Consumer Health: A Guide To Intelligent Decisions

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 The McGraw-Hill Companies

CONSUMER HEALTH: A GUIDE TO INTELLIGENT DECISIONS, NINTH EDITION

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ISBN 978-0-07-802848-9
MHID 0-07-802848-5

Vice President & Editor-in-Chief: Michael Ryan

Vice President & Director of Specialized Publishing: Janice M. Roerig-Blong
Publisher: David Patterson
Executive Editor: Christopher Johnson
Marketing Coordinator: Colleen P. Havens
Development Editor: Darlene Schueller
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Cover Designer: Studio Montage, St. Louis, Missouri
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Primary Typeface: 11-point Times
Composition: Stephen Barrett, M.D.
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All credits appearing on page or at the end of the book are considered to be an extension of the copyright page.

Library of Congress Cataloging-in-Publication Data

Consumer health : a guide to intelligent decisions / Stephen Barrett ...[et al.]. - 9th ed.
p. cm.
Includes bibliographical references and index.
ISBN 978-0-07-802848-9 (alk. paper)
1. Medical care. 2. Health products. 3 . Quacks and quackery. 4. Consumer education.
I. Barrett, Stephen, 1933-
RA410.5.C645 2013
362.1--dc23
2011039127

www.mhhe.com
 About the Authors

tephen Barrett, M.D., a retired psychiatrist who is also associate editor of Consumer Health Digest,
S resides near Chapel Hill, North Carolina, has
achieved national renown as an author, editor, and con-
co-host of the Credential Watch Web site, a consultant
to the Committee for Skeptical Inquiry, a Quackwatch
sumer advocate. In addition to heading Quackwatch, he advisor, an advisor to the American Council on Science
is vice president of the Institute for Scientific Medicine and Health (ACSH), a founding fellow of the Institute of
and a Fellow of the Committee for Skeptical Inquiry Science in Medicine, a member of the review board of
(formerly called CSICOP). In 1984, he received an the American Journal ofHealth Behavior, and a member
FDA Commissioner's Special Citation Award for Public of the International Editorial Board of the journal FACT
Service in fighting nutrition quackery. In 1986, he was (Focus on Alternative and Complementary Therapies:
awarded honorary membership in the American Dietetic An Evidence-Based Approach). He was an associate
Association. From 1987 through 1989, he taught health professor and chair of the Department of General Studies
education at The Pennsylvania State University. In 2001 at Charles Drew University of Medicine and Science,
he received the Distinguished Service to Health Educa- where he led the initiation of the Master's Program in
tion Award from the American Association for Health Urban Public Health. He has also been an associate
Education. He has been listed in Who's Who in America professor of health education at Kent State University;
since 2001 and is also listed in Who 's Who in Science founding president of the Ohio Council Against Health
and Engineering, Whos Who in Medicine and Health Fraud; president of the National Council Against Health
Care, and Who's Who in the World. Fraud; faculty mentor in public health at Walden Univer-
An expert in medical communications, Dr. Barrett sity; professor of Health Sciences at Touro University
operates 25 Web sites; edits Consumer Health Digest International; associate professor and director of the
(a free weekly electronic newsletter); is medical editor Graduate Program in Health Care Management at Col-
of Prometheus Books; and is a peer-review panelist for lege of St. Elizabeth; director of public health for ACSH;
several top medical journals. His 51 books include The director of communications at Columbia University's
Health Robbers: A Close Look at Quackery in America Mailman School of Public Health; and executive direc-
and seven of the previous editions of Consumer Health. tor of RAP, Inc., a nonprofit mental health and senior
His other major works include Dubious Cancer Treat- citizens service agency in Genesee County, New York.
ment, published by the Florida Division of the American
Cancer Society; Health Schemes, Scams, and Frauds,
published by Consumer Reports Books; The Vitamin
Pushers: How the "Health Food" Industry Is Selling
M anfred Kroger, PhD., is Professor Emeritus of
Food Science and Professor Emeritus of Sci-
ence, Technology and Society at The Pennsylvania
America a Bill of Goods, published by Prometheus State University, where he has won several teaching
Books; and Reader's Guide to "Alternative" Health awards. He is a science communicator for the Institute of
Methods, published by the American Medical Associa- Food Technologists and is scientific editor of its online
tion. His Quackwatch Web site, which serves as a clear- journal, Comprehensive Reviews in Food Science and
inghouse for information on health frauds and quackery, Food Safety. He also serves as associate editor of the
has won more than 70 honors and awards. Since moving Journal of Food Science, an ACSH scientific advisor,
to North Carolina in 2007, he has been swimming com- and a technical editor for Prometheus Books. He has
petitively and has won 25 state championship events. conducted research in analytical chemistry (pesticide
residues), food composition, fermented milk products,

W illiam M. London, EdD ., M.P.H., is a professor in

the Honors College and the Department of Public
Health at California State University, Los Angeles. He
and dairy processing technology. Even though retired, he
remains professionally active at Penn State and nation-
ally and internationally. His university courses included

iii
iv About the Authors

food laws and regulations, toxicology, introductory food obert S. Baratz, MD., DD.S., PhD.,who contrib-
science, dairy technology, and a very popular university-
wide general education course entitled "Food Facts and
R uted mainly to the medical and dental chapters of
this book, is an internist, dentist, and researcher who
Fads." His other professional activities include lecturing resides in Newton, Massachusetts. The founder of four
at public and professional meetings, expert testimony companies, he has also served as medical director for
in court and at government hearings, and translation of two others in the medical device and pharmaceutical
German writings. In 1999 he was elected as a Fellow of industries. He has been involved with issues regarding
the Institute of Food Technologists. In 2003, he served as the safety and proper use of drugs and biomaterials since
the editor of the Proceedings ofthe 12th World Congress 1980. He has served on the medical and dental faculties
of Food Science and Technology. of Northwestern and Tufts universities. Currently he
serves on the faculty of Boston University School of
arriet Hall, MD., is a retired family physician who Medicine, having initially been appointed in 1976. His
H resides in Puyallup, Washington. She served for 20
years in the U.S. Air Force, from which she retired in
broad knowledge of interactions of materials and the
body has been sought by numerous licensing boards,
1989 as a full colonel. In addition to practicing family regulatory agencies, universities, government agencies,
medicine and flight medicine, she held administrative insurance companies, and professional associations. He
positions including Chief of Aerospace Medicine and is also an expert in medical database applications and
Director of Base Medical Services. Since retiring, Dr. analyses.
Hall has devoted her time to investigating questionable Dr. Baratz has worked for more than 25 years in
health claims and writing and lecturing about pseudo- dental and medical practice for private, public, and
science, quackery, "alternative medicine," and critical government entities, including the Department of
thinking. She is a contributing editor to both Skeptical Veterans Affairs, The Daughters of Charity, and Beth
Inquirer and Skeptic magazines and writes the latter's Israel Hospital in Boston. He has also worked for the
"SkepDoc" column. She is also a founding member and Agency for International Development. Currently he is
editor of the Science-Based Medicine blog; an advisor President and Medical Director of South Shore Health
to the Quackwatch network; an editorial review board Care in Braintree, Massachusetts, where he practices
member for the Natural Medicines Comprehensive Da- internal and occupational medicine. He has also served
tabase; a Fellow of the Committee for Skeptical Inquiry; as NCAHF President; a scientific advisor to ACSH;
and a founding fellow and board member emerita of the and President of International Medical Consultation
Institute for Science in Medicine. Her 2008 book, Women Services, Inc., of Newton, Massachusetts. In 1992, the
Aren't Supposed to Fly: The Memoirs ofa Female Flight American Dental Association gave him a Presidential
Surgeon, describes how she became a pilot and helped Citation for his work in advancing oral public health. He
bring about equality for women physicians in the Air has been listed in Who's Who in America, Who's Who in
Force. Her Web site is www.ske_pdoc.info. the World, and Whos Who in Science and Engineering.
 To the Reader

Consumer Health offers a panoramic view of the

M ore is known today about achieving and maintain-
ing good health than ever before. Life expectancy
is at an all-time high, and although there is still much
health marketplace. It explains and supports the scientific
methods that are essential for validating claims about
room for improvement, health-related accomplishments how products and services affect health. It can help you to:
have exceeded the fondest dreams of past visionaries. • Understand how medical facts are determined and where
This progress has been partly due to a safer environ- to get appropriate information and advice
ment that includes cleaner water, safer food, and better • Avoid wasting money on unnecessary, ineffective, or unsafe
living space. Yet we hear plenty of news about the en- products and services
vironment that concerns us. Preventive and therapeutic • Take care of yourself and minimize your need to spend
medical care have advanced tremendously, yet we worry money on health products and services
about the risks associated with immunization, cancer • Choose appropriate health products and services to meet
therapies, prescription drugs, surgery, and many other your needs
• Get the most value out of your health dollars
methods of treatment. How can we resolve our concerns
• Optimize benefits from encounters with health-care provid-
and reap the benefits of modern scientific discoveries? ers and facilities while minimizing the potential for harm
The key is to become well-informed. • Assert and protect your rights
The challenges involved are enormous. The health • Set reasonable expectations for what health care can do
marketplace- the world of commercial activity for • Evaluate how political issues affect access to health-related
health-related products and services- is complex and innovations and accountability of marketers
dynamic. The Internet offers vast amounts of informa-
The key to intelligent decision-making is to use
tion, but much of it is not trustworthy. Health concerns
relevant and accurate sources of information. Consumer
can be overwhelming, especially for people confronted
Health is both an introductory text and a reference book
with medical crises. Quackery is more pervasive and far
on the opportunities and pitfalls of the health market-
trickier than most people realize. (As noted by the late
place. The various chapters offer hundreds of practical
James Harvey Young, Ph.D., "Quacks never sleep.")
tips; the Appendix provides a comprehensive list of
Health-care costs continue to rise despite numerous
trustworthy sources. You will get the most out of the book
reform efforts. The rapidly growing older adult popula-
by using the detailed Index to search for information
tion faces a bewildering array of choices and obstacles
and the Glossary for definitions of terms that might be
for obtaining and paying for appropriate health care. It
unfamiliar.
can also be difficult to determine what health care actu-
We also operate many Web sites that can supplement
ally costs and to obtain the best prices. In addition, many
your coursework. Consumer Health Sourcebook (www.
people lack access to adequate health care because of
chsourcebook.com) provides hyperlinks to dependable
cultural, transportation, language, and economic barriers.
online sources. It also links to Consumer Health Digest,
Government and private agencies protect consumer
a free weekly e-mail report of relevant news. Internet
rights in some ways but not others. The health-care
Health Pilot (www.ihealthpilot.org) is a gateway to ad-
industry is accountable to consumers to some extent,
ditional trustworthy information. Quackwatch (www.
but quality is often elusive and abuses persist. Some
quackwatch.org) and its many subsidiary sites provide
scams are even facilitated by legislation and government
comprehensive articles about quackery, health fraud, and
policies.
consumer health strategy. All of these sites are accessible
Consumer advocacy calls for justice and fair play
free of charge. Visiting them is a good way to enhance
in the marketplace. Yet many self-appointed "consumer
your learning experience.
advocates" do not act in the public's interest. Although
some are sincere and make a contribution, others engage Stephen Barrett, M.D.
in irrational business bashing or act from motives of per- William M. London, Ed.D, M.P.H.
sonal aggrandizement. Some business trade associations Manfred Kroger, Ph.D.
even pose as "consumer groups" and seek self-serving Harriet Hall, M.D.
legislation. Robert S. Baratz, M.D., D.D.S., Ph.D.

V
 Preface for Instructors

s have previous editions, this ninth edition of represent the latest authoritative information we could
A Consumer Health emphasizes the opportunities
and pitfalls in the health marketplace and aims to help
locate. Many more systematic reviews and meta-analyses
have been cited in this edition than in previous editions.
students protect their health and their pocketbook. Some references may seem outdated. However, unless
otherwise stated, we believe these still reflect the cur-
Goal for This Revision rent marketplace. References more than 10 years old are
The book's fundamental purpose is to provide trustwor- included for historical reasons or because they provide
thy information and guidelines to enable people to select insights or document the source of well-articulated quo-
health products and services intelligently. This edition tations that are still timely. Some reports published long
culminates our review of thousands of books, journal ago are the only ones available that address important
articles, Web sites, agency reports, and feature stories, concepts.
as well as our own original investigations and critiques. Chapter 1 provides information on how to read cita-
Readers will find the information useful in applying tions and locate the references cited in the text. Those that
the caveat emptor (let the buyer beware) concept to the
health marketplace.
The underlying principles of consumer protection + Publisher's Notice +
were identified in the Consumer Bill of Rights promul-
gated by President John F. Kennedy and have guided McGraw-Hill CreateTM
the development of this textbook. President Kennedy Craft your teaching resources to match the way you
declared that consumers have the right to purchase teach! With McGraw-Hill Create, you can easily rear-
safe products and services, to be correctly informed, to range chapters, combine material from other content
freely choose products and services, and to be heard by sources, and quickly upload content you have writ-
the government and others when injustices occur. We ten like your course syllabus or teaching notes. Find
strongly support consumer awareness and efforts to as- the content you need in Create by searching through
thousands of leading McGraw-Hill textbooks. Arrange
sert and protect these rights.
your book to fit your teaching style. Create even allows
you to personalize your book's appearance by selecting
Intended Audience the cover and adding your name, school, and course
Consumer Health has been designed as a sole required information. Order a Create book and you' ll receive a
textbook for consumer health courses. Selected chapters complimentary print review copy in 3-5 business days
of the book (see "Publisher's Notice" box) can also be or a complimentary electronic review copy (eComp)
useful as required or supplemental readings for other via e-mail in minutes. Go to www.mcgrawhillcreate.
courses in health education; community health; public CQm today and register to experience how McGraw-Hill

health; family and consumer sciences; consumer edu- Create empowers you to teach your students your way.
cation; health psychology; medical sociology; human Electronic Textbook Option
ecology; and social welfare. School districts will find This text is offered through CourseSmart for both in-
Consumer Health useful as a reference for teachers and structors and students. CourseSmart is an online resource
students as well as an aid in curriculum development. where students can purchase the complete text online
Professional health-care providers can use this text to at almost half the cost of a traditional text. Purchasing
prepare for public presentations and can make it avail- the eTextbook allows students to take advantage of
able in their offices for perusal by clients. CourseSmart's Web tools for learning, which include full
text search, notes and highlighting, and e-mail tools for
sharing notes between classmates. To learn more about
Timeliness of References CourseSmart options, contact your sales representative
Every topic in this book has been carefully researched. or visit www.CourseSmart.com.
In most cases, the more than 1500 cited references
vi
 Preface for Instructors vii

may be especially useful for students seeking additional aids, other devices, death-related services, and health-
information are listed with boldface numbers. When care facilities.
citing material on Web sites, we report the publication VI. Protection of the Consumer focuses on legal
date when the site identifies it. When no date is posted, and economic issues involved in protecting consumers.
we report when we last accessed the page. These include health insurance, health-care financing,
consumer-protection laws and agencies, and strategies
Internet Integration for intelligent consumers.
Another important feature of this edition is its integra-
tion with our Consumer Health Sourcebook Web site Features and New Material
(www.chsourcebook.com). The "References" section of All features from the eighth edition have been retained.
this site provides links to many full-text articles and to Many chapters contain vignettes ("Personal Glimpses")
abstracts of most of the journal articles. Suggestions for to stimulate reader interest and "Consumer Tip" and
course objectives, teaching/learning activities, a sample "Consumer Insight" boxes that emphasize key points.
course outline, and links to hundreds of organizations Many checklists and "It's Your Decision" boxes reflect
that provide trustworthy information are also posted. "real-life" decisions that readers may face. The "Key
We encourage students and instructors to subscribe Concepts" box at the beginning of each chapter states
to Consumer Health Digest, a free weekly e-mail news- what we believe are the most important lessons to be
letter edited by Dr. Barrett with help from Dr. London. learned from the chapter material. Extensive searches
(To subscribe, see www.ncahf.org/digest/chd.html.) of the scientific literature, court documents, and other
At the publisher's Web site (www.mhhe.com/bar- relevant reports over an 18-month period have provided
rell2.e)_, instructors will find sample test questions and information to update the contents of this edition.
PowerPoint presentations to use with the book.
• Chapter 1 (Consumer Health Issues) introduces the im-
Organization portant issues facing consumers in today's marketplace.
New material about cognitive bias explains how distortions
As in the eighth edition, the text is broadly divided into
of thinking can lead to inaccurate conclusions and faulty
six parts: judgment.
I. Dynamics ojthe Health Marketplace focuses on • Chapter 2 (Separating Fact from Fiction) describes how the
past and present problems. After defining the major scientific community strives to determine what is factual
consumer health issues, it discusses how the scientific and how consumers face an often bewildering array of
method is used to determine medical truths, how con- information that can be unbalanced, inaccurate, and even
sumers can separate fact from fiction, how frauds and fraudulent.
quackery can be identified, and how advertising and • Chapter 3 (Frauds an4 Quackery) explains why people are
other marketing activities influence consumer decisions. vulnerable and tells how to avoid quack practices. New
material notes how loss of faith in many of our once-trusted
II. Health-Care Avvroaches covers basic medical
institutions has made quack claims seem more credible.
care and the services of many types of practitioners and
• Chapter 4 (Advertising and Other Promotional Activities)
facilities. describes how sellers market their wares and notes how the
III. Nutrition and Fitness integrates what consum- multilevel marketing industry thwarted a proposed Federal
ers need to know about the extremely important topics Trade Commission rule intended to curb its misleading
of nutrition, weight control, and exercise. Its chapters practices.
provide the necessary tools to distinguish science-based • Chapter 5 (Science-Based Health Care) describes the
methods from fads, fallacies, and scams. training and professional activities of physicians and many
IV. Personal Health Concerns provides a guide to ancillary providers. It also incorporates U.S. Preventive
preventing and managing health problems, including Services Task Force's latest conclusions about screening
tests, including its skepticism about routine PSA testing.
several in which self-care is very important. Separate
• Chapter 6 (Mental and Behavioral Help) provides a com-
chapters cover cardiovascular disease and cancer with
prehensive guide to mental help and notes that psychiatrists
an emphasis on the choices consumers face. are shifting away from psychotherapy. The section on ques-
V. Other Products and Services covers a myriad of tionable practices and practitioners has been expanded and
other subjects that affect most, if not all, consumers. cautions against the use of poorly trained "life coaches."
These include drug products, skin care and image en- • Chapter 7 (Dental Care) provides a comprehensive dental
hancement, contraceptive methods, vision and hearing guide and warns against the increasing use of questionable
viii Preface for Instructors

screening devices and expensive cosmetic dental proce- • Chapter 20 (Health Devices) contains updated information
dures intended to create a "perfect bite." about device regulation and expanded coverage of question-
• Chapter 8 (The "CAM" Movement) describes a multitude able devices that have been flooding the health marketplace.
of theories and practices that remain unsubstantiated and New topics include spinal decompression machines, "de-
lack a scientifically plausible rationale. It also notes the toxification" devices, and alleged performance enhancing
failure of accrediting agencies to control the spread of bracelets.
unscientific teachings in professional schools (including • Chapter 21 (Coping with Death) provides current informa-
medical schools). tion on advance directives and organ donation and cautions
• Chapter 9 (A Close Look at Chiropractic) spotlights the in- about stem-cell clinics and "biologic age" testing.
fluence of chiropractic on the consumer health marketplace • Chapter 22 (Health-Care Facilities) notes how the delivery
and summarizes the latest research on spinal manipulation. of health-care services is changing and describes the salient
• Chapter 10 (Basic Nutrition Concepts) incorporates the features of various options. It also provides advice on how
latest Dietary Guidelines for Americans and the USDA to choose among the various alternatives.
Food Guidance System (Choose MyPlate) and tells where • Chapter 23 (Health Insurance) describes the basic types
to get trustworthy nutrition information and advice. and features of health insurance and outlines the major
• Chapter 11 (Nutrition Fads.Fallacies. and Scams) includes provisions of the Patient Protection and Affordable Care
up-to-date evaluations of dietary supplement products and Act.
herbal products and background material on promoters of • Chapter 24 (Health-Care Financing) provides the latest
nutritional misinformation. available statistics on national health expenditures, states
• Chapter 12 (Weight Control) notes the alarming increase why insurance reform has been desperately needed, and
of obesity in the United States and discusses appropriate describes the decades-long struggle to control costs and
and inappropriate weight-control measures. increase access to medical care.
• Chapter 13 (Fitness Concevts. Products. and Services) • Chapter 25 (Consumer Laws. Agencies. and Strategies)
reviews the fundamental concepts typically addressed in details the regulatory and educational activities of the U.S.
personal health courses, but also includes important details Food and Drug Administration and the FTC; describes
about practitioners, information resources, products, ser- physician regulation; and indicates what consumers can
vices, popular misconceptions, and scams. do to help improve the health marketplace.
• Chapter 14 (Personal Health and Safety), which is a new • The Appendix provides comprehensive lists of agencies
chapter, focuses on health promotion, injury prevention, and organizations that offer trustworthy information. The
risk perception, self-care, and the management of asthma, Consumer Health Sourcebook Web site links to most of
diabetes, high blood pressure, and other chronic condi- them.
tions. It also notes how information from the Internet and • The Glossary clarifies important jargon used in the book
elsewhere can help or undermine prudent behavior. A new and defines other terms of interest to health consumers.
section warns against the widely circulating myths that
undermine public health efforts. Acknowledgments
• Chapter 15 (Cardiovascular Disease) contains new and The authors thank John E. Dodes, D .D.S., who reviewed
updated information about risk factors for coronary heart the dental care chapter; Walter A. Zelman, Ph.D., of
disease and stroke and provides guidelines for reducing the
California State University (Los Angeles), who offered
risks.
• Chapter 16 ( ~ ) covers cancer causation, prevention, helpful suggestions for the chapters on insurance and
diagnosis, and prognosis and contrasts science-based and health-care financing.
dubious treatments. The new topics include vaccination The photograph on page 154 is reproduced with
against the human papilloma virus (HPV) and dubious permission from Aurora & Quanta Productions, Portland,
information sources. Maine. The VIPPS logo on page 358 appears with
• Chapter 17 (Drug Products) includes new information permission of the National Association of Boards of
about commonly used nonprescription (over-the-counter) Pharmacy.
drugs and how to save money on drug costs. Our project coordinator, who guided production and
• Chapter 18 (Skin Care and Image Enhancement) covers a permitted this text to remain a powerful voice, was Vicki
wide variety of topics related to skin care plus new material
Malinee of Van Brien & Associates.
about image-enhancement schemes and frauds .
• Chapter 19 (Sexual and Reproductive Health) covers Freelance editor Sarah West, of Belleville, Illinois,
products and services related to sexual and reproductive did her usual superb job of copy editing.
functions. It includes new and updated information about We also thank the many instructors who continue
birth control, birthing options, and hormone-replacement to provide suggestions for new research and topics to
therapy, and prevention of sexually transmitted diseases. include in the text.
 Contents

I. DYNAMICS OF THE HEALTH MARKETPLACE Exercise and Fitness Products, 60

Program-Length Infomercials, 60
1. Consumer Health Issues, 1 Multilevel Marketing (MLM), 61
Misleading Information, 2 Telemarketing Schemes, 62
Quackery and Health Fraud, 5 Industry Self-Regulation, 62
Problems with Products, 6 Regulatory Agencies, 63
Problems with Services, 7
Problems with Costs and Access, 8 II. HEALTH-CARE APPROACHES
Problems with Risk Perception, 8
5. Science-Based Health Care, 65
The Need for Consumer Protection, 8
Health-Care Personnel, 66
Intelligent Consumer Behavior, 10
Choosing a Physician, 70
2. Separating Fact from Fiction, 13 Basic Medical Care, 75
How Facts Are Determined, 14 Surgical Care, 80
Peer Review, 17 Quality of Medical Care, 82
Trustworthiness of Sources, 19 The Intelligent Patient, 85
Prudent Use of the Internet, 27
6. Mental and Behavioral Help, 89
Further Suggestions for Consumers, 30
Who Should Seek Help?, 90
3. Frauds and Quackery, 33 Mental Health Practitioners, 90
Definitions, 34 Psychologic Methods, 93
Scope,35 Drug Therapy, 94
Vulnerability, 36 Electroconvulsive Therapy, 95
Hazards, 37 Psychosomatic Disorders, 96
Common Misconceptions, 38 Inpatient Care, 96
Recognizing Quackery, 41 Help for Addictive Behavior, 96
Conspiracy Claims, 42 Selecting a Therapist, 97
The Freedom-of-Choice Issue, 43 Questionable "Self-Help" Products, 98
Questionable Practices, 100
4. Advertising and Other Promotional
Mismanagement of Psychotherapy, 107
Activities, 45
Psychologic Manipulation, 46 7. Dental Care, 111
Puffery, Weasel Words, and Half Truths, 48 Dentists, 112
Marketing Outlets, 49 Allied Dental Personnel, 112
Professional Advertising, 49 Tooth Decay, 113
Marketing by Hospitals, 50 Fluoridation, 114
Prescription Drug Marketing, 51 Periodontal Disease, 115
Nonprescription Drug Advertising, 53 Self-Care, 116
Tobacco Promotion, 53 Dental Products, 117
Food Advertising, 54 Dental Restorations, 119
Dietary Supplement Promotion, 54 Endodontics (Root Canal Therapy), 120
Mail-Order Quackery, 57 Orthodontics, 120
Weight-Control Promotions, 59 Dentures, 121
Youth and Beauty Aids, 59 Dental Implants, 121
ix
X Contents

Dental X-Ray Procedures, 121 11. Nutrition Fads, Fallacies, and Scams, 195
Questionable Procedures, 122 Food Faddism and Quackery, 196
Dental Quackery, 124 Dietary Supplements, 197
Choosing a Dentist, 126 Megavitamin Claims vs Facts, 203
Appropriate Use of Supplements, 206
8. The "CAM" Movement, 131
"Organic" Foods, 206
Classification, 132
"Health" and "Natural" Foods, 207
Popularity, 134
Raw Foods and "Juicing," 213
Common Themes, 135
"Medicinal" Use of Herbal Products, 213
Homeopathy, 137
Macrobiotic Diets, 219
Acupuncture and TCM, 141
Dubious Diagnostic Tests, 219
Naturopathy, 143
Promotion of Questionable Nutrition, 221
Natural Hygiene, 145
Promotional Organizations, 227
lridology, 145
Prominent Individual Promoters, 228
Reflexology, 146
Cranial Therapy, 147 12. Weight Control, 233
Aromatherapy, 147 Basic Concepts, 234
"Energy Healing," 147 Eating Disorders, 238
Massage Therapy, 148 The U.S. Weight-Loss Marketplace, 240
Psychic Healing, 148 Questionable Diets, 240
Astrology, 151 Prescription Drugs, 243
Transcendental Meditation, 152 Nonprescription Products, 244
Unscientific Medical Practices, 154 Low-Calorie Products, 246
Supportive Organizations 158 Bariatric Surgery, 248
"Medical Freedom" Laws, 158 Dubious Products and Procedures, 248
The NIH Center for Complementary and Federal Trade Commission Actions, 250
Alternative Medicine (NCCAM), 158 Weight-Control Organizations, 252
9. A Close Look at Chiropractic, 163 Suggestions for Weight Control, 254
Historical Perspective, 164 13. Fitness Concepts, Products, and
Chiropractic Philosophy, 165 Services, 259
Chiropractic Education, 168 Public Perceptions, 260
Research Findings, 169 Benefits of Exercise, 261
Problems for Consumers, 170 Types of Exercise, 262
Components of Fitness, 262
III. NUTRITION AND FITNESS
Starting an Exercise Program, 263
10. Basic Nutrition Concepts, 175 Personal Trainers, 269
Major Food Components, 176 Sports Medicine Specialists, 270
Meeting Nutrient Needs, 179 Exercise Equipment and Supplies, 270
Food-Group Systems, 182 Exercise Facilities, 276
Evaluating Your Diet, 183 Martial Arts Training, 278
Guidelines for Infants and Toddlers, 183 Children's Exercise Centers, 278
Vegetarianism, 184 Exercise While Traveling, 278
"Fast Food," 186 Exercise and Weight Control, 279
Nutrients of Special Concern, 186 Nutrition for Athletes, 279
Nutrition Labeling, 187 Anabolic Steroids, 281
Trustworthy Information Sources, 191 Other "Ergogenic Aids," 282
 Contents xi

IV. PERSONAL HEALTH CONCERNS Pharmacists, 351

Prescription Drugs, 353
14. Personal Health and Safety, 287
Generic vs Brand-Name Drugs, 354
Types (Levels) of Prevention, 288
Drug Interactions, 355
Health-Promoting Behaviors, 288
Drug Recalls, 355
Safety Measures, 291
Counterfeit Drugs, 355
Indoor Air Quality, 291
Risk Perception, 292 Internet Pharmacy Sales, 358
Self-Diagnosis, 292 Over-the-Counter Drugs, 359
Managing Chronic Disease, 295 External Analgesics, 360
Self-Help Advice, 300 Internal Analgesics, 361
Self-Help Groups, 301 Antacids and Other Heartburn Remedies, 364
Questionable Self-Help Devices, 301 Antimicrobial Drug Products, 364
Internet Considerations, 301 Cough and Cold Remedies, 365
Sore-Throat Products, 367
15. Cardiovascular Disease, 305 Ophthalmic Products, 367
Significance of Cardiovascular Diarrhea Remedies, 368
Disease, 306 Anti-Hernorrhoidals, 368
Risk Factors for Coronary Heart Laxatives, 369
Disease, 306
Smoking Deterrents, 370
Blood Lipid Levels, 307
Stimulants for Fatigue, 371
Cholesterol Guidelines, 309
Sleep Aids, 371
Dietary Modification, 311
Motion Sickness Remedies, 372
Lipid-Lowering Drugs, 315
Preventive Use of Aspirin, 317 Iron-Containing Products, 372
Questionable Preventive Measures, 318 Horne Medicine Cabinet, 373
High Blood Pressure, 320 Prudent Use of Medication, 373
Heart Attacks, 322 18. Skin Care and Image Enhancement, 379
Diagnostic Tests, 322 Cosmetic Regulation, 380
Surgery to Restore Blood Flow, 324 Soaps and Cleansers, 381
Cardiac Rehabilitation Programs, 326 Moisturizers, 381
16. Cancer, 329 Questionable Claims, 382
Avoidable Causes of Cancer, 330 Wrinkles and Age Spots, 383
Preventive Measures, 331 Fade Creams, 384
Diagnosis, 331 Antiperspirants and Deodorants, 384
Prognosis, 332 Acne Care, 384
Evidence-Based Treatment Methods, 332 Head Hair and Scalp Care, 386
Diet and Cancer Prevention, 333 Hair Loss, 388
Susceptibility to Cancer Quackery, 334 Tattoos and Permanent Makeup, 389
Questionable Methods, 335 Body Piercing, 390
Promotion of Questionable Methods, 344 Treatment of Common Foot Problems, 390
Trustworthy Information Sources, 345 Poison Ivy, 390
Treatment Guidelines, 345 Insect Repellents, 391
Consumer Protection Laws, 346 Sun Protection, 391
Camouflage Cosmetics, 393
V. OTHER PRODUCTS AND SERVICES
Cosmetic Procedures, 393
17. Drug Products, 349 Bogus Breast and Penis Enlargement
Medication Types, 350 Claims , 398
xii Contents

19. Sexual and Reproductive Health, 401 Assisted Living Facilities, 461
Menstrual Products, 402 Nursing Homes, 461
Menstrual Problems, 403 Continuing Care Retirement Communities,
Vaginal Hygiene, 404 464
Vaginitis, 405
VI. PROTECTION OF THE CONSUMER
"Jock Itch," 405
Sexually Transmitted Diseases, 405 23. Health Insurance, 467
Contraception, 406 Background, 468
Voluntary Abortions, 410 Comprehensive Medical Insurance, 468
Infertility, 411 Contract Provisions, 471
Genetic Testing and Prenatal Counseling, Types of Plans, 474
411 Consumer-Directed Expense Accounts, 476
Pregnancy and Delivery, 411 "Concierge Medicine," 476
Cord Blood Banking, 414 Indemnity vs Managed Care, 477
Infant Feeding, 414 Loss Ratios, 478
Choosing a Plan, 478
Treatment of Menopausal Symptoms, 415
Medicare, 480
Alleged Sex Enhancers, 416
Medicaid, 481
Genuine Help for Erectile Dysfunction, 416
Other Government-Sponsored Programs, 481
20. Health Devices, 419 Long-Term-Care Insurance, 481
Medical-Device Regulation, 420 Dental Insurance, 482
Vision Products and Services, 421 Collection of Insurance Benefits, 483
Hearing Aids, 427 Disability Insurance, 484
Humidifiers and Vaporizers, 429 24. Health-Care Financing, 487
Personal Emergency Response Systems, 430 Health-Care Costs, 488
Latex Allergy, 430 Cost-Control Methods, 492
Dubious Water Purifier Promotions, 430 Insurance Fraud and Abuse, 494
Spinal Decompression Machines, 431 National Health Insurance (NHI), 498
Quack Devices, 431
Consumer Strategy, 435 25. Consumer Laws, Agencies, and
Strategies, 503
21. Coping with Death, 437 U.S. Food and Drug Administration, 504
Advance Directives, 438 Federal Trade Commission, 515
Viatical Settlements, 441 U.S . Postal Service, 517
Donations of Organs and Tissues, 442 Other Federal Agencies, 51 7
Hospice Care, 443 State and Local Agencies, 518
Euthanasia and Assisted Suicide, 444 Physician Regulation, 518
Reasons for an Autopsy, 445 N ongovemmental Organizations, 519
Body Disposition, 445 Consumer Action, 522
Coping with Grief, 448 Appendix: Trustworthy Sources of
Life-Extension/Anti-Aging Quackery, 448 Information, 525
22. Health-Care Facilities, 453 Federal Government Agencies, 526
Accreditation, 454 Nongovernmental Organizations, 526
Outpatient Medical Facilities, 454
Glossary, 529
Hospitals, 457
Home Care Services, 460 lndex,541
 Part One
Chapter One

CONSUMER HEALTH
ISSUES
1
I 1 •
1!i!i;IJ.,i,!l~mllY;1!'*lt%C;!1~!,1lli~~

Reprinted with special permission from King Features Syndicate

Consumer health goes far beyond the decision to buy or not to buy.
The ever increasing perplexity of the health care delivery system; the
prevalence of myths and misconceptions about health, disease, and
remediation; the widespread usage of unproven health products and
services; and the rapidly escalating costs of health care have ushered
in the need to educate individuals in the proficient,judicious and eco-
nomical utilization of health information, products, and services.
NILES L. KAPLAN 1

Evidence clearly demonstrates that people are susceptible to error

even when choosing among a handful of alternatives to which they
can devote their full attention.
2
BARRY ScHWARTZ
2 Part One Dynamics of the Health Marketplace

Key Concepts
KEEP THESE POINTS IN MIND AS You STUDY Tms CHAPTER

• To get the most out of our health-care system, consumers must be knowledgeable and appropriately assertive.
• Virtually all legitimate health products and services have bogus counterparts.
• Intelligent consumers maintain an appropriate level of skepticism and recognize their susceptibility to perceptual
distortions and cognitive biases.
• Consumer protection agencies are unable to deal with many of the complaints they receive.
• Everyone in a free society has a stake in maintaining high standards in the health marketplace.

onsumer health encompasses all aspects of the This chapter comments on misleading information;

C marketplace related to the purchase of health

products and services. It includes such things as
buying a bottle of vitamins, a cold remedy, a dentifrice,
quackery; health frauds; and problems with health-care
products, services, costs, and access. It also outlines the
strengths and weaknesses of consumer-protection forces,
or exercise equipment and selecting a physician, dentist, how consumers make health-related decisions, and the
insurance policy, book, Web site, or other source of characteristics of intelligent consumers.
information.
Consumer health has both positive and negative as-
MISLEADING INFORMATION
pects. Positively, it involves the facts and understanding
that enable people to make medically and economically Health information has become increasingly voluminous
sound choices. Negatively, it means avoiding unwise and complex. Even well-trained health professionals can
decisions based on deception, misinformation, or other have difficulty sorting out what is accurate and signifi-
factors. Worksheet 1-1 provides an opportunity to test cant from what is not. Table 1-1 lists questions faced by
your knowledge of consumer health issues. many of today's consumers.

Worksheet 1- 1
TESTYOUR CONSUMER HEALTH 1.Q.

1. Everyone should have a complete physical examination every year or two. T F

2. Fluoride toothpaste works so well that water fluoridation is no longer important. T F
3. It is difficult for busy people to eat a balanced diet. T F
4 . People intelligent enough to graduate from college are unlikely to be victimized by quackery. T F
5. Accreditation of a school indicates that a regulatory agency considers its teachings sound. T F
6. Cigarette smoking is the leading cause of preventable death in the United States. T F
7 . Sugar is a major cause of hyperactivity and other childhood behavioral problems. T F
8. In most states no special training is legally required to offer counseling to the public. T F
9. Antioxidant supplements have been proven to protect against heart disease, stroke, and cancer. T F
10. Homeopathic remedies are a safe and effective alternative to many drugs that doctors prescribe. T F
11 . Taking large daily doses of vitamin C can cut the risk of catching colds in half. T F
12. All people age 21 or older should have their blood cholesterol levels checked once a year. T F
13 . Administering more than one vaccine at a time can overload the immune system. T F
14. The American Medical Association can revoke the license of a doctor who is practicing improperly. T F
15. Government reports indicate that the best person to consult for back pain is a chiropractor. T F
16. Most retailers of dietary supplements and herbal products are well informed about the products they sell. T F
17. Protein or amino acid supplements help bodybuilders and other athletes improve their performance. T F
18. The emergency department of a nonprofit hospital is a relatively inexpensive place to get medical care. T F
19. Natural cancer cures are being suppressed because drug companies don't want competition. T F
20. Most health-related books and magazine articles are vetted by experts prior to publication. T F
21 . Government agencies screen many ads for mail-order health products before they are published. T F

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 Chapter One Consumer Health Issues 3

Table 1-1
CONSUMER HEALTH QUESTIONS

How can the significance of research reports be judged? Will taking calcium supplements help prevent
How trustworthy are the media? How can trustworthy osteoporosis?
information sources be located? Are any herbal products worth taking?
What are the best ways to keep up-to-date on consumer How trustworthy is the advice given in health-food
health issues? stores?
How can quacks and quackery be spotted? Are food additives dangerous?
What should be done after encountering quackery or What is the safe way to lose and control weight? Are
health fraud? diet pills helpful or harmful?
Is it sensible to try just about anything for health Are electric vibrators and massage equipment useful
problems? for weight control or body shaping?
How should advertisements for health products and Which exercise equipment provides good value for its
services be analyzed? cost?
How should physicians, dentists, and other health-care Is it a good idea to join a health club or exercise center?
specialists be selected? What principles should guide the evaluation and man-
What should be done about excessive or unreasonable agement of blood cholesterol levels?
professional fees? Can magnetic devices enhance athletic performance?
When is it appropriate to obtain a second opinion about Can any food or dietary measures prevent or influence
recommended surgery? the course of arthritis or cancer?
What periodic health examinations are advisable? How Does it make sense to undergo detoxification?
much should they cost? How do pain relievers compare?
Where can competent mental help be obtained? Should laxatives be used? By whom?
What kinds of toothbrushes and dentifrices are best? Is it a good idea to use generic drugs?
Can mouthwashes and dentifrices control the develop- What products are useful for self-care and family care?
ment of plaque on teeth? What is the best strategy for protecting against sun
When are dental implants appropriate? exposure?
Do amalgam fillings pose any health hazard? Can any product help to grow, restore, or remove hair?
What rights should buyers and sellers have in the health Can wrinkles be removed with any product or with
marketplace? plastic surgery?
How trustworthy are chiropractors, naturopaths, and What forms of birth control are safest and most
acupuncturists? effective?
Is it advisable for people with back pain to see a Are over-the-counter pregnancy test kits reliable?
chiropractor? Are any over-the-counter drug products effective for
What is the best schedule for vaccinations? menstrual cramps?
Is vaccination with Gardasil prudent? What can women do about premenstrual syndrome
When are self-diagnosis and treatment appropriate? (PMS)?
How should a hospital, nursing home, or convalescent Does the patenting of a health device ensure its safety
facility be selected? and effectiveness?
What are the pros and cons of using an ambulatory How do the different types of contact lenses compare?
health-care center? Who should determine the need for eyeglasses, contact
What facilities are available for people who need long- lenses, or a hearing aid?
term care? How safe and effective is surgery to improve vision?
How can a balanced diet be selected? Does it make sense to prepay funeral expenses?
Does vegetarian eating make sense? What services are available for the terminally ill?
When is it appropriate to use vitamin or mineral Which health coverage provides the best protection?
supplements? How can consumers reduce their health-care costs?
Do antioxidant supplements prevent future diseases? How much money should be budgeted for health care?
Should "organic foods" or "health foods" be purchased? What agencies and organizations help protect
Are they worth their extra cost? consumers?
Can taking vitamin C supplements prevent or cure Which consumer groups are trustworthy?
colds? How can one register a complaint about a health prod-
Should extra vitamins be taken during pregnancy? uct or service?
4 Part One Dynamics of the Health Marketplace

The media have tremendous influence. Thousands be insignificant. The simplest strategy for keeping up-to-
of radio and television stations broadcast health-related date is to subscribe to trustworthy newsletters and other
news, commentary, and talk shows. Thousands of maga- review sources that place new information in proper
zines and newspapers carry health-related items, and perspective (see Chapter 2).
thousands of health-related books and pamphlets are Advertising should also be regarded with caution
published each year. Thousands of books recommend (see Chapter 4). Many advertisers use puffery, "weasel
unscientific health practices, as do countless Web sites, words," half-truths, imagery, or celebrity endorsements
blogs, and other computerized information sources. to misrepresent their products. Some marketers use
Gunther3 has noted that the mass media have four scare tactics to promote their wares. Some attempt to
main functions: to entertain, to inform, to carry adver- exploit common hopes, fears, and feelings of inadequacy.
tisements, and to make money for their stockholders. In Cigarette ads have used images of youth, health, vigor,
many cases what is transmitted depends on (a) how much and social acceptance to convey the opposite of what
it is expected to interest the target audience and (b) how cigarette smoking will do to smokers.Alcohol ads stress
advertisers may feel about it. Larkin,4 for example, has fun and sociability and say little about the dangers of
noted that many women's magazines publish sensational excessive drinking. Many ads for cosmetics exaggerate
claims and deliberately avoid information that might what they can do (see Chapter 18). Food advertising,
upset their advertisers. though not usually deceptive, tends to promote dietary
Fast-breaking news should be regarded cautiously. imbalance by emphasizing snack foods that are high
Many reports, though accurate, tell only part of the in fat and calories. Radio and television infomercials
story.5 Unconfirmed research findings may tum out to abound with promoters of health misinformation.

+ Personal Glimpse +
Doctors and Patients in Cyberspace
Physicians were once able to carry in their little black With the rapid growth and popularization of the
bags most of the tools needed to diagnose and treat pa- Internet, access to the universe of medical information
tients. They could store in their own minds the informa- has been fundamentally altered. Physicians and the public
tion necessary for the majority of their work. Experience may draw on the resources of medical discussion groups
broadened one's ability to handle difficult or unusual and reference databases with unprecedented ease.
cases, and patients relied upon their physicians as the pri- But a new dilemma comes with this wonderful ad-
mary source of information on both health and disease. vance. For decades, inquisitive patients have turned to
The logarithmic increase in biomedical knowledge ... health letters and magazines to supplement the informa-
has changed the doctor-patient relationship dramatically. tion gained from consultation with their physician. These
The history and physical examination, once the basis for publications filled a gap in doctor-patient communication.
all medical practice, are now only the first exploratory As demands on the physician's time have multiplied, the
steps in the process of making a diagnosis and planning a explanations offered to patients are too often cursory and
treatment regimen. The immense proliferation of labora- incomplete. As the concept of individual responsibility
tory tests, imaging techniques, and diagnostic procedures for health has grown, the computerized medical database
is stunning. The specialties of medicine have further has broadened the patient's horizons .. ..
branched into subspecialties as basic research and clini- It is too early to analyze the virtues and problems
cal knowledge have greatly expanded. Medical journals of the information revolution. But some are obvious.
and textbooks have multiplied in number, along with the For example, a World Wide Web query for the
arrival of new means of information delivery. keyword "health" found .. . documents , ranging from
No individual physician, no matter how capable or commercial health products and alternative therapies to
experienced, is able to absorb and memorize more than a issues of sexuality, obesity, aging, and environmental
small portion of this database. This is true despite the fact health .. . .
that convenient access to the information is developing Since even physicians can have difficulty sorting
rapidly. One can search the literature rapidly with the out the truth in cyberspace, imagine the problem for the
National Library of Medicine's MEDLINE service to average person browsing the Internet.
discover the latest in diagnosis, treatment, and outcome
for any disease, common or rare. Michael Kashgarian, M.D.6
 Chapter One Consumer Health Issues 5

Although many authoritative publications are avail-

able, greater numbers of books, magazines, newsletters,
+ Personal Glimpse +
and Web sites promote false ideas. Chapter 2 discusses
False Beliefs Can Kill
this problem in detail and provides guidance on choosing
trustworthy sources. The danger of denying that the human immunodefi-
ciency virus (HIV) is the causal agent of AIDS was
spotlighted in 2005 by the sudden death of 3-year-old
QUACKERY AND HEALTH FRAUD Eliza Jane Scovill of Van Nuys, California, during
a bout of AIDS-related pneumonia. Eliza's mother,
Quackery is definable as the promotion of a false or Christine Maggiore, was HIV-positive. Medical man-
unproven health method for profit (see Chapter 3). agement of infected pregnant women had reduced the
Fraud involves deceit. Despite tremendous progress in reported incidence of HIV/AIDS in children under age
medical science and health education, Americans waste 13 from 952 in 1992 to only 59 in 2003 . But Maggiore
billions of dollars each year on products and services refused treatment for herself and did nothing to prevent
that are unsubstantiated or bogus. Dr. William Jarvis7 transmission of the virus to her daughter. In fact, dur-
calls quackery "a national scandal." Barrett and Herbert8 ing her pregnancy, she even appeared on the cover of
Mothering Magazine with the word AZT in a circle with
have noted:
the slash through it and the headline "HIV+ Moms Say
People generally like to feel that they are in control of their NO to AIDS Drugs." (AZT is an anti-AIDS drug.)
life. Quacks take advantage of this fact by giving their clients Maggiore ran Alive & Well AIDS Alternatives, a
things to do-such as taking vitamin pills, preparing special nonprofit organization which falsely proclaimed that
foods, meditating, and the like. The activity may provide a (a) most of the AIDS information the public receives
temporary psychological lift, but believing in false things was based on unsubstantiated assumptions, unfounded
can have serious consequences. The loss may be financial, estimates, and improbable predictions and (b) the
psychological (when disillusionment sets in), physical (when symptoms associated with AIDS were treatable with
the method is harmful or the person abandons effective care), "non-toxic, immune enhancing therapies." Maggiore
or social (diversion from more constructive activities) . ... herself died in 2008. Although an autopsy was not
Quacks portray themselves as innovators and suggest obtained, knowledgeable observers believe that she
that their critics are rigid, elitist, biased, and closed to new died of AIDS-related pneumonia.9
ideas. Actually, they have things backwards. The real issue is
whether a method works. Science provides ways to judge and
discard unfounded ideas. Medical science progresses as new
methods replace less effective ones. Quack methods persist
foods; and (d) no nonprescription pill can produce rapid
as long as they remain marketable.
or permanent weight loss. Chapters 3, 11 , and 12 cover
Quackery promoters are adept at using slogans and these subjects thoroughly.
buzzwords. During the 1970s their magic sales word Victims of quackery usually have one or more of
was "natural." During the 1980s the word "holistic" was the following vulnerabilities:
popularized. Today's leading buzzwords are "alterna-
LACK OF SUSPICION: Many people believe that if something is
tive" and "complementary." These terms are misleading printed or broadcast, it must be true or somehow its publica-
because methods that do not work are not reasonable tion would not be allowed. People also tend to believe what
alternatives to proven treatment and combining them others tell them about personal experience.
with standard methods increases cost but not effective- DESPERATION: Many people faced with a serious health problem
ness. This textbook places the words "alternative" and that doctors cannot solve become desperate enough to try
"complementary" in quotation marks when referring to almost anything that arouses hope. Many victims of can-
unsubstantiated methods that lack a scientifically plau- cer, arthritis, multiple sclerosis, and AIDS are vulnerable
sible rationale. Chapter 8 discusses them in detail. in this way.
ALIENATION: Some people feel deeply antagonistic toward
Although most people think of themselves as hard to
scientific medicine but are attracted to methods that are
fool, the majority of Americans are victims of quackery.
"natural" or otherwise unconventional. They may also
Contrary to popular beliefs, for example: (a) most people harbor extreme distrust of the medical profession, the food
who take vitamin supplements don't need them; (b) vita- industry, drug companies, and government agencies.
mins do not make people more energetic, more muscular, BELIEF IN MAGIC: Some people are easily taken in by the promise
or less stressed; (c) "organically grown" foods are neither of an easy solution to their problem. Those who buy one fad
safer nor more nutritious than conventionally produced diet book after another fall into this category.
6 Part One Dynamics of the Health Marketplace

OVERCONFIDENCE: Despite P.T. Barnum's advice that one products have any usefulness against disease, and most
should "never try to beat a man at his own game," some that do- such as niacin for cholesterol control- should
strong-willed people believe they are better equipped than not be taken without competent medical supervision.
scientific researchers and other experts to tell whether a Although some herbs sold for medicinal purposes
method works.
are useful, most are not, and some are dangerous (see
Chapter 11). Because the U.S. Food and Drug Admin-
PROBLEMS WITH PRODUCTS istration (FDA) does not require standards of identity or
In light of scientific and technologic advances, it is not dosage for herbal products, consumers may be unable
surprising that many people believe that health is pur- to tell what the products contain or how to use them.
chasable. The health marketplace abounds with products Moreover, many of the conditions for which herbs are
of every description to accommodate people's desires. recommended are not suitable for self-treatment.
The problem areas include dietary supplements; herbal The vast majority of mail-order health products
and homeopathic products; exercise devices; diet pills are fakes (see Chapter 4). The common ones include
and potions; self-help books, recordings, and gadgets; weight-loss products (mostly diet pills), "hair restor-
youth and beauty aids; magnets; and some types of over- ers," "wrinkle removers," and alleged sex aids. Figure
the-counter drug products. 1-1 illustrates the flamboyant claims found in ads for
Thousands of "supplement" products are marketed mail-order diet and "nerve" pills.
with false claims that they can boost energy, relieve Many worthless devices are claimed to "synchro-
stress, enhance athletic performance, and prevent or nize" brain waves, relieve pain, remove unwanted fat
treat numerous health problems (see Chapter 11). Ads deposits, improve eyesight, relieve stress, detoxify
for "ergogenic aids" feature champion bodybuilders or the body, and ward off disease. Thousands of self-
other athletes without indicating that the real reason instructional products and programs are marketed with
for their success is vigorous training. Few supplement false claims that they can help people lose weight, stop

It May Be
alories Your Nerves
Mei11111: A.tter [IQ l11n1 la-. hi. 'fglil'f l ody l ru \s Dow•
8ulgi1g h 1 IAd l rflS II Awly - So 'flt ,rcw 11iuer
tad Slua•cr Frt• MuJlo Mui. lup L1 1 1111sin satllu
11 ;11stH1,sJ • , uyH mrlt 1w1y l»olll 1Ji,1ndihUI
Ill IM.red1~t1 r11u1 H a atb H
Do you suffer from
Lack of Energy
Cold hands and feet
Poor Concentration
?
Jealousy and Bad Temper
lmtab,hty
Fears and Uneasy Feelings
Short Temper
Impatience, Fatigue
Wandering of the Mind
Dull Pains, Dizziness
2 POUNDS GONE THE FIRST 24 HOURS Depression Physical Exhaustion
6 POUNDS GONETHEFIRST 48 HOURS
10 POUNDS GONETHE FIRST 7 DAYS
Melancholia I Self-consciousness
Decline in Sex Drive
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.......
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IT MAY BE YOUR NERVES
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Ol[ll5T llSHAD OI STO! lD-Ul'fAr
nervous system. It is the dominant power of
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IJOl1t le atOll Sl..l'.:A-'LR INSI CAO r# fATrEA Art(A LICH l[ST0f All - YOU SU.t Sl• fOI UO~ l{(.AltS( Al l CIIS How JUS' lhmll wti. tt11, g,ul A~ll fA( wuPtlft au,1, lo Our Brain, Heart, Stomach, Liver,
l.,l$l , YOU IIA\1 Ill' TOIi NAIii$ a llfthltl WlUOll 10 OlllNO 10'1- II al Yl&lf lilt )'Oil' w hall lo lll)lll olt vu.ss pourm tat ttc
t.~YOU tAT•
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are directly governed by the nerves receiving
FIGURE 1-1.Ads for dubious mail-order products. The diet pill ad was published theirpowerthrough the nerves. Nerve Force,
in many magazines during the late 1970s. Although no product can "neutralize therefore, is the basis of all efficiency -
Mental, Organic and Muscular.
calories" or fulfill the other promises in this ad, countless "weight-loss" products The entire body contains a network of tiny
have been advertised in this way. The "nerve tonic" ad is from a 1996 flyer from fibers and nerve fil ame nts. The extreme
delicacy of the nervous system is shown in
a company that specializes in herbal products. Some of its statements about body refl ex actions . Any dera ngement of these
physiology are true, but most are not related to each other, and the overall message nerve fib ers may interfere with the proper
functioning o f the entire nervous system.
is pseudoscientific gibberish. No ingredients are identified, and no product can The nervous system is extremely complex
remedy the long list of problems listed in the ad. Promotions like these are still and frequently mislead ing. Pains may be
fe lt in pa rts of the body far remote from the
common today because regulatory agencies lack the resources to control them, actual seat of the trouble.
many people are unsuspecting enough to buy them, and many magazine and VIRO TABLETS
newspaper publishers value ad revenues more than ethics. Reg. Price ~ e 200-0NLV $9.95
 Chapter One Consumer Health Issues 7

smoking, enhance athletic performance, quit drinking,

think creatively, raise IQ, make friends, reduce pain,
Homeo1,a1h.c remedy
improve vision, restore hearing, cure acne, conquer fears, NOC 51979-9756-43
read faster, speak effectively, handle criticism, relieve
depression, enlarge breasts, and do many other things
Oscillococcinum®
J Roy

(see Chapter 6). Magnets embedded in clothing, mat- CONTAINS ANAS BARBARIA:
tresses, or other products are falsely claimed to relieve HEPATIS ET CORDIS
EXTRACTUM HPUS 200 C
pain, increase blood flow, boost immunity, and provide for relief of flu-like
other health benefits (see Chapter 20) . symptoms
contents J tubU• o t 1 g 10 OJ~2 0 11 <'ncn
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health-related products, almost all of which are either in- BORNEMAN

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appropriate or overpriced (see Chapter 4) . The products tJ ,. 1:'0fl ' •, ~ ,c, ...., •• uia::,
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are sold by individual distributors who also attempt to ' (Iii °\.~If
recruit friends, neighbors, relatives, and others to do the
same. Several million people are involved in multilevel
marketing. FIGURE 1-2. Homeopathic product "for the relief of colds and
Most over-the-counter drug products can be useful flu-like symptoms, such as fever, chills and shivering, body
in self-care. However, many ads encourage pill-taking aches and pains." The box states that its active ingredient is
for insomnia, lack of energy, constipation, and other "Anas barbarire hepatis et cordis extractum HPUS 200C."
problems that may have better solutions. Homeopathic This ingredient is prepared by incubating small amounts of a
"remedies" are the only category of spurious products freshly killed duck's liver and heart for 40 days. The resultant
legally marketable as drugs. Figure 1-2 illustrates a solution is then filtered, freeze-dried, rehydrated, repeatedly
product that does not contain any molecules of its alleged diluted, and impregnated into sugar granules.
The "200C" designation means that the dilution (1: 100) is
"active ingredient."
done 200 times. If a single molecule of the original substance
Exercise equipment varies greatly in quality, use- were to survive the dilution, its concentration would be 1 in
fulness, and price. Before investing in equipment, it is 100200 (1 in 10400). The number 100200 is vastly greater than
important to determine what it can do and whether it can the estimated number of molecules in the universe. These
meet one's needs or will be too monotonous for regular numbers don't make sense, and neither does purchasing the
use (see Chapter 13). Some devices are gimmicks that product. Ye, as noted in Chapter 8, tit is legal to market it as
have little or no effect on fitness. a nonprescription drug in the U.S .

PROBLEMS WITH SERVICES

Although health care in America is potentially the Most dentists provide competent care, but consum-
world's best, many practitioners fall short of the ideal, ers should be alert to the signs of overselling and dental
some are completely unqualified, and many consumers quackery. Dodes and Schissel 11 also warn that many
have problems with access and affordability. dentists fail to get optimal results because they work
Many physicians prescribe too many drugs, order too quickly (see Chapter 7).
too many tests, fail to keep up-to-date, or pay insuf- Many people who represent themselves as "nu-
ficient attention to preventive measures. Some do tritionists" lack adequate training and engage in un-
not spend sufficient time interviewing, examining, or scientific and quack practices (see Chapter 11). Many
advising their patients. Unnecessary surgery is also a commercial weight-loss clinics lack qualified personnel
significant problem. The percentage of physicians who and promise too much in their advertising (see Chapter
furnish seriously deficient care is unknown. The Public 12).
Citizen Health Research Group (HRG) 10 estimates that A wide variety of practitioners engage in "alterna-
about O.8 % of physicians commit serious offenses each tive" practices that are not science-based and lack
year, more than double the number actually disciplined. proven value. This includes small percentages of
Practitioner discipline is covered in Chapter 25. medical and osteopathic physicians; large percentages
The mental health marketplace is replete with un- of chiropractors, naturopaths, massage therapists, and
qualified therapists, some of whom have no training acupuncturists; and others whose activities are described
whatsoever (see Chapter 6). in Chapters 8 and 9.
8 Part One Dynamics of the Health Marketplace

The quality of care in hospitals and nursing homes If you make a list of environmental risks in order of how many
varies considerably from one to another. The best ones people they kill each year, then list them again in order of how
have well-trained nurses who monitor their patients alarming they are to the general public, the two lists will be
closely. In some facilities, unlicensed personnel provide very different. . . . The risks that kill you are not necessarily
the risks that anger and frighten you .. . .
services for which they are not adequately trained. Pa-
tients confronted with a succession of tests and consul- Media reports can greatly influence what people
tants may feel frustrated and bewildered if the reasons for perceive as hazardous. For example, at various times,
them are not explained. Noise may interfere with getting the media have promoted widespread fears that cellular
adequate rest. In some nursing homes, physical restraints phones, video display terminals, coffee, electric blan-
or sedative drugs are used excessively, patients receive kets, the artificial sweetener saccharin, commercial hair
insufficient medical attention, and neglect by the nurs- dyes, and potato chips pose serious risks. The American
ing staff results in infections and bedsores. Hospitals, Council on Science and Health15 has noted that all of
long-term care facilities, and other health-care delivery these scares were based on "questionable, hypothetical,
systems are discussed in Chapter 22. or nonexistent scientific evidence." FDA scientist Robert
Scheuplein 16 has noted that "scientists, managers and
regulators who study risks for a living are constantly
PROBLEMS WITH COSTS AND ACCESS
dismayed because the public seems to worry about the
Rising costs and lack of adequate insurance coverage wrong risks."
have made high-quality health care unavailable to many Chapter 14 discusses health and safety risks and
people in the United States. The cost of health care in appropriate consumer responses to these risks.
the United States has risen much faster than inflation for
several decades and is approaching 18% of our gross
domestic product. In 2009 close to 50 million Americans THE NEED FOR CONSUMER PROTECTION
ages 19 to 64 had no health insurance 12 and many others The caveat emptor doctrine ("let the buyer beware"),
were underinsured. A recent study 13 concluded that ill- which originated in the Middle Ages, was based on the
ness and medical bills were linked to nearly two thirds assumption that buyers and sellers had equal bargain-
of bankruptcies. Inefficiency, waste, and fraud are also ing positions. This was reasonable because (a) goods
serious problems. (such as fresh vegetables and cloth) could be examined
In 2009, after decades of inaction, the U.S. Congress thoroughly for defects and (b) people bargained almost
enacted a hotly contested reform bill in an attempt to entirely with neighbors who risked severe social reper-
improve access and decrease the cost of health care. cussions if they acted dishonestly. However, as trade
However, the new law only partially addresses the prob- expanded and technology advanced, it became apparent
lems, and powerful vested interests and many confused that individual caution is not enough. Even highly intelli-
members of the public oppose its implementation (see gent individuals may go astray in situations in which they
Chapters 23 and 24). lack expert knowledge or are emotionally vulnerable.
The funeral industry has a disgraceful record of
price-gouging. Many funeral directors fail to disclose Protective Forces
costs, add dubious items to their bills, and/or pressure Because the caveat emptor philosophy is inadequate to
emotionally vulnerable survivors into spending more protect health consumers.many of today's laws are based
than necessary (see Chapter 21). Although comparison on the concept of caveat vendor (let the seller beware),
shopping or joining a memorial society can greatly lessen but gaps in consumer protection remain. Better enforce-
the cost of death care, many people are not in a position ment of existing laws is also needed.
to do these things. Prepaid funeral plans that are badly The FDA is concerned about the safety, effective-
managed or fraudulent are also a serious problem. ness, and marketing of foods, drugs, cosmetics, medical
devices, and other health-related products. The FDA
operates under powerful laws but lacks sufficient re-
PROBLEMS WITH RISK PERCEPTION
sources to handle the enormous number of violations
People are most likely to take steps to take care of it encounters . In addition, a 1994 law generated by the
themselves when they perceive that doing so will reduce health-food industry and its allies has decreased the
important health and safety hazards. Butrisk-communi- agency's ability to regulate claims for dietary supple-
cationexpertPeterM. Sandman,PhD. 14 has concluded: ments and herbs (see Chapters 11 and 25).
 Chapter One Consumer Health Issues 9

Table 1-2
ANALYSIS OF CONSUMER-PROTECTION FORCES

Agency/Organization Potential Role Limiting Factors

School accreditation Improve the quality of training Teachings are not required to be science-based
agencies
State licensing boards State laws set standards for entry into Licensure does not ensure that a profession practices
profession. Boards can act in cases scientifically. Board resources are limited; courts
of fraud , incompetence, or other may delay or overrule board actions; many
unprofessional behavior dubious practitioners are unlicensed
Insurance companies Gatekeeper function; can refuse to pay for Laws or court actions may force companies to pay
unsubstantiated treatment for unsubstantiated procedures
Medicare and Medicaid Can eject errant practitioners Fraud can be difficult to detect
Managed care Can exclude or eject practitioners who Selection criteria may be based on economic
plans don't meet their criteria or who engage factors rather than quality of care; laws and court
in unprofessional conduct actions can force managed-care plans to accept
practitioners they don't want
Professional societies Set ethical standards for members Have no legal power; cannot influence nonmembers
Specialty boards Set high performance standards and Unrecognized boards may have low standards or be
ensure them by rigid examinations bogus
Advisory panels Issue guidelines based on professional Have no legal power; some guidelines conflict with
consensus others
Hospitals Credentialing and peer-review processes Practitioners not on hospital staff are unaffected;
can restrict unqualified practitioners some hospitals have lax standards
Food and Drug Regulates food , drugs, and cosmetics; can Limited resources, especially if court action is
Administration (FDA) act against drugs and devices that are required; current laws interfere with regulation of
not proven safe and effective vitamins, herbs, and homeopathic products
Federal Trade Commis- Can act against false advertising Very aggressive but has limited resources and tends
sion (FTC) to move slowly
U.S . Postal Service Can stop frauds involving use of the mail No recent regulation of mail-order health products
State attorneys general Can stop fraudulent activities Can pursue only a small percentage of complaints
Voluntary and consumer Can educate the public and campaign for Many groups are underfunded; some promote
groups stronger laws quackery

The Federal Trade Commission (FTC) has primary Accreditation agencies set standards for educa-
jurisdiction over most types of advertising. It administers tion and quality of care. Those serving schools for the
a powerful law and has been enforcing it vigorously dur- science-based professions generally to do an excellent
ing the past decade. But, like the FDA, it can only act job but have failed to protect students from an invasion
against a small percentage of the problems it encounters. of "complementary and alternative medicine" teachings.
State attorneys general enforce several types of The agencies that oversee chiropractic, naturopathy,
consumer-protection laws. In most states, however, few acupuncture, and massage therapy schools make little or
health-related cases are pursued. no effort to prevent unscientific teachings (see Chapters
State laws for licensing health professionals set 8 and 9).Accreditation of hospitals, nursing homes, and
minimum requirements for training and knowledge but other health-care facilities generally increases the quality
do not specify that practices must be science-based. of their care, but it also adds to the cost of administering
Even physicians and dentists are not required by law to that care.
practice according to scientific principles, although they Hospitals oversee the activities of their staffs (see
generally do so. The quality of state regulation varies Chapter 22). Those that do so effectively provide a
from state to state and from board to board. Many licens- very valuable consumer-protection service to their
ing boards lack the resources to investigate all of the communities.
complaints they receive. Those that oversee chiroprac- Insurance companies and other third-party pay-
tors, naturopaths, acupuncturists, and massage therapists ers can refuse to cover services that are excessive or
do very little to protect consumers against unscientific unsubstantiated. However, state legislatures and courts
practices. sometimes force them to pay for inappropriate treatment.
10 Part One Dynamics of the Health Marketplace

Professional societies set standards for their mem- practitioners and the health-food industry want the laws
bers, but they lack the force of law and have little or weakened (see Chapters 8, 11, and 25).
no influence on nonmembers. Some societies can help Table 1-2 summarizes the functions and limitations
consumers settle disputes over billing and ethical issues. of the protective forces just discussed.
Recognized specialty boards set standards (through
examinations) to identify practitioners who have
achieved a high level of professional competence. Some INTELLIGENT CONSUMER BEHAVIOR
"specialty boards" lack professional recognition, and Intelligent health consumers have the following
some are bogus (see Chapter 5). characteristics:
Many health-related agencies and organizations 1. They understand the logic of science and why
issue voluntary guidelines for science-based practices. scientific testing is needed to test and to determine which
The most comprehensive set is maintained by the U.S. theories and practices are valid. Chapter 2 covers this
Preventive Services Task Force. Its reports, as discussed in detail. They also understand and guard against their
in Chapter 5, examine the best current evidence for own vulnerabilities and cognitive biases (see Personal
benefits and harms of various screening tests and preven- Glimpse Box on page 12).
tive measures and make recommendations based on the 2. They seek reliable sources of information. They
benefit/harm ratio. are appropriately skeptical about advertising claims,
Voluntary and consumer groups serve as watchdogs, statements made by talk-show guests, and "break-
information sources, and legislative advocates. Some throughs" reported in the news media. New information,
deal with many health-related issues; others deal with even when accurate, may be difficult to place in perspec-
few. Some advocate strengthening consumer-protection tive without expert guidance. Most physicians, dentists,
laws. Groups that represent the interests of "alternative" allied health professionals, health educators, government

It's Your Decision

Cognitive Bias

Cognitive bias is a general term for distortions of thinking INGROUP BIAS: the tendency for people to give preferential
that are difficult to eliminate and can lead to inaccurate treatment to others they perceive to be members of
judgment and faulty conclusions. Many types of cogni- their own groups .
tive bias influence choices related to health care. Some NEGATIVITY BIAS: the tendency to pay more attention and
common ones are listed below. How vulnerable do you give more weight to negative than positive experiences
think you are to each type? or other kinds of information.
NEGLECT OF PROBABILITY: the tendency to completely
AVAILABILITY CASCADE: a self-reinforcing process in which disregard probability when making a decision under
a collective belief gains more and more plausibility uncertainty.
through its increasing repetition in public discourse OVERCONFIDENCE EFFECT: excessive confidence in one's own
("repeat something enough and it will become true") . answers to questions.
BANDWAGON EFFECT: the tendency to do (or believe) things ILLUSION OF CONTROL: the tendency to overestimate one's
because many other people do (or believe) the same. degree of influence over external events.
HALO EFFECT: the tendency for a person's positive or PSEUDOCERTAINTY EFFECT: the tendency to make risk-averse
negative traits to "spill over" from one area of their choices if the expected outcome is positive, but make
personality to another in others' perceptions of them. risk-seeking choices to avoid negative outcomes.
We are inclined to accept statements by people we like. REACTANCE: the urge to do the opposite of what someone
ILLUSORY CORRELATION: inaccurately perceiving a relation- wants you to do out of a need to resist a perceived at-
ship between two events, either because of prejudice or tempt to constrain your freedom of choice.
selective processing of information. WISHFUL THINKING: the formation of beliefs and the making
INTERLOPER EFFECT: the tendency to value third-party con- of decisions according to what is pleasing to imagine
sultation as objective, confirming, and without motive. instead of by appeal to evidence or rationality.
MERE EXPOSURE EFFECT: the tendency to express undue lik- ZERO-RISK BIAS: preference for reducing a small risk to zero
ing for things merely because of familiarity with them. over a greater reduction in a larger risk.
 Chapter One Consumer Health Issues 11

Worksheet 1-2
CONSUMER HEALTH PROFILE

This exercise can help you analyze your approach to health information and professional care.
Place an X in the column to the right that best represents your answer.
(VM = very much; M = much; S = some; L = little; N = none.) VM M s L N
Are you sufficiently informed to be able to make sound decisions?
Do you maintain a healthy lifestyle?
From what sources do you seek information when needed?
Professional health organizations/individuals
Health books, magazines, newsletters
Government health agencies
Advertisements, retail salespeople
Newspapers
Radio/television
Laypersons you know
To what extent do you accept statements in news reports at face value?
To what extent do you accept statements in ads at face value?
How well can you identify quacks, quackery, fraudulent schemes, and hucksters?
When selecting health practitioners, to what extent do you:
Talk with or visit before the first regular appointment?
Check/inquire regarding qualifications/credentials?
Ask friend/neighbor about reputation?
Inquire about fees and payment procedures?
Do you undergo appropriate periodic medical examinations?
Do you undergo appropriate periodic dental examinations?
When you have been exposed to a fraudulent practice, quackery, or a substandard
product or service, to what extent do you report your experience?

agencies, professional societies, and health-related vol- 6. When a health problem arises, they take an active
untary organizations are reliable (for more information role in its management. This entails understanding the
see Chapter 2 and the Appendix). nature of the problem and how to do their part in dealing
3. They maintain a healthy lifestyle. This reduces with it. People with chronic illnesses, such as asthma,
the odds of becoming seriously ill and lowers the cost of diabetes, or high blood pressure, should strive to become
health care. Prudent consumers avoid tobacco products, "experts" in their own care and use their physicians as
eat sensibly, exercise appropriately, maintain a reason- "consultants."
able weight, use alcohol moderately or not at all, and 7. They communicate effectively. They present their
take appropriate safety precautions (such as wearing a problems in an organized way, ask appropriate questions,
seat belt when driving). and tactfully assert themselves when necessary.
4. They select practitioners with great care. It has 8. They are wary of treatments that lack scientific
been said that primary-care physicians typically know a support and a plausible rationale. These are discussed
little about a lot and specialists typically know a lot about throughout this book.
a little. The majority of people would do best to begin 9. They are familiar with the economic aspects of
with a generalist and consult a specialist if a problem health care. They obtain appropriate insurance coverage,
needs more complex management. inquire in advance about professional fees , and shop
5. They undergo appropriate screening tests and, comparatively for medications, eyeglasses, and other
when illness strikes, use self-care and professional care products.
as needed. Excellent guidebooks are available to help 10. They report frauds , quackery, and other wrong-
decide when professional care is needed (Chapter 14). doing to appropriate agencies and law enforcement