain areas with musical training. They found that as kids age, the ones taking music lessons had more rapid growth and maturation of brain centers involving not only motor planning and coordination, but also emotional self-control and impulse regulation.

When you exercise a muscle, it grows bigger and stronger. The same thing, essentially, happens in the brain—but it’s more complicated, because different parts of the brain do different things. What this study confirms is that at least with music, the areas of the brain exercised with musical training become “stronger”—or, at least, larger and thicker, which in brain-terms means more effective. The authors speculate that conditions like ADHD, where those same areas of brain seem relatively under-functioning, might be helped by learning to play a musical instrument.

Think about the bigger picture, too. Whatever your kids are doing, that’s the area of the brain they’re exercising. If they’re reading, they’ll become better readers; if they’re playing tennis, they’ll get better at seeing and hitting a little fuzzy yellow ball. If video games are their main hobby, they’ll get better at making fast decisions and moving their hands quickly. Katy Perry fans will get good at dancing like sharks. You get the idea. At the same time, kids who don’t practice the self-control needed to learn a musical instrument might be missing out on at least one way to help their brains mature.

Get practicing!

Some solid reassurance about BPA – one more thing you don’t need to worry about

February 16, 2015

The Pediatric Insider

© 2015 Roy Benaroch, MD

Remember BPA? It’s a chemical used in the manufacture of plastic things, food can liners, and lots of other things. For a while, everyone seemed to be worried about it. Stickers started showing up on bottles – “BPA FREE!”—which created all kinds of anxiety among people who had no idea there was BPA in their water bottles to begin with. It’s a scary sounding, chemically kind of thing, bisphenol-A, so we’d be better off without it. Right?

I last wrote about BPA in 2008. It wasn’t worth worrying about then, and it’s even less worth worrying about now.

There have been dozens of studies of BPA over the last few years. I’ll just highlight a few recent ones:

JAMA, 2011. Adults eating canned soup – from ordinary cans manufactured with BPA in the liners – had 1200% percent more BPA in their urine than adults consuming fresh soup. Bloggers like this one completely misunderstood the significance of this, with headlines like “BPA rises 1200% after eating from cans.” Yes, it does rise—IN THE URINE. That’s how you get rid of the stuff. High amounts in the urine are good, it means your body is excreting it. That’s what kidneys do. They’re the real detox system—not the expensive BS from the health food store. Want to rid your body of “toxins”? Drink some water and let your kidneys do their job.

Toxicology Science 2011. Adults consuming a high-BPA diet had blood and urine levels monitored. Urine levels were much higher than blood levels – good! It’s excreted! – and in fact blood levels remained extremely low, or undetectable. BPA doesn’t seem to have a chance to make it into body tissues, or concentrate there. It’s peed out. (This study is reviewed in detail here.)

Environmental Health Perspectives, 2013. High doses of BPA solutions were placed in the mouth of anesthetized beagles, and blood levels showed that this method of administration led to higher absorption of BPA than BPA swallowed into the gut. (Lesson: It may not be a good idea to just hold soup in your mouth for hours. Just swallow it, OK?)

Toxicology and Applied Pharmacology, 2015. To evaluate the potential for oral absorption of BPA in humans, adult volunteers were fed warm tomato soup with added BPA—after coating their mouths with every spoonful, they swallowed it. This recreated a genuine eating experience better than the beagle studies (the dogs were anesthetized and their BPA just sat in their mouths.) In this human study, BPA levels in the blood remained low, and as has been observed previously, almost all of the BPA absorbed was quickly deactivated and excreted in the urine.

What’s the harm in replacing BPA in food containers? There’s always a trade-off. Those other kinds of plastics may be more hazardous.

BPA is just one of many “chemical” bugaboos to attract media attention. Caramel coloring? Eek! BHT? Lawds! There are entire industries out there making money off of food fears and nutrition fears. And vaccine fears. There’s enough unnecessary fear out there to power an entire media empire based on one person with vain hair, a magnifying glass, and a kindergartener’s understanding of chemistry.

Don’t live in fear. If you want to avoid plastics, that’s great—eat fresh things, grow a garden, cook and eat with your family. The cans of beans in your pantry, they’re not going to kill you any time soon.

More about BPA from Science 2.0


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