Rachel’s Musings

As I have mentioned before, I have hypothyroidism caused by Hashimoto’s Disease. A couple of weeks ago, I finally realized that my lack of energy might have something to do with my thyroid. I had two normal TSH tests earlier this year, so it took me a bit to make that linkage. My TSH levels had increased more than 7-fold. I am now on a higher dosage but am wondering what created that increase in TSH values less than 4 months after a completely normal test. Plus my symptoms are pretty persistent.

One of the things that I keep reading is that the generic drugs aren’t as good as the name brands. That sounds very fishy to me since that’s not the case with any other drug but I figured it’s worth investigating. It looks like there’s indeed something fishy going on there: Research comparing the most popular brand-name drug with another brand-name and two generics was suppressed. The researchers found:

For all nine comparisons, there was no statistically significant difference between the four formulations, indicating that they were bioequivalent, even using a criterion for bioequivalence considerably more stringent than that employed by the FDA for other compounds. The authors concluded that the four generic and brand levothyroxine preparations studied were bioquivalent and interchangeable for most patients taking levothyroxine hormone.

The authors were forced to withdraw the article one day before the JAMA issues was supposed to go to print. Instead the opposite of their findings were published in a little known journal claiming that the brand-name was superior. Although it looks like it was published a year after these issues were raised. Note the small sample size of 22 patients, though. (Also read Public Citizens statement on the efforts of the brand-name manufacturer to keep control of the market).

While trying to find answers and a more reliable treatment, it’s almost inevitable that I come across websites peddling Armour Thyroid, a supposedly natural desiccated thyroid alternative to the synthetic medications that are prescribed. Public Citizen dared to advice against Armour Thyroid. The author of the article, self-proclaimed patient advocate Mary Shomon, then goes on to commit just about every logical fallacy there is while attempting to defend Armour Thyroid. She takes issue with Public Citizen’s reliance on the American Thyroid Association’s statement and then suggests rewriting it as: “There is no evidence in the form of published, peer-reviewed, double-blind studies that desiccated thyroid, a biological preparation, has any advantage over synthetic thyroxine.” Well, that would mean that there is no scientific evidence for desiccated thyroid. Anecdotal evidence doesn’t count, sorry Mary.

Most of Shomon’s arguments take the form of “there’s something wrong with the synthetic thyroid medicine, therefore the desiccated thyroid must be good.” Uhm, no. It could mean that both are bad. It definitely means that we need more research, some of which was suppressed as Shomon pointed out (though, unlike what she’s implying that research did not include desiccated thyroid; plus, as I pointed out above the JAMA did publish the article in 1997, six years before Shomon’s post). And one of her main arguments, that Synthroid isn’t properly FDA approved, was true until 2006: “Synthroid did not have FDA approval, but now all L-thyroxine preparations have FDA approval.” Shomon couldn’t have know that, of course, when she wrote the article in 2003…

Shomon also points to a study that found that “among patients taking thyroid medication, only 60% were within the normal range of TSH.” She writes that this fact “indicates that either vast numbers of doctors do not know how to properly prescribe levothyroxine, or it may not be as effective as its manufacturers and supporters claim.” First, again, that doesn’t mean that the “natural” alternative is any better because they, too, might be exaggerating their claims. And I would not be as quick to dismiss the improper prescription levels by doctors. Both hypothesis seem plausible to me. Though I’d start with checking on the skill of prescribing the right level of hormone replacement, especially given that many doctors are still using an outdated TSH range.

Why does Shomon think Armour Thyroid is still being used? The first reason is price. What a sorry reason! Homeopathic remedies are also pretty cheap but are worthless. Price does not say anything about the quality of something. The second reason is price again, this time hidden behind the claim that synthetic thyroid medication manufacturers are gouging consumers. But again something bad about another thing doesn’t make the alternative good! Third, T4 replacement might not be enough. There’s a study that shows this based on 33 patients, which is hardly conclusive. The authors of that study conclude:

In patients with hypothyroidism, partial substitution of triiodothyronine [T3] for thyroxine [T4] may improve mood and neuropsychological function; this finding suggests a specific effect of the triiodothyronine normally secreted by the thyroid gland.

This is not an endorsement of Armour Thyroid simply because that contains both T4 (thyroxine) and T3 (triiodothyronine). There might be other, better alternatives. Also, it seems to me that there might be something else going on: T3 is the active form of T4, the body converts T4 to T3. So, maybe there’s something going wrong with that conversion process that could be treated directly. In their subscription-only article on Armour Thyroid, Public Citizen points out that “Three randomized controlled studies published in late 2003 failed to confirm any benefit of combined T4 and T3 treatment compared to T4 given alone” (one on 46 patients, two on 40 patients, and three on 110 patients).

Why does Public Citizen think that Armour Thyroid is still in the top 200?

Why, after over 25 years of advice to the contrary, is Armour Thyroid in the top 200 most frequently prescribed drugs in the United States? One explanation appears to be that thyroid replacement therapy with natural thyroid appears to have become a niche market for unscrupulous complementary and alternative medicine (CAM) practitioners, some of whom are licensed MDs. Some of these CAM practitioners are also promoting natural thyroid hormone as a part of their weight loss programs. This is a dangerous practice, but it is not new.

Incidentally, Public Citizen does not advocate Synthroid, which is what Shomon seems to imply to discredit their whole argument against Armour Thyroid. They are advocating using synthetic levothyroxine in generic form.

I do agree with Mary Shomon on one thing:

The best thyroid drug for each patient is the drug that safely and effectively works the best for each patient. To suggest otherwise displays a lack of knowledge about the current state of thyroid treatment, and an utter disregard for the quality of life, future, health – and pocketbooks – of millions of Americans.

Well, it didn’t sound to me, though, that Shomon was objectively evaluating the available options. She was defending Armour Thyroid, not arguing for more nuanced treatment options, except in this last paragraph. What is need, in my opinion, are more independent studies, like the one that was suppressed, which compare the available options and figure out which work best. Clinging to an outdated medication is not the best option. Patient advocates who so blatantly dismiss the scientific method do not help us thyroid patients. They just add to our confusion.

It’s National Singles Week and as promised, I would like to celebrate it by writing up my notes from my interview prep. Beth Hughes, the SF Chronicle reporter, had asked me to talk about overcoming singlism (I know, that’s not really reflected in her article but it was great food for thought!).

Singlism is a term coined by Bella DePaulo to describe discrimination and bias against people who are not married or part of a couple. It comes in an overt form, such as the 1000+ benefits married folks get from the government. Yet, it also has an internalized aspect that is a reflection of the matrimanical myths we are bombarded with on a daily basis.

Overcoming singlism requires at least three elements

1. We need to recognize singlism both in society and in ourselves. A good place to start is DePaulo’s book since it helps clearly define singlism in society. You can also check out DePaulo’s two blogs (here and here) and, of course, I try to point out singlism wherever I see it. There is a growing body of books that can help as well.

2. We need to raise awareness by pointing out singlism wherever and whenever we see it and to counter the marriage myths. For example, I contacted my bank because they suggested security questions that assumed I am married. And I’ve written my fingers sore countering the way-too-insidious myth that married people are happier. Most research that claims to show married folks are more [fill in your favorite claim] than single people fall for the fallacy that correlation means causation. It does not. Otherwise, I could go out and buy an expensive car to get rich… (Hat tip to Kai). We can also counter singlism by presenting ourselves as examples of happily single people (at least most of the time, some dragon taming might be required sometimes .

3. We need to counteract singlism by embracing being single as a completely valid choice and by valuing all our relationships. On a more political level, we need to counteract singlism by demanding that benefits are disentangled from relationship status as Nancy Polikoff, for example, has outlined. We can support the Alternatives to Marriage Project, an advocacy group fighting for just such a separation of rights and status.

       One of my favorite definitions of atheism is that I believe in one less god than believers. Well, we can apply the same thinking to living single: There are billions of potential partners out there. Most coupled people have chosen one of them and thus have not chosen billion others. As a single person, I simply choose one less partner than coupled people… There is absolutely nothing wrong with that, yet, it is somehow not considered a valid choice (most of the time).

Of course, none of this can be done in a vacuum. These elements are interdependent: We cannot counteract without recognizing singlism nor without raising awareness of singlism.

A study published in the September edition of the Journal of Health and Social Behavior is in the news. The researchers, Debra Umberson and Hui Liu, looked at data from the National Health Interview Survey from 1972-2003 to investigate the health of married and non-married people. Michigan State University summarized their findings:      Continue reading this post » » »

The Stanford Prison Experiment (SPE) by Phil Zimbardo has been for me an example of the astonishing things that we humans are capable of. I guess as an example of human gullibility, I had not been skeptical about the experiment, which lacks quite a few scientific markers (aside from its ethical problems). During a talk by Barbara Oakley, she was asked to comment about the SPE because it showed the influence the situation and roles could have on human behavior. She responded that there are quite a few questions about this experiment and pointed us to a summary of the critique at Wikipedia. I finally had a chance to review this and am retiring another holy cow now: the experiment is, well, crap not nearly as thoroughly tested against reality as we are led to believe… (Thanks to a discussion in the comments, I now understand that Zimbardo does deserve credit for pointing to the importance of situational influences. I still think, though, that he, at best, could use SPE for the development of hypotheses, not as support for a theory, as he seems to be doing. I find it mindboggling that someone can become famous with such shoddy research – of course, who am I to criticize the famous Zimbardo. Well, I am a human being with a brain and I occasionally use that to debunk things, mostly for myself, but also for the few people who read my blog).

     Continue reading this post » » »

There are a couple of interesting recent studies that provide updates to the gender and science discussion between Harvard professors Steven Pinker and Elizabeth Spelke both pointing toward Spelke’s side of the argument that most, if not all, of the gender gap can be explained by the influence of social forces rather than by innate differences.

First, there is an interesting post on the Feminist Philosophers’ blog that summarizes a NY Times article on gender discrimination at universities, clearly supporting Spelke’s side by documenting differential treatment of applicants depending on gender. Although Pinker might be correct that there are innate differences, that does not excuse discrimination, though they might provide convenient self-justifications. If anything, the social forces are exaggerating these innate differences rather than compensating for them.

And then, articles here and here summarize a recent study using data collected by PISA, which

suggests that, when it comes to math, we can forget biology, as social equality seems to play a dominant role in test scores.^(source)

The overall result showed the usual pattern: Boys did better than girls in math and girls did better than boys in reading. But there was a catch: that result differed by country making the authors curious if there might be a relationship between the score differential and the status of women. They created a gender equality score and found that countries with very high gender equality do indeed have a much smaller math performance difference. Whereas countries with lower gender equality showed a much larger difference in math performance.

The correlations between gender equality and math scores held up under a statistical test designed to catch spurious associations. The authors even checked out the possibility of genetic effects not linked to the Y chromosome by examining whether genetic similarity between various European populations could account for these differences, but they found that it could not.^(source)

One of Pinker’s central arguments was that the gender gap was primarily prevalent in the extremes of the distribution. So, it is particularly interesting what this study found there:

The researchers also studied the percentage of students of each sex among the top scorers on the test. In the gender-equal countries, girls made up half or more of those who scored in the top one percent.^(source)

The results support Spelke’s argument, although it is interesting to note that Pinker never said that all of the gender gap can be explained by biology. His claim was that “the contribution of biology is greater than zero.” However, it seemed that he was using that to argue away the societal influences. We clearly cannot do that. This latest study shows the influence of gender inequality on girl’s math performance. It does not say that there are no innate differences. It simply highlights that the social forces Spelke pointed to have a dramatic effect. This study might also be the first step to the experiment Spelke suggested at the end of her talk: Remove the gender discrimination and biased treatment and then see what happens to the percentage of women in mathematics and science.

Timothy D. Wilson’s book Strangers To Ourselves provides compelling evidence for an adaptive unconscious, a part of us that evolved to make decisions for us. Wilson’s evidence came mostly from psychological experiments, which did not involve brain scans. There is also evidence from neuroscience for non-conscious decision making. The Wall Street Journal reports on several studies that found evidence in the brain of a decision made before it became conscious.

In one experiment with a small sample, researchers at the Bernstein Center for Computational Neuroscience found

signals [of brain behavior leading up to the moment of conscious decision] that let them know when the students had decided to move 10 seconds or so before the students knew it themselves. About 70% of the time, the researchers could also predict which button the students would push.

Other researchers have shown similar predictive power from observing brain activity right before experiment participants verbalized their decision. They also found that different brain regions are involved during the preparation and the execution of a task. Already in the early 1980s, research was published that indicated that brain activity clearly preceded a conscious activity suggestion that an unconscious decision had been made before it became conscious.

Robert Lee Hotz, the WSJ science journalist, summarizes the implications of this research:

Such experiments suggest that our best reasons for some choices we make are understood only by our cells. The findings lend credence to researchers who argue that many important decisions may be best made by going with our gut — not by thinking about them too much.

Wilson, for example, talks about letting the adaptive unconscious make decisions for us (p. 172):

The point is that we should not analyze the information in an overly deliberate, conscious manner, constantly making explicit lists of pluses and minuses. We should let our adaptive unconscious do the job of forming reliable feelings and then trust those feelings, even if we cannot explain them entirely.

Interestingly, the neuroscientists maintain that this does not preclude free will. Somehow because we’re studying how we think gives us free will. Hotz puts it this way:

All this work to deconstruct the mental machinery of choice may be the best evidence of conscious free will. By measuring the brain’s physical processes, the mind seeks to know itself through its reflection in the mirror of science.

“We are trying to understand who we are,” said Antonio Damasio, director of the Brain and Creativity Institute at the University of Southern California, “by studying the organ that allows you to understand who you are.”

Daniel Dennett would agree with this assessment:

People have this strange antipathy for evolution and for materialism. They think that if evolution is true, then they’re just animals or automatons — that they won’t have freedom and they won’t have responsibility, and life will have no meaning. [...] On the contrary, it’s only when you understand life from an evolutionary point of view that you understand what our freedom really is. You realize that it’s real. It’s different and better than the freedom of other animals, but it’s evolved. It’s not supernatural.

The role of the adaptive unconscious is to help us make decisions, to sort through the millions of pieces of information we are absorbing constantly. Then we can use our freedom to make better decisions: We can consciously intervene in the unconscious decision process, though sometimes that leads to ineffective decisions, or we can decide to learn to utilize the process better in a manner similar to what Wilson suggested. Either way, we’re free to decide.

(Hat tip to Butterflies and Wheels for the link to the WSJ article).