The nation was stunned on Monday when the World Health Organization announced that hot dogs are not healthy…said no one, ever. We all knew—or at least had a sneaking suspicion—that those little tubes of mushy meat product were a questionable dietary choice at best. But if I’m completely honest with myself, sometimes they just hit the spot. And sometimes they’re the only thing those little maniacs that terrorize my husband and me on a daily basis (a.k.a. our offspring) will eat. You know I’m right.

So why the uproar? Is it because the WHO report used the “c-word?” Or because they compared processed meats to cigarettes? Or perhaps because they told us eating processed meats increased your risk of cancer by a whopping 18%? Probably all of the above, plus the fact that it got so much press (thanks, Mark Zuckerberg). Imagine if a report came out tomorrow about smoking. It would be loaded with terrifying (and real) statistics like “smoking increases your risk of lung cancer 25-fold” and “smoking causes 90% of all lung cancers.” It would, rightfully so, get a lot of attention.

I have compiled a list of Frequently Asked Questions about the report and shared it below. For educational purposes, the WHO definition of processed meat is “meat that has been transformed through salting, curing, fermentation, smoking, or other processed to enhance flavor or improve preservation.” Okay, now we know. Moving on.

1. Does the study apply to me? Probably, but maybe not. As a physician, you want a research study to use a population of patients that is similar to the one you treat. Otherwise, it’s less helpful (and, at times, completely useless). The WHO combed through over 800 epidemiological studies, which were done in multiple countries spanning several continents. Many ethnicities and diets were included in the mix. That’s good, right? Well, yes. It means that the information is probably generalizable for a lot of people. It also means they compiled data from many different studies to include lots and lots of people, which typically strengthens research. But it can also potentially water down the data. Let me show you what I mean:

-Situation 1: In a Pennsylvania town, which is predominantly Amish, almost everyone consumes only food that can be produced within the community without using modern conveniences. However, a small portion of the population eats 50 grams of processed meat daily. The difference in health between the Amish folk and the processed meat lovers will likely be drastically different for reasons other than the differences in processed meat consumption.

-Situation 2: In a poor Southern town, the population tends to eat more affordable foods which tend to be less healthy overall. In this group, the difference in health between someone who eats 50 grams of processed meat and someone who does not will probably not be very different.

Now, average the two studies. See what I mean? This is an extreme example, but it illustrates what the WHO scientists did in their analysis. Which is fine, because they’re the World Health Organization. But when you try to apply their research to a specific population (i.e. Americans), just be careful that you don’t under- or overestimate the impact of the thing being studied. My point is this: We are in America. Americans tend to have a Western diet which can differ drastically from the diets followed in other countries.

2. Have I already screwed the pooch and given my child cancer because of that week he ate only hot dogs for every meal? No.

3. An 18% increased risk of cancer sounds like a lot. What does that really mean? You’re right, it does sound like a lot. But it’s all relative. If your lifetime risk for developing colorectal cancer is 80%, then an 18% increase brings your risk up to a whopping 94.4%! Ain’t nobody got time for that. Likewise, if your risk is 0.5% (hardly worth worrying about), then an 18% increase brings that up to 0.59% (still hardly worth worrying about). Something else will most likely kill you. In reality, the average lifetime risk of developing colorectal cancer is 1 in 20, or 5%. So, a daily diet rich in processed meats would be associated in a nearly 1% increase in colorectal cancer.

Just being human puts you at 5%. Adding processed meats adds another 0.9%.

4. But seriously, though. Cancer is no joke. That’s not a question, but whatever. I get your point. And I agree with you that cancer is no joke. But here are some things to consider:

-Colorectal cancer is a cancer that can be screened for. This means that more cancers are found at early (i.e. treatable and even potentially curable) stages. This is one of many reasons it’s different from a cancer like lung cancer (see below for others).

-Speaking of colorectal cancer screening, it is estimated that if everyone received screening for colorectal cancer according to the guidelines, it would result in a 40% decrease in cancer. That’s because colonoscopies not only allow us to take a look at the colon to see if there are any cancers there to be treated, it also allows us to remove precancerous lesions before they ever cause problems to begin with.

An ideal screening test is applicable to most of the population, screens for a relatively common disease, and changes outcome by diagnosing disease at an earlier stage or preventing the disease altogether.

But anyway, back to my original point: Colorectal cancer screening can reduce your risk from 5% to 3%. That’s a 2% absolute risk reduction. More than two times the increased risk attributed to processed meats.

5. Is eating processed meats the same as smoking a cigarette? The WHO compared the two because they both result in exposure to carcinogens that have been linked to cancer and they both have shown to be associated with an increased risk of cancer in epidemiologic studies. But I want to give you some perspective. The WHO scientists attributed an 18% increase in colorectal cancers to eating 50 grams of processed meats daily. Cigarette smoking results in a 15-30 fold increased risk of lung cancer (the wide range has to do with amount of exposure, both in years and packs per day). Said another way, that’s a 1,500-3,000% increase. Wow. Even the low end of that range is something I want nothing to do with.

And here’s one more little statistic nugget for you: the IARC says there were 34,000 deaths attributable to processed meats in 2012, and 8.2 million cancer deaths total. Feel free to check my math, but, by my calculations, that works out to 0.4% of all cancer deaths (not all deaths) caused by excessive processed meat consumption. On the other hand, smoking is blamed for about 30% of all cancer deaths. So yeah, that’s 2.5 million.

Bottom line, everything can be bad for you if taken in a high enough quantity. Literally everything. Illicit drugs? Of course. Medications? Certainly. Foods high in fat/carbs/etc? Uh-huh. Water? Yes, even water. Processed foods lie somewhere on that spectrum, closer to the other harmful foods than either illicit drugs or water.

Did I write this piece to make light of cancer or to give blanket permission to eat whatever you want “all day err day?” Of course not. But I give each and every one of the [five] people reading this article permission to not be perfect 100% of the time. And if you are in fact reading this, you probably already think about what you put in your body day in and day out, and you probably don’t eat 50 grams of processed meats a day. If you do…stop it! It’s bad for many reasons, not just for increasing your cancer risk. But if you have the occasional hot dog, don’t kill yourself over it. The most successful dieters are the ones for whom nothing is completely off limits.

Processed meats are just one of many things in this world that contributes to your daily risk of dying. Here are some others: Car crash, plane crash, train crash, bus crash, bike crash, stabbing,… okay, the internet is telling me I’m running out of space, so I’d better wrap it up.

In conclusion, there’s enough badness out there to keep you worrying 24/7. Just try to do your best, make good decisions most of the time, and enjoy living.

That is all.

I referred to the following when writing this:

“Cancer Facts & Figures 2014”

Cancer.org

“Carcinogenicity of consumption of red and processed meat.” Véronique Bouvard, Dana Loomis, Kathryn Z Guyton, Yann Grosse, Fatiha El Ghissassi, Lamia Benbrahim-Tallaa, Neela Guha, Heidi Mattock, Kurt Straif on behalf of the International Agency for Research on Cancer Monograph Working Group. Published Online: 26 October 2015

CDC.gov

International Agency for Research on Cancer

“Long-term colorectal-cancer incidence and mortality after lower endoscopy.” Reiko Nishihara, Kana Wu, Paul Lochhead, Teppei Morikawa, Xiaoyun Liao, Zhi Rong Qian, Kentaro Inamura, Sun A. Kim, Aya Kuchiba, Mai Yamauchi, Yu Imamura, Walter C. Willett, Bernard A. Rosner, Charles S. Fuchs, Edward Giovannucci, Shuji Ogino, Andrew T. Chan, New England Journal of Medicine, September 19, 2013, 369:1095-1105

My brain

WHO: Processed meat cancer report message ‘misinterpreted.’ The Irish Times. Friday, October 30, 2015.

    

1. Haters Gonna Hate. And Post. A Lot. You can find anything on the internet. Anything. If you want someone to validate your distaste for cute, cuddly, perfect Cocker Spaniel puppies, just Google it. You’ll probably find an article called “20 Things I Hate About Cute, Cuddly, Perfect Cocker Spaniel Puppies” in about 2.2 seconds. It will be full of compelling reasons to hate puppies and, if you weren’t a puppy hater before, by the end of the article you’ll certainly be considering it. It’s easy to find both sides of any argument on the internet. And it’s even easier to share said argument with 500 of your closest friends. Most of the time, the articles are well written and authoritative. Most of the time, they are nothing more than opinion pieces written by someone who lacks the credentials to have an actual opinion. (Case in point: former Playboy model Jenny McCarthy. Yes, I went there.) Harsh, I know, but true. Admit it.

2. Haters Wanna Benefit from Everyone Else. Haters be like “I got Herd Immunity.” Aww, nah. Herd immunity is like that lane on the interstate that’s closed 500 feet ahead. There’s always that one guy who drives up the lane and cuts in at the last second, causing all the cars behind him to have to slow down. Dude. It’s 7:50 on Monday morning. Everyone is running late. You are no more important than anyone else on the road right now. Notable exceptions are as follows (in no particular order):

1. The pregnant woman in active labor, extra points if the baby is crowning. Negative points if the woman is driving herself—that’s just all kinds of dangerous.

2. Any emergency vehicles (this is an obvious one), especially if they are going to fix the problem that got the lane closed to begin with.

3. The unfortunate sufferer of food poisoning, viral gastroenteritis, or even an especially bad flare-up of IBS.

4. The person who will suffer serious consequences if they are late. This category is on the honor system. You usually know deep down if your situation justifies trumping everyone else on the road. Examples include those going to a job interview, an important meeting, his or her own wedding (e.g. the bride or groom – everyone else in the wedding party is going to have to roll in late).

But I digress. Herd immunity, where enough people are immune that an outbreak doesn’t occur in the first place, is to be enjoyed only by those who can’t safely get vaccines. I’m talking about the immune-compromised, the very young, the seriously allergic, the pregnant (in some cases, not all). Otherwise, it just doesn’t work. The goal vaccination rate for the total population is 90-95% for herd immunity to work. We got a first-hand look at this breakdown in herd immunity with the 2015 outbreak of measles beginning in California. It can be quite scary for those of us with children too young to be vaccinated.

3. Haters Don’t Really Get It. They be like “Vaccines are bad for you.” This is actually a three part argument.

3a. Haters say vaccines give you the infection you’re trying to avoid. We’ve all heard some iteration of the following: “I never got the flu until the one year I actually got the flu vaccine.” Seems like a compelling argument. Either the vaccine gave your friend the flu or, at the very least, it didn’t protect him against it. Here is an example of similar logic: I got in a car accident while wearing my seatbelt and suffered an injury. Oh man, must have been because you had the seatbelt on. Or at the very least, the seatbelt didn’t protect you. Or what if the seatbelt actually caused the accident?

Everyone reading this can appreciate the flawed logic in the above statement. There is no cause and effect. Just coincidence and perhaps some unrealistic expectations. And while the seatbelt may not have kept you from getting injured, it may have just saved your life. The flu vaccine often keeps one from contracting the flu in the first place, but it also lessens the severity of the illness in those who get infected despite receiving the vaccine. In the case of the flu, this protection is often as important as the prevention aspect. Some years, despite their best efforts, the vaccine developers don’t get the match quite right because of mutations that occur after the strains are chosen for the vaccine.

And as for whether the flu shot causes the flu, it doesn’t. It just doesn’t. While the intranasal form of the vaccine has a theoretical risk of causing a flu infection (because it is an altered form of the live virus and therefore has the afore-mentioned propensity for mutation), the injection is a dead virus. And viruses are not zombies. They do not come back alive for one last hurrah terrorizing humans.

There are over 300 million people in this country. Everyone has heard a story from someone about the flu shot “making them sick,” but in the end it’s all about odds. They were going to get sick, anyway. It’s just coincidence. And if it was at least two weeks after the shot, then they can be grateful because it could have been a lot worse.

3b. They say vaccines cause autism: This is the argument that’s gotten the most press recently. Autism rates have increased at alarming rates over the past two decades. Over the same time period, the number of recommended vaccines has increased. Again, correlation does not prove causation. A lot has changed in that time frame. One notable change was in the criteria used to diagnose autism. Another was in provider awareness of the disorder. These two things don’t actually change the prevalence of a disease, they just change the perceived prevalence.

A now infamous study by Andrew Wakefield claimed to show a connection between vaccines (specifically, the MMR vaccine) and autism. Usually, doctors evaluate the quality of a study based on its ability to prove its hypothesis by how well it was designed: were there enough patients? Was it randomized? Was all potential bias removed? You get the point.

However, this study failed on several more serious counts. The study authors began the study in an attempt to provide a basis for a lawsuit to win money. That’s just a bad start. Then, patients were recruited by an anti-vaccine group. This is an example of selection bias. Then, medical records were intentionally falsified. Wait, isn’t that?…Why yes. Yes it is quite illegal. It’s called fraud. And that’s why the article was retracted by the original journal in which it was published.

But people still want to trust lying, cheating Andrew Wakefield over the doctor they have chosen to care for their child in all other aspects. The doctor who has taken a Hippocratic Oath to “first, do no harm.” The doctor who, dollars to donuts, has vaccinated the crap out of his or her own children. Yes, there are bad people in medicine. Just like there are bad people in every profession. But the law of probabilities would argue that we can’t all be bad. If it’s true that the entire medical community can’t be trusted, then society has much bigger problems than anyone realized.

As a side note, the preservative thimerosal has also received a bad rap lately because it contains mercury in very small amounts. Again, there has been no literature to prove a negative effect of this, but as a precautionary measure, the AAP/USPHS recommended removing thimerosal from several vaccines to reduce the cumulative exposure over time. So to recap, the regulatory boards recognized a potential health risk, albeit one that had not been proven, and decided to err on the side of caution and eliminate the possibility of this preventable risk.

3c. Haters say vaccines overwhelm the immune system: Some worry that children are exposed to too many antigens at once, that it weakens the immune system or causes it to be oversensitive and lead to illnesses such as autoimmune conditions or asthma. Again, there is just no evidence to support this.

Anyone who knows me knows I am a huge proponent of letting my children eat dirt, lick the floor, etc. I wholeheartedly believe we shouldn’t follow our children around, sterilizing each surface they come into contact with. There is a benefit to challenging their little immune systems so they aren’t completely taken off guard when they finally come into contact with a more dangerous bacteria or virus.

But a vaccine is a challenge to the immune system in the purest sense. It simulates a “first” infection so that it will then respond much more quickly if exposed a “second” time. Scientists figured out this is the way immunity works and used it to our advantage. Science is awesome that way.

And while I do believe in encouraging natural exposure to infections at an early age, if given the opportunity to test this theory with potentially fatal illnesses in my children, my answer will always be, “Thanks, but no thanks.” I’ve seen enough to know better. In my opinion, that would be akin to letting child jump off a 100 foot bridge to teach him not to jump off 100 foot bridges in the future.

If you’re still not convinced, I’ll share this interesting fact: with ongoing vaccine development, the number of antigens children are exposed to today is about 10% of what it was in 1980.

4. Haters haven’t learned from the past. They think vaccines are irrelevant. Who’s scared of polio, anyway? Do you even know anyone who has polio? Exactly. But let me assure you, people used to be plenty scared of polio. And the measles, mumps, rubella…I could go on, but in the interest of time I won’t. Everyone has a grandparent or great-grandparent who had a sibling or child die when he or she was a child. The cause of death for most of these children, if it didn’t occur during childbirth, was usually some sort of infection. In fact, the leading causes of child mortality in 1900 were infectious diseases—a whopping 61.6%. In 1998, death attributable to infectious disease was only 2%. During that same time period, the absolute death rate plummeted from >3% to <0.2%, reflecting an even greater absolute (total) reduction in infectious diseases. While this decline reflects many changes during that time period including improved antiseptic techniques, antibiotic development and cleaner living conditions, vaccines played a major role in this shift.

And, lest we forget that not all vaccine-preventable infections end in death, other potential consequences include but are not limited to hearing loss, increased susceptibility to other infections, encephalitis, pneumonia, ear infections, bronchitis, dehydration, vomiting, difficulty breathing…it’s a little reminiscent of the disclaimer at the end of a Viagra commercial, isn’t it?

5. Haters say doctors just want to give a bunch of medications.

Vaccines are actually a prime example of preventative medicine. Yes, they come in a vial. But when used correctly, they significantly lower the need for hospitalizations, antibiotics, and other therapies. Like a healthy diet and lifestyle, in an ideal world, vaccines should lead to fewer doctor visits and interventions.

In conclusion, medicine is not black and white, as much as we would often like it to be. There are times when we have to choose the best for our patients based on a risk-benefit analysis. And based on the information available, the benefits of getting vaccinated far, far outweigh the risks. And so we will carry on, spending extra time educating our patients, cringing when we hear of the next outbreak that could have been prevented, and praying for the children and the parents of the children who fall ill or even die from a preventable illness.

Disclaimer: The opinions expressed in this blog post are not meant to offend, but to reinforce proven information in an entertaining way. The facts presented in this blog post are facts.

The following resources were referred to during the preparation of this post:

CDC.gov

Deer B. How the case against the MMR vaccine was fixed. BMJ 2011; 342:c5347. (An interesting article by the investigative reporter who uncovered Andrew Wakefield, et al., had committed fraud.)

DeStefano F, Price CS, Weintraub ES. Increasing exposure to antibody-stimulating proteins and polysaccharides in vaccines is not associated with risk of autism. J Pediatr 2013; 163:561.

Guyer B, Freedman MA, Strobino DM, Sondik EJ. Annual summary of vital statistics: trends in the health of Americans during the 20^th century. Pediatrics. 2000 Dec; 106(6): 1307-17.

Iqbal S, Barile JP, Thompson WW, DeStefano F. Number of antigens in early childhood vaccines and neuropsychological outcomes at age 7-10 years. Pharmacoepidemiol Drug Saf 2013; 22:1263.

Lieberman JM. Myths regarding immunization. In: An Ounce of Prevention: Communicating the Benefits and Risks of Vaccines to Parents. Infectious Diseases in Children. Slack Incorporated, Thorofare, NJ 2003. P.6.

Lyren A, Leonard E. Vaccine refusal: issues for the primary care physician. Clin Pediatr (Phila) 2006; 45:399.

Offit PA, Quarles J, Gerber MA, et al. Addressing parents’ concerns: do multiple vaccines overwhelm or weaken the infant’s immune system? Pediatrics 2002; 109:124.

Vaccines.gov

Wakefield AJ, Murch SH, Anthony A, et al. Ileal-lymphoid-nodular hyperplasia, non-specific colitis, and pervasive developmental disorder in children. Lancet 1998; 351:637. (The original article “linking” vaccines and autism which was later retracted.)

*There have been many large studies and reviews showing no link between the MMR vaccine and autism, too many to list here. If you are interested, please contact me for a comprehensive list.