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James McCormack
@medmyths
Pharmacist/Professor/Medication Mythbuster/Healthy Skeptic at the Fac of Pharm Sci at UBC. Author of The Nutrition Proposition - you can find it on Amazon.
Vancouvertherapeuticseducation.comJoined October 2012

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Totally agree! From my experience across fields, the "smartest people" are sometimes just "the people who fit in the best". But the people who stood out the most to me were the ones motivated by honest curiosity (many of whom weren't "geniuses", they just had the right mindset).
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I'm always impressed my brother gets most of this stuff. And he's not a health professional. I think you 1) just need an inquisitive mind and 2) not really care what the answer is, but care to know the answer. This fundamentally changes the way you look at and report evidence.
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Replying to @medmyths
In a work of fake news and 10 trillion opinions, here's mine: I despair more & more at the inability/refusal of smart people to thoroughly read evidence & respond to it clearly...or to not extrapolate from weak evidence just because the weak extrapolation serves their agenda.
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Fascinating an 1800 word article can contain basically no evidence or put it into any sort of context. It's these sorts of articles that got me to write my book The Nutrition Proposition. I show all the numbers for UPF so you can make up your own mind. nutritionproposition.com
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Fast food fever: how ultra-processed meals are unhealthier than you think theguardian.com/science/2022/o via @guardian & #AndrewAnthony
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I wouldn't look for a guideline as they are typically not that evidence-based. I would go Look for a well-done systematic review like the Cochrane one you tweeted. Supplements not mentioned in my book-most have 0 evidence of benefit-didn't have energy to sort through all that BS.
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Hi James @medmyths , do you have any good evidence-based guidelines for the use of Vit D in pregnancy please? @PharmRJ
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Ever wonder how many new medications are better than what we already have? Check out what Prescrire and the Canadian Patented Medicines Prices Review Board thought. <5% are substantially improved. Are you surprised? It's why I say don't keep up, just use the meds we have better.
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Have you ever wondered if a T2DM guideline could contain ~34 pages, ~19,000 words, ~350 references, 1 table, and 5 figures yet not provide a single numeric representation of the evidence for the key risks/benefits/harms around treatment? Well, here it is.
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IMHO acetaminophen really doesn’t work for much - not OA or back pain - maybe headaches?? And we already have aspirin so no need for ibuprofen. At least that’s what we thought.
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Replying to @adamcifu @medmyths and @Sensible__Med
What about acetaminophen and ibuprofen?
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We certainly debated statins-ended up choosing meds that also dec. symptoms. Given the absolute reduction in mortality with statins even in secondary prevention is only ~2%/5 years it's very unlikely statins are the reason you are alive. Regardless, it is certainly great you are.
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Replying to @adamcifu @medmyths and @Sensible__Med
I doubt I'd be alive to read this if it were not for statins. Well, other drugs too but those don't deserve to be on the list. Take PEG off. Psyllium is a plant, as is senna, so no need for a drug for constipation, per se. It'll free up a spot for something that reduces mortality
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Thanks for all the great comments - but if you want to add medications you have to take some off!!
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A super thought provoking article today by @medmyths What drugs, currently available today, do you think are really the most useful? Give it a read. Share your thoughts. The Top 20 MVPs , by @Sensible__Med sensiblemed.substack.com/p/the-top-20-m
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Cool - really appreciate the response. I submitted feedback on your site earlier today. Sure hope your group considers using absolute numbers to describe the risk instead of (or in addition to) words - our goals should be to clearly inform rather than instil fear. 👍👍😀
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Replying to @medmyths
Thanks for your feedback! We hope you submit it here: bit.ly/3TQoEmH Input like this is helpful. We're also aware some groups have different drinking patterns (e.g., all at once, not spread out over the week). Great discussion
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Good point. The numbers are absolute increases for 1) PREMATURE (before age 75) ALCOHOL ATTRIBUTABLE DEATH and 2) ALCOHOL ATTRIBUTABLE DEATH - at least those are the definitions used in the guideline I've made changes in the figure to reflect this. Thanks👍👍
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Replying to @medmyths and @CCSACanada
I'm still not sure how to clearly interpret the rates given for "premature death" and "death" tbh. Are these the increases from the expected death rate? Absolute increase, or relative? Way more readable though.
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The CCSA just published a “Low-risk alcohol drinking guideline” and have requested public consultation. Their 1-page public summary does not IMHO do a great job of representing the risk. The images list my issues and my draft attempt for how to improve it. Thoughts?
CCSA Summary
My Alcohol Summary
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Thanks Loren - hope you enjoy the rest of it. If you find any errors, areas of confusion, or missing evidence please let me know. I can update the book easily in 1-2 days. It's simply about showing the best evidence in an understandable way for something we all do every day.🍔🍎
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The Nutrition Proposition a.co/d/i81iVeu #Amazon. Got my copy and started diving in to an informative & entertaining book on food/diet/nutrition and best evidence. Enjoying already. Well done ⁦@medmyths⁩ !
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If you haven't seen this documentary you are really missing a fascinating look into the world of boxing in the era of Ali - it was SO MUCH more than the boxing.
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One of my fave moments ever in making docs was during Facing Ali, sitting by the ring talking life, left hooks & Ali with Smokin' Joe in his 4-sale gym as his ghetto blaster played James Brown, he scoffed a turkey sandwich & I floated in general disbelief that I was there.#legend twitter.com/Super70sSports…
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Agree but it doesn't hurt to say it again.😃 IMHO understanding what impacts the placebo group is essential to understand if you want to be good at figuring out if a medic' is actually helping a person. In most cases if a person has improved on a med it's not because of the med.
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Replying to @medmyths
I mean, you literally said "not necessarily the placebo effect" in the original tweet, so this whole discussion seems a bit defunct!
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Thanks for responding - not at all suggesting that what happens in the placebo group is the placebo effect - in fact I would suggest most, if not almost all of it, is not. BUT it is what happens in the placebo group. Are you OK with that clarification? No grain of salt needed?
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Replying to @medmyths
The ‘placebo effect’ is not estimated correctly in many trials. So-called placebo effects are often massively overestimated and the result of poor design and analysis. I find it quite worrying that the medical world seems to overlook this with abandon.
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Not sure what you mean by take with "a pinch of salt". And do you mean all trials that include a placebo arm are a "total mess"? If so, I would love to hear of an alternative approach to try to figure out if things work because I don't have one.
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Replying to @medmyths
Considering the fact that the placebo literature is a total mess, this can be taken with a pinch of salt.
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The image shows a brief synopsis of the 4 main statin/lipid guidelines in Canada/USA. There are always arguments as to who is right. The group I work with-the green column-simply says discuss benefits/harms and do shared-decision making. I think it's the best approach. Thoughts.
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David - you have a unique population - by all accounts what you do is VERY good for them - which is great. I just don't think it applies to the vast majority who might be trying to lose a few pounds (for whatever reason - unlikely health reasons) etc. Mediterranean in Moderation
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Replying to @medmyths
Thanks 😊 The question is why are my patients able to eat less ? They tell me they are less hungry on low carb. I believe it’s hunger we are battling with not calories @davidludwigmd has published on this Our second battle is food addiction, for some moderation is impossible 1/2
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Don't get me wrong-I think it is great but RCT doesn't support that it is the only/best way. There are other options. The best diet is the one a person will stay on and enjoy-the best weight is the weight they are when eating as healthily as they can and are physically active.
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Replying to @_eleanorina @medmyths and 2 others
it is documented clinical experience which is teachable and duplicates to other practices with large, not subtle effects wondering, why doesn't your evaluation criteria include that evidence
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Hi Joy - not saying that "eat less" is the only/best answer. Low-carb also says "eat less" but focuses on carbs. Most low-carb trials put people on restricted calories (eat less). I've attached the results for the low-carb vs low fat trials. At 12 months really no difference.
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Replying to @medmyths
The problem with "eat less" advice is it gives people the impression they are overweight or have high blood sugar because they lack self-control to eat less. They believe that *they* are the failure, rather than their body's response to the food they eat.
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I don't believe that what I happen to believe is irrelevant when my "beliefs" are based on a decent understanding of what the best available evidence for dietary interventions shows. Not saying decreasing food intake is the only/best way to lose weight but it does work.
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Replying to @medmyths
What you happen to “believe” is irrelevant. What is relevant is health outcomes, lives changed and disease reversed.
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Except I would suggest that snake oil actually represents the placebo effect plus the natural history - in fact I would suggest that almost all the effect of snake oil is natural history and NOT the placebo effect - just like any other placebo.
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Replying to @medmyths
It is a great chart! There may be some confusion as the bottle of snake oil does not just represent the placebo effect but rather the {placebo + "natural" recovery}.
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David - totally agree - you are doing great work. When it comes to nutrition the personal touch is always important. I still believe you could get similar results if people just ate less. Then people wouldn't have to give up lot's of great food which happens with a low-carb diet.
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Replying to @medmyths
Hi James all fair points but none of this reflects what may be being achieved in particular clinics @DocRunner1 & I have 20% of our entire t2 diabetic register in drug free remission -120 individuals @LoCarbFreshwell has 15% And we save on the drug budget nutrition.bmj.com/content/early/
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As appropriately requested by many people, I've provided the references for my chart. I've also tweaked the chart a bit as there was some new evidence - I created this 3-4 years ago. If you see any errors/have any concerns please let me know. Always happy to correct and improve.
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Hi Stavros - here is what we found when we reviewed the evidence. "Approximately one in ten patients show meaningful clinical improvement when treated for six months and ~1 in ten patients stop using the drug due to an adverse event" . Thoughts? gomainpro.ca/wp-content/upl
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Replying to @medmyths
Professor, please update your nice graph, no dementia drug proved clinically effective! archive.ph/SCU5o archive.ph/KIv3N archive.ph/5s1W8 archive.ph/XDTA0
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Totally agree - one always has to look at what endpoint is being evaluated. Certainly not suggesting asthmatics stop their treatment. The graphic is just to show one needs to have an idea of what happens in the placebo group and then what happens in the treatment group.
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Replying to @drpjhughes and @medmyths
I was surprised by the asthma/COPD. But outcome is exacerbations: in trials usually means 3+ days steroid boost, ED attend or admit- relatively rare for most ppl w asthma. Doesn't mean steroids don't improve day to day symptoms. Great graphic but care needed in interpretation!
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Hi Boris: Maybe I'm missing something but isn't that exactly what my figure shows?
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Replying to @medmyths
The next natural step is to report the proportion of patients who would benefit from the drug and wouldn’t without it. methods are available tiny.cc/SAP2022
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In the last 2 chapters (~65 pages) of my book The Nutrition Proposition, I explain as best/simply as I can everything the public/students need to know about study design, research numbers, bias, outcomes, risk factors, and surrogate markers. Check it out. nutritionproposition.com
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Created this ~3 years ago - almost all the numbers come from systematic reviews (primarily Cochrane) if I remember correctly. Give me ~2-3 days and I'll try to piece together the ref's. If anyone has contradictory numbers or if you are surprised by some of them let me know👍👍
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Replying to @medmyths
Brilliant James! Is there a link to the data/sources/sauces? 😉
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Great analogy. But in Hamilton at least the music is good🤣 Which reminds me - check out my 2016 musical parody outlining the problems with guidelines. youtu.be/DHDnqQ_mCBA. Check out all the other parodies on my channel as well - I think many of them stand the test of time.
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Replying to @gjonitz and @medmyths
The trick is finding the evidence in a 364 page guideline. Is on par with me reading “Hamilton” to understand the US constitution. 🤷‍♂️
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Here's a useful (hopefully) graphic showing the benefit from the medication treatment of 16 common conditions seen in primary care. You can also see what happens in the placebo group (not necessarily the placebo effect) which serves as a useful additional discussion point.
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So are you saying that clinicians can easily find in the that guideline many of the numbers that I reported in my tweet thread? If so great!! I still believe if there are more than 10-20 pages for a primary care guideline the writers need to reassess their approach.
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Replying to @medmyths
Guideline report has 364 pages. You‘ll find no better evidence-based guideline.
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Good grief. When we do our simplified guidelines we go with 10 pages max and often less than that. I think if guideline committees were mandated to 10 pages or less we would end up with MUCH more useful guidelines. Anyone want to start a petition?😀👍 peerevidence.ca
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Replying to @medmyths
The German UTI guideline from 2017 is 250 pages ("short" version is 75). And it's only about community acquired uncomplicated cystitis and pyelonephritis.
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