GET https://rct.dev.bbntimes.com/science/nutrient-supplements-and-summary-judgment-baby-and-bathwater-revisited-again

Response
200 OK
IP
3.22.66.147
Profiled on
Token
13c621

ArticleController :: show

Request

GET Parameters

None

POST Parameters

None

Uploaded Files

None

Request Attributes

Key Value
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"App\Controller\ArticleController::show"
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"_security_main"
_stopwatch_token 
"09ec2f"
category 
"science"
slug 
"nutrient-supplements-and-summary-judgment-baby-and-bathwater-revisited-again"

Request Headers

Header Value
accept 
"*/*"
accept-encoding 
"gzip, br, zstd, deflate"
connection 
"close"
cookie 
"PHPSESSID=9v647501bs90r0djbm93f9bqta"
host 
"rct.dev.bbntimes.com"
user-agent 
"Mozilla/5.0 AppleWebKit/537.36 (KHTML, like Gecko; compatible; ClaudeBot/1.0; +claudebot@anthropic.com)"
x-php-ob-level 
"1"

Request Content

Request content not available (it was retrieved as a resource).

Response

Response Headers

Header Value
cache-control 
"no-cache, private"
content-type 
"text/html; charset=UTF-8"
date 
"Sat, 22 Feb 2025 13:49:58 GMT"
link 
"</build/runtime.js>; rel="preload"; as="script",</build/644.js>; rel="preload"; as="script",</build/502.js>; rel="preload"; as="script",</build/app.js>; rel="preload"; as="script",</build/view-more.js>; rel="preload"; as="script",</build/term-condition.js>; rel="preload"; as="script",</build/contact.js>; rel="preload"; as="script",</build/scroll-infinite-article.js>; rel="preload"; as="script",</build/app.css>; rel="preload"; as="style",</build/cookie-style.css>; rel="preload"; as="style",</build/term-condition-css.css>; rel="preload"; as="style",</build/contact-css.css>; rel="preload"; as="style",</build/comment-css.css>; rel="preload"; as="style""
x-debug-token 
"13c621"

Cookies

Request Cookies

Key Value
PHPSESSID 
"9v647501bs90r0djbm93f9bqta"

Response Cookies

No response cookies

Session 6

Session Metadata

Key Value
Created 
"Sat, 22 Feb 25 13:49:34 +0000"
Last used 
"Sat, 22 Feb 25 13:49:56 +0000"
Lifetime 
0

Session Attributes

Attribute Value
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"-Ovw9NJuKWnT6uEy6w06SSMcGEVpxPrdtpMhzIDXZ3M"
_csrf/https-cookie_accept 
"g8CMrPq0Rdcx021wycLjWaW_N88pVcyLPabbzQWdicw"

Session Usage

6 Usages
Stateless check enabled
Usage
Symfony\Component\Security\Csrf\TokenStorage\SessionTokenStorage:76
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Symfony\Component\Security\Csrf\TokenStorage\SessionTokenStorage:79
Show trace 
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Symfony\Component\Security\Csrf\TokenStorage\SessionTokenStorage:52
Show trace 
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Symfony\Component\Security\Csrf\TokenStorage\SessionTokenStorage:56
Show trace 
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    "function" => "show"
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    "function" => "run"
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    ]
    "function" => "require_once"
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]
Symfony\Component\Security\Core\Authentication\Token\Storage\UsageTrackingTokenStorage:41
Show trace 
[
  [
    "file" => "/var/www/vhosts/dev.bbntimes.com/rct.dev.bbntimes.com/vendor/symfony/security-core/Authentication/Token/Storage/UsageTrackingTokenStorage.php"
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    "function" => "getMetadataBag"
    "class" => "Symfony\Component\HttpFoundation\Session\Session"
    "type" => "->"
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]
Symfony\Component\Security\Http\Firewall\ContextListener:171
Show trace 
[
  [
    "file" => "/var/www/vhosts/dev.bbntimes.com/rct.dev.bbntimes.com/vendor/symfony/security-http/Firewall/ContextListener.php"
    "line" => 171
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    "function" => "__invoke"
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Flashes

Flashes

No flash messages were created.

Server Parameters

Server Parameters

Defined in .env

Key Value
APP_ENV 
"dev"
APP_SECRET 
"0a988e63f011514eaabfc650b599af4d"
CORS_ALLOW_ORIGIN 
"*"
DATABASE_URL 
"mysql://bbndb_rctuser:33F5W25z40or0f7@localhost:3306/rct_bbntimes"
GOOGLE_RECAPTCHA_SECRET_KEY 
"6LdV5fgpAAAAANxzTG8ZMfIjil1wu-1vrQvnUt-x"
GOOGLE_RECAPTCHA_SITE_KEY 
"6LdV5fgpAAAAAENKcn73MJAhQrbtQeqgyC4wDLMP"
MAILER_DSN 
"smtp://no-reply%40rct.dev.bbntimes.com:Bl6%26gLD48%26Of919@rct.dev.bbntimes.com:465"
MARIADB_PASSWORD 
"i!87pK&!85ezc8"

Defined as regular env variables

Key Value
APP_DEBUG 
"1"
BASE 
"/public"
CONTEXT_DOCUMENT_ROOT 
"/var/www/vhosts/dev.bbntimes.com/rct.dev.bbntimes.com"
CONTEXT_PREFIX 
""
DOCUMENT_ROOT 
"/var/www/vhosts/dev.bbntimes.com/rct.dev.bbntimes.com"
FCGI_ROLE 
"RESPONDER"
GATEWAY_INTERFACE 
"CGI/1.1"
HTTPS 
"on"
HTTP_ACCEPT 
"*/*"
HTTP_ACCEPT_ENCODING 
"gzip, br, zstd, deflate"
HTTP_CONNECTION 
"close"
HTTP_COOKIE 
"PHPSESSID=9v647501bs90r0djbm93f9bqta"
HTTP_HOST 
"rct.dev.bbntimes.com"
HTTP_USER_AGENT 
"Mozilla/5.0 AppleWebKit/537.36 (KHTML, like Gecko; compatible; ClaudeBot/1.0; +claudebot@anthropic.com)"
PASSENGER_COMPILE_NATIVE_SUPPORT_BINARY 
"0"
PASSENGER_DOWNLOAD_NATIVE_SUPPORT_BINARY 
"0"
PATH 
"/usr/local/sbin:/usr/local/bin:/usr/sbin:/usr/bin:/sbin:/bin:/snap/bin"
PHP_SELF 
"/public/index.php"
PP_CUSTOM_PHP_CGI_INDEX 
"plesk-php81-fastcgi"
PP_CUSTOM_PHP_INI 
"/var/www/vhosts/system/rct.dev.bbntimes.com/etc/php.ini"
QUERY_STRING 
""
REDIRECT_BASE 
"/public"
REDIRECT_HTTPS 
"on"
REDIRECT_PASSENGER_COMPILE_NATIVE_SUPPORT_BINARY 
"0"
REDIRECT_PASSENGER_DOWNLOAD_NATIVE_SUPPORT_BINARY 
"0"
REDIRECT_REDIRECT_HTTPS 
"on"
REDIRECT_REDIRECT_PASSENGER_COMPILE_NATIVE_SUPPORT_BINARY 
"0"
REDIRECT_REDIRECT_PASSENGER_DOWNLOAD_NATIVE_SUPPORT_BINARY 
"0"
REDIRECT_REDIRECT_SCRIPT_URI 
"https://rct.dev.bbntimes.com/science/nutrient-supplements-and-summary-judgment-baby-and-bathwater-revisited-again"
REDIRECT_REDIRECT_SCRIPT_URL 
"/science/nutrient-supplements-and-summary-judgment-baby-and-bathwater-revisited-again"
REDIRECT_REDIRECT_SSL_TLS_SNI 
"rct.dev.bbntimes.com"
REDIRECT_REDIRECT_STATUS 
"200"
REDIRECT_REDIRECT_UNIQUE_ID 
"Z7nWBZDyWLT8YV1VjBpc8gAAAJE"
REDIRECT_SCRIPT_URI 
"https://rct.dev.bbntimes.com/science/nutrient-supplements-and-summary-judgment-baby-and-bathwater-revisited-again"
REDIRECT_SCRIPT_URL 
"/science/nutrient-supplements-and-summary-judgment-baby-and-bathwater-revisited-again"
REDIRECT_SSL_TLS_SNI 
"rct.dev.bbntimes.com"
REDIRECT_STATUS 
"200"
REDIRECT_UNIQUE_ID 
"Z7nWBZDyWLT8YV1VjBpc8gAAAJE"
REDIRECT_URL 
"/public/science/nutrient-supplements-and-summary-judgment-baby-and-bathwater-revisited-again"
REMOTE_ADDR 
"3.22.66.147"
REMOTE_PORT 
"28684"
REQUEST_METHOD 
"GET"
REQUEST_SCHEME 
"https"
REQUEST_TIME 
1740232197
REQUEST_TIME_FLOAT 
1740232197.8118
REQUEST_URI 
"/science/nutrient-supplements-and-summary-judgment-baby-and-bathwater-revisited-again"
SCRIPT_FILENAME 
"/var/www/vhosts/dev.bbntimes.com/rct.dev.bbntimes.com/public/index.php"
SCRIPT_NAME 
"/public/index.php"
SCRIPT_URI 
"https://rct.dev.bbntimes.com/science/nutrient-supplements-and-summary-judgment-baby-and-bathwater-revisited-again"
SCRIPT_URL 
"/science/nutrient-supplements-and-summary-judgment-baby-and-bathwater-revisited-again"
SERVER_ADDR 
"5.196.1.209"
SERVER_ADMIN 
"[no address given]"
SERVER_NAME 
"rct.dev.bbntimes.com"
SERVER_PORT 
"443"
SERVER_PROTOCOL 
"HTTP/1.1"
SERVER_SIGNATURE 
"<address>Apache Server at rct.dev.bbntimes.com Port 443</address>\n"
SERVER_SOFTWARE 
"Apache"
SSL_TLS_SNI 
"rct.dev.bbntimes.com"
SYMFONY_DOTENV_VARS 
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Sub Requests 6

CookieController :: renderAnalysis (token = 405980)

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AppController :: renderHeader (token = 1c6ff6)

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ArticleController :: trendingArticle (token = 31b1f5)

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ArticleController :: relatedArticles (token = be36f0)

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App\Entity\Article {#1094
  -id: 12119
  -title: "Nutrient Supplements and Summary Judgment: Baby and Bathwater, Revisited Again"
  -slug: "nutrient-supplements-and-summary-judgment-baby-and-bathwater-revisited-again"
  -introtext: "<p>In common, I suspect, with most members of my professional clan- specialists in&nbsp;<a href="https://www.acpm.org/" target="_blank" rel="nofollow noopener">Preventive Medicine</a>- I have a respect bordering on reverence for the&nbsp;<a href="https://www.uspreventiveservicestaskforce.org/uspstf/" target="_blank" rel="nofollow noopener"><em>U.S. Preventive Services Task Force</em></a>.</p>\r\n"
  -content: """
    \r\n
    <p>&nbsp;The Task Force meticulously weighs up relevant evidence to establish letter-grade guidance for clinical preventive services such as cancer screening, the assessment of various biomarkers, clinical counseling, and immunization.&nbsp;Those recommendations carry the veritable weight of gospel for practitioners, translating more or less directly into the standard of care; and exert a powerful influence on policy makers and the prevailing standards of health insurance coverage as well.&nbsp;<a href="https://www.uspreventiveservicestaskforce.org/uspstf/topic_search_results" target="_blank" rel="nofollow noopener">Task Force recommendations</a>&nbsp;on a wide expanse of pertinent topics are at the disposal of any with Internet access.</p>\r\n
    <p>Conceding all such due respect, I am nonetheless very much aware of important Task Force limitations.&nbsp;Three come immediately to mind; they are very far from inconsequential; and all three pertain to the&nbsp;<a href="https://jamanetwork.com/journals/jama/fullarticle/2793446" target="_blank" rel="nofollow noopener">recent guidance regarding nutrient supplements</a>&nbsp;that – yet again- spawned&nbsp;<a href="https://jamanetwork.com/journals/jamainternalmedicine/fullarticle/2793623" target="_blank" rel="nofollow noopener">commentary</a>&nbsp;and&nbsp;<a href="https://www.usatoday.com/story/life/health-wellness/2022/06/30/new-study-says-evidence-insufficient-recommend-common-vitamins/7763252001/" target="_blank" rel="nofollow noopener">media coverage</a>&nbsp;far and wide.&nbsp;We will return to the matter of those supplements; first, though, those limitations.</p>\r\n
    <p>To begin, the Task Force enjoys a luxury clinicians and patients lack: they can conclude not to conclude anything.&nbsp;In their&nbsp;<a href="https://www.uspreventiveservicestaskforce.org/uspstf/about-uspstf/methods-and-processes/grade-definitions" target="_blank" rel="nofollow noopener">letter grade system</a>, this is an “I,” standing for “insufficient.”&nbsp;Reviewing&nbsp;<a href="https://www.linkedin.com/pulse/what-true-evidence-base-evidence-based-david/" target="_blank" rel="noopener">evidence</a>&nbsp;of only a particular type and quality (an emphasis is placed on randomized controlled trials, or RCTs), this conclusion is reached often and translates to: &nbsp;“<em>there is insufficient evidence in quality, quantity, or both to recommend for or against a given practice</em>.”</p>\r\n
    <p>Of- to my count-&nbsp;<a href="https://www.uspreventiveservicestaskforce.org/uspstf/topic_search_results" target="_blank" rel="nofollow noopener">87 Task Force recommendations</a>&nbsp;on distinct topics, an “I” conclusion appears 46 times.&nbsp;Were clinicians to function accordingly- telling well over half of all patients “<em>there is insufficient evidence to decide whether to treat you or not…</em>” – clinical care would come completely undone.&nbsp;<a href="https://us.sagepub.com/en-us/nam/clinical-epidemiology-evidence-based-medicine/book8792" target="_blank" rel="nofollow noopener">Functioning despite residual uncertainty</a>&nbsp;is a critical element in clinical care and might be filed under “judgment,” or as preferred, the “art” of medicine.</p>\r\n
    <p>Second, because of the inflexible requirements for a specific standard of evidence, the Task Force is ill-equipped to distinguish&nbsp;<em>absence of evidence</em>&nbsp;from&nbsp;<em>evidence of absence</em>&nbsp;(the former means evidence is lacking; the latter means evidence proves a lack of effect).&nbsp;Much of what is perfectly clear to the average human would evoke an “I” recommendation from the Task Force for want of randomized trials.&nbsp;That list would include: children&nbsp;<a href="https://www.linkedin.com/pulse/science-advisory-children-should-keep-running-except-david/" target="_blank" rel="noopener">running with scissors</a>; looking both ways before crossing a busy street; and playing with fire, to name a few.&nbsp;I have looked and found no RCTs nor meta-analyses on any of these topics.&nbsp;Examples, all, of “absence of evidence,” i.e., a lack of studies; but surely not examples of “evidence of absence,” i.e., proof that running with flaming scissors into traffic is perfectly safe.&nbsp;</p>\r\n
    <p>Third, the Task Force generates answers only to the questions explicitly posed, and those questions can be bad.&nbsp;As there are no good answers to bad questions, this is a serious problem.&nbsp;The badness in question traverses a host of liabilities from a “one-size-fits-all” coarseness where nuance is required; failure to align a given question with the&nbsp;<a href="https://bmcmedresmethodol.biomedcentral.com/articles/10.1186/s12874-019-0811-z" target="_blank" rel="nofollow noopener">requisite sources</a>&nbsp;of a reliable answer; failure to account for the influence and potency of countervailing forces; failure to distinguish real-world from randomized trial circumstances; and more.&nbsp;Each of these is a lengthy disquisition in its own right, so I am hoping I may invoke&nbsp;<a href="https://us.sagepub.com/en-us/nam/clinical-epidemiology-evidence-based-medicine/book8792" target="_blank" rel="nofollow noopener">my prior work</a>&nbsp;and ask you to take my word for it.</p>\r\n
    <p>Of note, a bad question does not tend to get any better with repetition, nor does the likelihood of a good answer improve.&nbsp;With no disrespect to the Task Force, “<em>Do nutrient supplements prevent cardiovascular disease or cancer, or reduce all-cause mortality?</em>” is a rather bad question now, just as it was&nbsp;<a href="https://www.huffpost.com/entry/isaac-newtons-nutrient-supplements_b_6763572" target="_blank" rel="nofollow noopener">the last time</a>&nbsp;they posed it. &nbsp;I took care of patients for over 30 years and recall not a single instance where one of them took a multivitamin to prevent a heart attack, cancer, or death.&nbsp;As noted in the Task Force’s own paper on the topic, most people- including my patients- take a multivitamin “<a href="https://jamanetwork.com/journals/jama/fullarticle/2793446" target="_blank" rel="nofollow noopener"><em>for overall health and wellness and to fill nutrient gaps in the diet</em></a>.”</p>\r\n
    <p>To begin the indictment, then, if not of the Task Force conclusion about nutrient supplements, at least of the widespread commentary over-interpreting it: the question the Task Force asked is largely irrelevant to prevailing practice.&nbsp;Select nutrients have been studied for the prevention of heart disease (e.g., vitamin E) or cancer (e.g., Beta-carotene), with negative results- although even here there are subtleties related to the spectrum of disease largely absent from the public discourse.&nbsp;But the blending of a judgment about this with commentary on nutrient supplementation in general for very different purposes is about as nuanced as the infamous failure to differentiate baby from bathwater.</p>\r\n
    <p>All three liabilities noted above impact the Task Force position on nutrient supplementation.&nbsp;First, the conclusion regarding multivitamin use for prevention of major disease or death is an “I,” meaning insufficient evidence to conclude for or against.&nbsp;Since these are not the reasons people take a multivitamin, the lack of clarity is actually a surprising endorsement.&nbsp;Multivitamins might confer such a benefit, in other words, you just can’t count on it.&nbsp;</p>\r\n
    <p>If multivitamins do confer a mortality benefit, why is it so hard to prove?&nbsp;Consider that any such benefit, to qualify as “evidence,” would need to be adjusted for all other relevant factors: lifestyle behaviors, dietary pattern, toxic exposures, and medication use to name a few.&nbsp;Imagine how small the residual effect of a multivitamin on mortality risk would likely be when lifestyle and medication were reliably matched.</p>\r\n
    <p>Let’s say, for instance, that in reality (to be clear, I am making this up)- multivitamins, even when added to state-of-the-art pharmacotherapy (and, ideally,&nbsp;<a href="https://www.lifestylemedicine.org/" target="_blank" rel="nofollow noopener">lifestyle medicine</a>, too) reduce mortality from heart attack by one case in 60,000 per year.&nbsp;In a clinical trial, if 60,000 people at risk not merely for a heart attack within a year, but dying of a heart attack within a year, were randomized to multi-vitamin, and another 60,000 were randomized to matching placebo, the mortality difference would be something like 1, and thus- statistically invisible.&nbsp;This trial of 120,000 very high-risk participants would not be nearly large enough, and a year not nearly long enough, to find meaningful “evidence.”</p>\r\n
    <p>If this effect were real, however, since&nbsp;<a href="https://www.cdc.gov/heartdisease/facts.htm" target="_blank" rel="nofollow noopener">well over 600,000 people die of myocardial infarction</a>&nbsp;each year in the United States alone, it would mean more than 10 lives saved annually- by means of a multivitamin.&nbsp;I am not saying this effect is real; I am simply pointing out that even if it were, it would be very hard to capture in any clinical trial.</p>\r\n
    <p>So, what about nutrient supplements for health benefits?&nbsp;Well, in some cases the evidence has been so clear that what started as “supplementation” migrated to “fortification” of the food supply to ensure that all would benefit.&nbsp;Fortification is really just supplementation by alternate means, and the nutrients addressed that way should not be backed out of the dialogue.&nbsp;Grains are fortified with&nbsp;<a href="https://www.cdc.gov/ncbddd/folicacid/features/folic-acid-helps-prevent-some-birth-defects.html" target="_blank" rel="nofollow noopener">folate to prevent neural tube defects</a>; many products are fortified with vitamin D to prevent the deficiency that would otherwise prevail.&nbsp;These and other exceptions suffice to prove the rule: nutrient supplements most certainly can confer a decisive and important health benefit.</p>\r\n
    <p>As for multivitamins, their likely effect is subject to the paramount, and routinely neglected, consideration governing supplementation:&nbsp;<em>supplemental to what</em>?&nbsp;The very name denotes that all supplements are meant to be added to something else.&nbsp;That something else- the nutrients derived from food- is almost never known, due to historical challenges in assessing dietary intake.&nbsp;This stage of my career is devoted to popularizing&nbsp;a solution to that very problem, and making diet the vital sign it deserves to be.&nbsp;When nutrient intake from food can be reliably captured, the personalized case for or against any given nutrient supplement is far better informed.&nbsp;</p>\r\n
    <p>Stated bluntly, the likelihood of benefit rises when the “fix” pertains to something known to be broken (we do all learn in medical school: “if it ain’t broke, don’t fix it”).&nbsp;Boosting the level of a nutrient that is low (not at all uncommon for many nutrients in the context of a ‘typical’ American diet) is far more apt to confer benefit than providing more of what is already ample.&nbsp;By way of analogy, the very best antihypertensive medications would fail to show benefit if only ever tested in people with normal blood pressure at the start.</p>\r\n
    <p>I believe nutrient supplementation should be personalized accordingly.&nbsp;Supplements should indeed be supplemental to,&nbsp;<a href="https://health.usnews.com/health-news/blogs/eat-run/2013/04/29/to-supplement-or-not-to-supplement" target="_blank" rel="nofollow noopener">never substitutes for</a>, the benefits of eating well.&nbsp;Knowledge of dietary intake to inform both should be universal; diet should be a vital sign.</p>\r\n
    <p>As for the Task Force recommendation, it should be understood in context, and with due consideration of the question asked and answered (<a href="https://health.usnews.com/health-news/blogs/eat-run/2013/12/27/multivitamins-revisited-again-mission-methods-and-muddled-messages" target="_blank" rel="nofollow noopener">again</a>).&nbsp;You should not rely on a multivitamin to prevent heart attack, cancer, or death.&nbsp;Benefits related to the more realistic motivations of energy, well-being, and so on - all fall outside the scope of the Task Force probe.&nbsp;</p>\r\n
    <p>Medicine, in practice, is both art and science for the good reason that much decision-making is required where data are sparse.&nbsp;Absence of evidence is not evidence of absence.&nbsp;<a href="https://www.amazon.com/Nutrition-Clinical-Practice-David-Katz/dp/1975161491" target="_blank" rel="nofollow noopener">Nutrient supplementation is a broad expanse</a>&nbsp;with real estate enough for both baby and bathwater.&nbsp;Be judicious, and strive to distinguish between them.</p>
    """
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CookieController :: renderCookie (token = 4157ae)

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