Friday, February 27, 2015

Landmark Peanut Allergy Study: The media is not impressed

Ground-breaking studies are rare. This is one of them. The first randomized trial of peanut consumption in infants at risk for peanut allergies (eczema, egg allergies). A study out of London provides the first strong evidence, experimental evidence, that eating peanuts early in life prevents peanut allergies. Half the kids received nuts between 4 and 11 months and continued eating them regularly (early exposure), the other half, no nuts at all (early avoidance). Later at age 5, children who ate nuts were significantly less likely to have a peanut allergy - only 2% became allergic, compared to 14% who avoided nuts.

Several years ago the current research team, led by Gideon Lack, found Jewish children raised in the UK had 10 times the rate of peanut allergies as Israeli children. The first group generally avoided nuts, the second, ate them as infants. The results got people wondering whether early avoidance was the wrong approach.

Huge implications here. HUGE.

The WHO recommends early avoidance of nuts. In 2000 the American Academy of Pediatrics started recommending children should delay eating nuts until age 3, those at most risk, not until age 8. Naturally, pregnant and breastfeeding women were also told not to eat nuts. Then in 2008 the AAP retracted its early avoidance recommendation citing a lack of evidence for its support. So the pediatric group now doesn't push early avoidance but it does not recommend early exposure as a prevention of allergies. Maybe it will soon. Some high-profile doctors are calling for immediate changes, namely testing at-risk infants for peanut allergies and for those not yet allergic, providing them with small doses of peanuts.

What a reversal. This kind of sweeping change does not often visit the parenting public, certainly not results with such life-altering consequences. Savor it. Relish it. Empirical evidence answering some very important questions.

This is a big moment. Big news. No, I am not being snide, I really mean big news this time.  

"This is a major study — really what we would call a landmark study," says Scott Sicherer, who advises the American Academy of Pediatrics on allergies. "There's been a huge question about why there's an increase in peanut allergy and what we can do to try to stem that increase. And this is a study that directly addresses that issue." NPR 
"For a study to show a benefit of this magnitude in the prevention of peanut allergy is without precedent. The results have the potential to transform how we approach food allergy prevention." Anthony S. Fauci, M.D., National Institute of Allergy and Infection Disease, Science  Daily
"This is transformational, it's the first time it's ever been done...Recent advances in research have shown that you can be desensitized once you have it. Up until now, there hasn't been any research on how to prevent it," says Dr. Lee Tak Hong, director of the Allergy Centre of the Hong Kong Sanatorium and Hospital. CNN

The media, of course,  responded to the enormity of the occasion:

Early Consumption May Prevent Peanut Allergies, New Study Suggests CNN 
Feeding Babies Foods With Peanuts Appears To Prevent Allergies NPR 
Feeding Infants Peanut Products Could Prevent Allergies, Study Suggest Well Blog, New York Times 
Eating Peanuts Early Could Prevent Allergy in Infants Yahoo News

 Could. May. Appears. Suggests. 

This was the moment, my dear headline writers, to pull out the causal language, the GROUDBREAKING STUDY - as opposed to the times writing about all those studies of questionable or limited societal or scientific import. You know, the ones that get the causal, dramatic treatment every other day. I mean, seriously, now you get hesitant? This is what happens when we become de-sensitized to dramatic news articles and headlines. If every study reportedly shows A Causes B, when the big study comes along showing A causes B, then people don't recognize it. The little studies start looking big and the big ones, not so great. Yikes. It might also be the case that given the gravitas of the study, the media chose to pull out the caution. I don't know. I wish I did. 



You can read the study for free right now at The New England Journal of Medicine. 

Friday, February 20, 2015

If Only Online Comments Were Just Mindless Entertainment

By now it's no surprise that people don't base their opinions of public health recommendations only on health information alone. That would be boring. Very boring. We have known for a long time that prior beliefs, friends' beliefs, mood, etc. influence judgments.

But now we also have to consider the effects of the online comments sections. A growing body of research has shown online comments matter. A few years ago a now oft-cited study found negative comments can heavily influence perceptions of health or science-related articles. Now comes word that the credibility of the comment, the poster's perceived authority or expertise matters too.

According to a new study out of Washington State University, if a source is deemed credible, say a health expert, their comments influence perceptions of health information. And if you're not totally tuning out the current media frenzy over vaccines (yes, I said that after complaining for 14 years that the media was not providing enough nuanced, accurate coverage of the issue!) - the team of researchers tested if "perceived source credibility" influenced readers' reactions to pro- and anti-vaccine messages.

So did commenters who appeared to have some measure of expertise sway anyone? You bet. People were more persuaded by a highly credible commenter, here, a medical doctor, than the actual content of the PSA. This is good news if perceived experts comment with some degree of accuracy. But if Dr. So and So posts inaccurate or flat out wrong remarks, well, not so good.

The New York Times had a piece worth reading about online comments, including a blip about the study above, this past week. They didn't quite get the headline right though: What Your Online Comments Say About You. It's more a matter of What Others Think About You From Your  Comments.

The Danger of Reading the Comments. Slate didn't quite get the headline right in their article. Comments aren't all dangerous. If a credible, informed person makes a nuanced, accurate remark then  reading the comments can be beneficial. Especially if the health article contains incorrect information and a credible source debunks it. Debunking is still a good thing!

Now go forth and post accurate, nuanced comments. Speaking of online comments....

Eula Biss, author of On Immunity and Dr. Jerome Groopman, Harvard M.D. and New Yorker staff writer are talking about vaccines and measles right now on the Brian Lehrer Show at NPR. The Stories We Tell Ourselves. Haven't heard the whole interview yet.

But check out the comment section.

The most recent comment, the one right below the podcast right now (Consuelo, NYC). It's a long-winded argument against vaccination. The first several comments, in fact, are all anti-vaccination. My favorite part, though it that the posters are bashing Brian for only presenting one side of the issue - and not including someone who opposes vaccination.

So rich.

How many times over the years I have sat and listened to more than a few NPR interviews with Brian or other hosts talking to supposed experts who questioned vaccines or promoted a link between vaccines and autism!! Just so rich.

It is still a crap shoot of credibility, misinformation and absurdity in the NPR comments section. If only we could sit back and view it as mindless entertainment.

Wednesday, February 11, 2015

Early Puberty: How Parenting Advice Goes Wrong


"RECORD numbers of girls not yet old enough for middle school are starting puberty.”

So begins a recent op-ed in the New York Times written by the authors of a new book on puberty. This sounds alarming, like there’s a near epidemic of girls in large numbers entering puberty earlier than ever before. There is some evidence girls are experiencing breast development earlier, some by the authors, but the baseline data is not great. Girls don’t appear to be getting their periods earlier but some health professionals don't agree. The historical record is sparse. It is not a stretch to say it has not firmly established the timing of puberty.  Much of the data involves girls of European, mostly northern European descent. I wrote about it here and at my column at Psychology Today if you want to read about the issues with the historical evidence (e.g., how do we know when girls started puberty 50, 100 years ago?). 

But hey, let’s accept girls are entering puberty earlier and by that we’re really talking about breast development. Take a look at the other claims. 
“Early puberty can lead to eating disorders, depression, substance abuse, early sexual activity and, later in life, breast cancer.”
The thinking from early in the days of adolescence psychology (1960s and 70s) has been girls who started developing earlier were at risk for a variety of social and psychological harms. Why? Because they were different from their peers, they looked different. They were treated differently. They probably acted older too. Older boys paid attention to them. Older girls let them hang out with them. They started drinking and having sex earlier.  

But here is where things get tricky. The above argument, except for the breast cancer evidence, suggests girls are vulnerable because they’re different from their same-aged classmates and peers. If large percentages of girls are developing earlier than is “sticking out” so noticeable and thus perilous? If everybody is doing it earlier, then how is the mature girl more at risk now? If there are more girls starting puberty earlier than ever, shouldn’t this risk be reduced? If puberty is skewing earlier, it might have new effects, true. Sure but if there are “record numbers” of girls getting breast at nine, ten or younger, doesn’t it become the norm?  

"RECORD numbers" suggests a large percentage of girls start earlier. If that's the case then it's the norm. On the other hand, as I suspect, it's only a small percentage of girls affected, then making it sound like an epidemic is not perhaps the best way to discuss it - and we can still worry about girls sticking out and feeling and looking different. I bet this is cleared up in the book. 

“But as doctors, we wince at misleading stories that blame substances that are not likely to bear the primary responsibility — hormones in our meat or soy in our diets, for instance. The real culprits include two problems that are often overlooked: obesity and family stress.”
I like the nod to debunking and correcting misinformation. But this is bold, identifying the causes of early puberty – there are many different opinions and much mixed research results. These authors worked on the research showing breast development at earlier ages. Surely they’re aware there’s divided opinion about the role of obesity here.

But okay let’s accept obesity and move on.

Family stress.

This is not a new claim or phenomenon. Again, though, remember the authors’ first statement? “Record number of girls.” This supposed increase is explained by two factors in their opinion – obesity and family stress. Thus more families must be in crises than ever. True, more kids are living in single-parent households. But are they more stressed than ever? Are families in general more stressed? Do you think this really explains it? How on earth are families more stressed than 100 years ago? The authors refer to “toxic stress” so it sure sounds like they believe this to be true. Am I the only having issues with this argument?

Here is the cause for my real frustration with this op-ed.
"Providing a warm emotional environment at home can not only help prevent early puberty, but also mitigate the psychological effects if it occurs. To buffer against toxic stress, parents should prioritize setting aside time to engage with their daughters and bond emotionally."
This is what gives parenting and child experts a bad reputation. 

To suggest parents can prevent early puberty by getting all warm and cozy with their daughters is absurd. They might as well have said Moms, dads, if you don't listen to and show love towards your daughters, they will start puberty earlier and endure all the terrible risks associated with it. Nonsense and offensive. And the patronizing sentiment here, just incredible. I’d be nearly speechless, wordless, if I weren’t so offended. If toxic stress does exist I guarantee this kind of advice does not buffer it.

Maybe some experts should prioritize setting aside time to engage with their own advice and logic. 

NOTE: I have not read the book yet. Sometimes as we've heard from adolescent psychologist Laurence Steinberg, the limited space doesn't always lend itself to a nuanced discussion. I read and enjoyed his Steinberg's book on adolescence, by the way, and put it on my best books of 2014. 

Wednesday, February 04, 2015

Media, Measles and Seeds of Doubt?

The media is gorging on the measles outbreak. Well it’s about time the media took measles seriously. I should be thankful after almost 15 years of bemoaning the media’s less than accurate coverage of vaccines and the thoroughly debunked link between the MMR and autism. Even in 2000 there were studies showing no link existed but the media then was not particularly interested in that empirical evidence. Certainly not persuaded. Major media outlets featured scientists, pediatricians and mothers attributing autism and a host of other ills to childhood immunizations. Of course a person can still find those voices in the media. Now thanks to measles at Disneyland it’s a hey day of mostly correct facts and figures accompanied by some finely nuanced reporting. In fact, so many good articles it’s hard to single out just a few.

And yet. I do wonder how the current coverage will be perceived. What will be the lingering effects of this media storm? Will it change the minds of parents on the line over whether to vaccinate or whether to refuse or delay some portion of the recommended vaccines? If so, how?

Many of these recent stories, even if they ultimately appear to champion vaccines or dismiss the autism-vaccine link, also feature some measure of concern, anxiety or doubt about the safety of vaccines. In other words – uncertainty where none exists in the scientific community. This is not to say that vaccines don't carry risks, they do albeit very rare ones but the evidence discrediting the autism-vaccine link is robust, the evidence is plentiful and strong. 

Both news and opinion articles still leave some room for doubt to creep in, portraying the scientific community or evidence as less certain about the link or the safety of vaccines or the risks of not vaccinating. Sometimes the distrust or fear of vaccination seeps in through the comments of parents who haven’t vaccinated. Sure they say they will vaccinate now or just did but this information comes along with their personal stories filled with reasons why they didn’t vaccinate in the first place. Of course I'm not event referring to the comments sections here. 

Sometimes the doubt comes from supposed experts.

Sometimes politicians. Even the President is not immune to uncertainty about vaccines:

"I understand that there are families that in some cases are concerned about the effect of vaccinations. The science is, you know, pretty indisputable. We've looked at this again and again. There is every reason to get vaccinated, but there aren't reasons to not," the president explained. Barack Obama, Today Show

What’s not to love here? The President advocating for childhood immunizations on national television. Well, he’s not quite right. The science is not “pretty indisputable.” The scientific research discrediting the autism-vaccine link is not “pretty indisputable.” It is not kinda sorta certain on this issue. The commander-in-chief’s comment suggests some uncertainty exists in the scientific community. The scientific evidence however is beyond a shadow of reasonable doubt. But this is progress. Back in 2008 the President called the science “inconclusive” and said “We’ve seen just a skyrocketing autism rate. Some people are suspicious that it’s connected to the vaccines” according to the Wall Street Journal.  He also obviously forgot to that there are kids and adults who can't get immunized for very good reasons like suppressed immune systems. It's just not accurate to say "there aren't reasons to not" vaccinate. I suppose he meant to say "choose not to vaccinate" but he didn't. 

Other elected officials have done the bait and switch in a more significant manner.

"All I can say is we vaccinated ours," Christie said, while touring a biomedical research facility in Cambridge, England, which makes vaccines. The New Jersey governor added that "parents need to have some measure of choice in things as well, so that's the balance that the government has to decide." New Jersey Governor Chris Christie, CNN

And this:

“I’m not arguing vaccines are a bad idea. I think they’re a good thing, but I think the parents should have some input," he added. "The state doesn’t own your children. Parents own the children and it is an issue of freedom.”

"I have heard of many tragic cases of walking, talking normal children who wound up with profound mental disorders after vaccines," he said. Rand Paul, CNBC via ABC News

True politicians and elected officials are not health professionals. Unless of course they are like Rand Paul, an ophthalmologist who should know studies have documented the safety of the American Pediatric Association’s recommended vaccination schedule. He should also know studies show spacing out or delaying vaccines carries risks.

As Frank Bruni rightly reported in his column Vaccine Lunacy, the media has contributed to the current public health crisis by “covering the news in an on-one-hand, on-the-other-hand fashion that sometimes gives nearly equal time to people citing facts and people weaving fiction.”

How true. Balance is not always the ideal. Not when the full weight of science comes down on one side.

What’s not certain - how people perceive media articles when they also contain seeds of doubt. 

It’s not clear how people react to these kinds of public health messages but recent research suggests a couple possibilities. Graham Dixon and Christopher Clark conducted a study to see how the balance of news articles influenced student’s perceptions of the vaccine-autism link. The researchers had students read actual news articles that contained either pro-link claims only, anti-link claims only or a balance of pro- and anti-claims. Students also reported how certain they thought scientists and medical professionals were about the link. Compared to those with anti-link claims, balanced news articles inspired less confidence that there is no link. In other words, balanced articles introduced uncertainty over the present science. 

Interestingly there were no significant differences between the balanced and pro-link conditions. News articles with either balanced or pro-link messages were perceived similarly, both introducing some measure of doubt that no links exists. This uncertainty stemmed in part from how divided readers judged the scientific community to be on the issue of vaccines and autism.

So understandably I wonder how coverage of doubts and fears colors perceptions of the accurate portrayal of scientific evidence. Does it introduce doubt?