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Tag: limited evidence

  • Being Alive Is Bad for Your Health

    Being Alive Is Bad for Your Health

    In 2016, I gave up Diet Coke. This was no small adjustment. I was born and raised in suburban Atlanta, home to the Coca-Cola Company’s global headquarters, and I had never lived in a home without Diet Coke stocked in the refrigerator at all times. Every morning in high school, I’d slam one with breakfast, and then I’d make sure to shove some quarters (a simpler time) in my back pocket to use in the school’s vending machines. When I moved into my freshman college dorm, the first thing I did was stock my mini fridge with cans. A few years later, my then-boyfriend swathed two 12-packs in wrapping paper and put them under his Christmas tree. It was a joke, but it wasn’t.

    You’d think quitting would have been agonizing. To my surprise, it was easy. For years, I’d heard anecdotes about people who forsook diet drinks and felt their health improve seemingly overnight—better sleep, better skin, better energy. I’d also heard whispers about the larger suspected dangers of fake sweeteners. Yet I’d loved my DCs too much to be swayed. Then I tried my first can of unsweetened seltzer at a friend’s apartment. After years of turning my nose up at the thought of LaCroix, I realized that much of what I enjoyed about Diet Coke was its frigidity and fizz. That was enough. I switched to seltzer on the spot, prepared to join the smug converted and receive whatever health benefits were sure to accrue to me for my good behavior.

    Except they never came. Seven years later, I feel no better than I ever did drinking four or five cans of the stuff a day. I still stick to seltzer anyway—because, you know, who knows?—and I’ve mostly forgotten that Diet Coke exists. But the diet sodas had not, as it turns out, been preventing me from getting great sleep or calming my rosacea or feeling, I don’t know, zesty. Besides the caffeine, they appeared to make no difference in how good or bad I felt at all.

    Yesterday, Reuters reported that the WHO’s International Agency for Research on Cancer will soon declare aspartame, the sweetener used in Diet Coke and many other no-calorie sodas, as “possibly carcinogenic to humans.” I probably should have felt vindicated. I may not feel better now, but many years down the road (knock on wood), I’ll be better off. I’d bet on the right horse! Instead, I felt nothing so much as irritation. Over the past few decades, a growing number of foods and behaviors have become the regular subject of vague, ever-changing health warnings—fake sweeteners, real sugar, wine, butter, milk (dairy and non), carbohydrates, coffee, fat, chocolate, eggs, meat, veganism, vegetarianism, weightlifting, drinking a lot of water, and scores of others. The more warnings there are, the less actionable any particular one of them feels. What, exactly, is anyone supposed to do with any of this information, except feel bad about the things they enjoy?

    It’s worth reviewing what is actually known or suspected about diet sodas and health. The lion’s share of research on this topic happens in what are known as observational studies—scientists track consumption and record health outcomes, looking for commonalities and trends linking behavior and effects. These studies can’t tell you if the behavior caused the outcome, but they can establish an association that’s worth investigating further. Regular, sustained diet-soda consumption has been linked to weight gain, Type 2 diabetes, and increased risk of stroke, among other things—understandably troublesome correlations for people worried about their health. But there’s a huge complicating factor in understanding what that means: For decades, advertisements recommended that people who were already worried about—or already had—some of those same health concerns substitute diet drinks for those with real sugar, and many such people still make those substitutions in order to adhere to low-carb diets or even out their blood sugar. As a result, little evidence suggests that diet soda is solely responsible for any of those issues—health is a highly complicated, multifactorial phenomenon in almost every aspect—but many experts still recommend limiting your consumption of diet soda as a reasonable precaution.

    A representative for the IARC would neither confirm nor deny the nature of the WHO’s pending announcement on aspartame, which will be released on July 14. For the sake of argument, let’s assume that Reuters’s reporting is correct: In two weeks, the organization will update the sweetener’s designation to indicate that it’s “possibly carcinogenic.” To regular people, those words—especially in the context of a health organization’s public bulletins—would seem to imply significant suspicion of real danger. The evidence may not yet all be in place, but surely there’s enough reason to believe that the threat is real, that there’s cause to spook the general public.

    Except, as my colleague Ed Yong wrote in 2015, when the IARC made a similar announcement about the carcinogenic potential of meat, that’s not what the classification means at all. The IARC chops risk up into four categories: carcinogenic (Group 1), probably carcinogenic (Group 2A), possibly carcinogenic (Group 2B), and unclassified (Group 3). Those categories do one very specific thing: They describe how definitive the agency believes the evidence is for any level of increased risk, even a very tiny one. The category in which aspartame may soon find itself, 2B, makes no grand claims about carcinogenicity. “In practice, 2B becomes a giant dumping ground for all the risk factors that IARC has considered, and could neither confirm nor fully discount as carcinogens. Which is to say: most things,” Yong wrote. “It’s a bloated category, essentially one big epidemiological shruggie.”

    The categories are not at all intended to communicate the degree of the risk involved—just how sure or unsure the organization is that there’s a risk associated with a thing or substance at all. And association can mean a lot of things. Hypothetically, regular consumption of food that may quadruple your risk of a highly deadly cancer would fall in the same category as something that may increase your risk of a cancer with a 95 percent survival rate by just a few percentage points, as long as the IARC felt similarly confident in the evidence for both of those effects.

    These designations about carcinogenicity are just one example of how health information can arrive to the general public in ways that are functionally useless, even if well intentioned. Earlier this year, the WHO advised against all use of artificial sweeteners. At first, that might sound dire. But the actual substance of the warning was about the limited evidence that those sweeteners aid in weight loss, not any new evidence about their unique ability to harm your health in some way. (The warning did nod to the links between long-term use of artificial sweeteners and increased risks of cardiovascular disease, Type 2 diabetes, and premature death, but as the WHO noted at the time, these are understood as murky correlations, not part of an alarming breakthrough discovery.)

    The same release quotes the WHO’s director for nutrition and food safety advising that, for long-term weight control, people need to find ways beyond artificial sweeteners to reduce their consumption of real sugar—in essence, it’s not a health alert about any particular chemical, but about dessert as a concept. How much of any sweetener would you need to cut out of your diet in order to limit any risks it may pose? The release, on its own, doesn’t specify. Consider a birthday crudités platter instead of a cake, just to be sure. (Is that celery non-GMO? Organic? Just checking.)

    The media, surely, deserve our fair share of blame for how quickly and how far these oversimplified ideas spread. Many people are very worried about the food they eat—perhaps because they have received so many conflicting indicators over the years about how that food affects their bodies—and flock to news that something has been deemed beneficial or dangerous. At best, the research that many such stories cite is rarely definitive, and at worst, it’s so poorly designed or otherwise flawed that it’s flatly incapable of producing useful information.

    Taken in aggregate, this morass of poor communication and confusing information has the very real potential to exhaust people’s ability to identify and respond to actual risk, or to confuse them into nihilism. The solution-free finger-wagging, so often about the exact things that many people experience as the little joys in everyday life, doesn’t help. When everything is an ambiguously urgent health risk, it very quickly begins to feel like nothing is. I still drink a few Diet Cokes a year, and I maintain that there’s no better beverage to pair with pizza. We’re all going to die someday.

    Amanda Mull

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  • The Future of Monkeypox

    The Future of Monkeypox

    The World Health Organization has recommended a new name for monkeypox, asking countries to forget the original term in favor of a new one, “mpox,” that scientists hope will help destigmatize the disease. But in the United States, the request seems to be arriving late. The outbreak here has already been in slow retreat for months—and has already left many Americans’ minds.

    About 15 cases are now being recorded among Americans each day, less than 4 percent of the tally when the surge was at its worst. After a sluggish and bungled early rollout, tests and treatments for the virus are more available; more than a million doses of the two-shot Jynneos smallpox vaccine have found their way into arms. San Francisco and New York—two of the nation’s first cities to declare mpox a public-health emergency this past summer—have since allowed those orders to expire; so have the states of New York and Illinois. “I think this is the endgame,” says Caitlin Rivers, an infectious-disease epidemiologist at the Johns Hopkins Center for Health Security.

    But “endgame” doesn’t mean “over”—and mpox will be with us for the foreseeable future. The U.S. outbreak is only now showing us its long and ugly tail: 15 daily cases is not zero daily cases; even as the number of new infections declines, inequities are growing. Black and Latino people make up a majority of new mpox cases and are contracting the disease at three to five times the rate of white Americans, but they have received proportionately fewer vaccines. “Now it’s truly the folks who are the most marginalized that we’re seeing,” says Ofole Mgbako, a physician and population-health researcher at New York University. “Which is also why, of course, it’s fallen out of the news.” If the virus sticks around (as it very likely could), and if the disparities persist (as they almost certainly will), then mpox could end up saddling thousands of vulnerable Americans each year with yet another debilitating, stigmatized, and neglected disease.

    Read: America should have been able to handle monkeypox

    At this point, there’s not even any guarantee that this case downturn will persist. “I’m not convinced that we’re out of the woods,” says Sara Bares, an infectious-disease physician at the University of Nebraska Medical Center, in Omaha. Immunity, acquired through infection or vaccines, is now concentrated among those at highest risk, says Jay Varma, a physician and epidemiologist at Weill Cornell Medicine. But researchers still don’t know how well those defenses can stave off another infection, or how long they might last—gaps in knowledge that may be tough to fill, now that incidence is so low. And although months of advocacy and outreach from the LGBTQ community have cut down on risky sexual activities, many cautionary trends will eventually reset to their pre-outbreak norm. “We know extensively from other sexually transmissible infections that behavior change is not usually the most sustained response,” says Boghuma Kabisen Titanji, an infectious-disease physician at Emory University.

    At the same time, this year’s mpox outbreaks are stranger and more unwieldy than those that came before. A ballooning body of evidence suggests that people can become infectious before they develop symptoms, contrary to prior understanding; some physicians are concerned that patients, especially those who are immunocompromised, might remain infectious after the brunt of visible illness resolves, says Philip Ponce, an infectious-disease physician at the University of Texas Health Science Center at San Antonio and the medical director of San Antonio’s Kind Clinic. (Some 40 percent of Americans who have been diagnosed with mpox are living with HIV.) Researchers still don’t have a good grip on which bodily fluids and types of contact may be riskiest over the trajectory of a sickness. Cases are still being missed by primary-care providers who remain unfamiliar with the ins and outs of diagnosis and testing, especially in people with darker skin. And although this epidemic has, for the most part, continued to affect men who have sex with men, women and nonbinary people are getting sick as well, to an underappreciated degree.

    Read: What should worry most Americans about our monkeypox response

    Intel on the only mpox-fighting antiviral on the shelf, a smallpox drug called tecovirimat, also remains concerningly scant, even as experts worry that the virus could develop resistance. The treatment has been given a conditional greenlight for use in people who are currently, or at risk of becoming, severely sick. Anecdotally, it seems to work wonders, shaving days or weeks off the painful, debilitating course of symptoms that can send infected people into long-term isolation. But experts still lack rigorous data in humans to confirm just how well it works, Bares, who’s among the scientists involved in a nationwide study of the antiviral, told me. And although clinical trials for tecovirimat are under way, she added, in the U.S., they’re “struggling to enroll patients” now that infections have plummeted to such a sustained low. It’s a numerical problem as well as a sociocultural one. “The urgency with which people answer questions declines as case counts go down,” Varma told me.

    Recent CDC reports show that a growing proportion of new infections aren’t being reported with a known sexual-contact history, stymieing efforts at contact tracing. That might in part be a product of the outbreak’s gradual migration from liberal, well-off urban centers, hit early on in the epidemic, to more communities in the South and Southwest. “In small towns, the risk of disclosure is high,” Bares told me. In seeking care or vaccination, “you’re outing yourself.” When mpox cases in Nebraska took an unexpected nosedive earlier this fall, “a colleague and I asked one another, ‘Do you think patients are afraid to come in?’” Those concerns can be especially high in certain communities of color, Ponce told me. San Antonio’s Latino population, for instance, “tends to be much more conservative; there’s much more stigma associated with one being LGBT at all, let alone being LGBT and trying to access biomedical interventions.”

    Hidden infections can become fast-spreading ones. Monitoring an infectious disease is far easier when the people most at risk have insurance coverage and access to savvy clinicians, and when they are inclined to trust public-health institutions. “That’s predominantly white people,” says Ace Robinson, the CEO of the Pierce County AIDS Foundation, in Washington. Now that the mpox outbreak is moving out of that population into less privileged ones, Robinson fears “a massive undercount” of cases.

    Americans who are catching the virus during the outbreak’s denouement are paying a price. The means to fight mpox are likely to dwindle, even as the virus entrenches itself in the population most in need of those tools. One concern remains the country’s vaccination strategy, which underwent a mid-outbreak shift: To address limited shot supply, the FDA authorized a new dosing method with limited evidence behind it—a decision that primarily affected people near the back of the inoculation line. The method is safe but tricky to administer, and it can have tough side effects: Some of Titanji’s patients have experienced swelling near their injection site that lasted for weeks after their first dose, and now “they just don’t want to get another shot.”

    The continued shift of mpox into minority populations, Robinson told me, is also further sapping public attention: “As long as this is centered in BIPOC communities, there’s going to be less of a push.” Public interest in this crisis was modest even at its highest point, says Steven Klemow, an infectious-disease physician at Methodist Dallas Medical Center and the medical director of Dallas’s Kind Clinic. Now experts are watching that cycle of neglect reinforce itself as the outbreak continues to affect and compress into marginalized communities, including those that have for decades borne a disproportionate share of the burden of sexually associated infections such as syphilis, gonorrhea, and HIV. “These are not the groups that necessarily get people jumping on their feet,” Titanji told me.

    Some of the people most at risk are moving on as well, Robinson told me. In his community in Washington, he was disappointed to see high rates of vaccine refusal at two recent outreach events serving the region’s Black and American Indian populations. “They had no knowledge of the virus,” he told me. Titanji has seen similar trends in her community in Georgia. “There’s some sense of complacency, like, ‘It’s no longer an issue, so why do I need to get vaccinated?’” she said.

    Read: America is zooming through the pandemic panic-neglect cycle

    The tide seems unlikely to shift. Even tens of thousands of cases deep into the American outbreak, sexual-health clinics—which have been on the front lines of the mpox response—remain short on funds and staff. Although the influx of cases has slowed, Ponce and Klemow are still treating multiple mpox patients a week while trying to keep up the services they typically offer—at a time when STI rates are on a years-long rise. “We’re really assuming that this is going to become another sexually associated disease that is going to be a part of our wheelhouse that we’ll have to manage for the indefinite future,” Klemow told me. “We’ve had to pull resources away from our other services that we provide.” The problem could yet worsen if the national emergency declared in August is allowed to expire, which would likely curb the availability of antivirals and vaccines.

    Rivers still holds out hope for eliminating mpox in the U.S. But getting from low to zero isn’t as easy as it might seem. This current stretch of decline could unspool for years, even decades, especially if the virus finds a new animal host. “We’ve seen this story play out so many times before,” Varma told me. Efforts to eliminate syphilis from the U.S. in the late ’90s and early 2000s, for instance, gained traction for a while—then petered out during what could have been their final stretch. It’s the classic boom-bust cycle to which the country is so prone: As case rates fall, so does interest in pushing them further down.

    Our memories of public-health crises never seem to linger for long. At the start of this mpox outbreak, Titanji told me, there was an opportunity to shore up our systems and buffer ourselves against future epidemics, both imported and homegrown. The country squandered it and failed to send aid abroad. If another surge of mpox cases arrives, as it very likely could, she said, “we will again be going back to the drawing board.”

    Katherine J. Wu

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