May 30, 2024 • 54 mins
What can we learn from the latest research on krill oil's effects on knee osteoarthritis? We dive deep into the study's transparency and rigor, exploring the impact of adherence rates and the significance of measurable markers like effusion synovitis. Our spirited debate covers biases in healthcare, the balance between skepticism and openness to new evidence, and the emotional responses tied to negative trial outcomes. This episode is packed with thoughtful reflections and expert insights, making it essential listening for anyone interested in evidence-based integrative medicine. Tune in for a comprehensive and engaging exploration of the complexities of clinical trials!
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Episode Transcript
Available transcripts are automatically generated. Complete accuracy is not guaranteed.
Introducer (00:02):
Welcome to the Dr Journal Club podcast, the show
that goes under the hood ofevidence-based integrative
medicine.
We review recent researcharticles, interview
evidence-based medicine thoughtleaders and discuss the
challenges and opportunities ofintegrating evidence-based and
integrative medicine.
Continue your learning afterthe show at www.
(00:23):
d rjournalclub.
com.
Dr. Joshua Goldenberg (00:31):
Please bear in mind that this is for
educational and entertainmentpurposes only.
Talk to your doctor beforemaking any medical decisions,
changes etc.
Everything we're talking aboutthat's to teach you guys stuff
and have fun.
We are not your doctors.
Also, we would love to answeryour specific questions on
drjournalclub.
com.
You can post questions andcomments for specific videos,
(00:55):
but go ahead and email usdirectly at josh at
drjournalclub.
com.
That's josh at drjournalclub.
com.
Send us your listener questionsand we will discuss it on our
pod.
Hello and welcome to the DrJournal Club podcast, where I've
(01:15):
missed my podcasting partnerlately.
It's good to have you back, sir, I have to say.
Dr. Adam Sadowski (01:20):
Hello, hello, hello.
How are you?
Dr. Joshua Goldenberg (01:23):
Good, good, you were well missed.
I do have to say I don't knowif you listened to the last um,
the last pod, but I I had a odeto I owe to you in the middle.
It's like, oh, this is soboring.
I just it was so weird talkingto myself about the, the paper,
I just felt like it was uhspeaking out into the ether like
the the old days, or somethinglike that that's probably gonna
(01:45):
have the the most views or themost downloads to watch yeah,
they're like hey, everyone,adam's not on this one, take a,
take a listen.
Yeah, although it's funny, likeyou get into your rhythm and
then you just start talking andit feels normal, but at first
you're like I'm talking tonobody.
This is very, very strangeright and I was realizing like
(02:07):
we've done this for a long time,like it was kind of weird at
that point because you know,basically I think we've been
doing this for a year and a half, something like that,
definitely over a year sincelast october, I think oct.
Dr. Adam Sadowski (02:21):
Because I remember it was the fall or the
winter of my final year ofresidency and I just remember us
talking about studies and wewere like let's just you know we
already talked about all ofthis.
Why don't we just share it withothers?
Dr. Joshua Goldenberg (02:39):
Yeah, let's just basically still do it
.
Dr. Adam Sadowski (02:42):
And then literally the next week week.
We just started doing that.
Dr. Joshua Goldenberg (02:47):
Yeah, and it's been fun.
Man, it's getting easier andeasier to podcast, I have to say
, and now there's liketechnology that we can remove
filler words and all this jazz,but anyway.
So how are you?
Briefly, how are you in life?
It's been a while.
The listeners haven't heardfrom you in like months and
months and months and months.
How are you doing?
(03:07):
What are you doing?
The rumor on the street is youare no longer training for
triathlon.
Is that true?
Is that a blatant lie?
Are you back on the saddle?
What is going on?
Dr. Adam Sadowski (03:17):
The rumors are semi-true.
Overall, life is great, butwith the triathlon training and
working as a full-time clinicianand doing a lot of other
extracurricular things andwanting to also have a life,
it's that last piece that'sgonna get you every time yeah
and it was just a culmination ofthings and just honestly
(03:41):
started feeling really burnt outwith it.
Uh, when I first started Iactually just truly enjoyed the
training component of it andreally just liked going to every
training session, and then thatonly recently really um,
started to dwindle to the pointwhere I then just hated every
single training session I wasdoing and then I was like, why
(04:03):
am I actually doing this?
I'm not a professional triathlon, you know triathlete if it's
not fun, you gotta stop yeah andI was like I'm not trying to
prove this to anyone and I knowI can do all of the events
because I I've, you know, I'vedone every single event on its
own and I have done combinationsof it.
(04:24):
I've just never done the fullthing, like at an actual iron
man event.
And then I was like, well, youknow, if I, if I know I can do
all these things, that wasreally kind of the internal
motivating factor of it.
I was like, well, can I even doit check?
I don't need to prove it toanyone else.
And then why do I have to bringit on a very specific day,
(04:47):
right at a very specific time,when it at first is like, hey, I
feel really good today, likelet's just go, versus let me go
to a race event and have all thestuff that I'm used to be, all
these like weird variables inthe way of like you know a
different hotel room and likesleeping at a different hour and
like you know nutrition's notthe room, and like sleeping at a
different hour and like youknow nutrition is not the same
(05:09):
versus like, hey, I just woke up, felt really good and went for
it.
Dr. Joshua Goldenberg (05:11):
Yeah, no, that makes sense.
I mean, you, you hit your goals, so now you just got to find
new, new goals, to have newthings to hit from her.
For, like, that's the thing Ilike about having some sort of
like I hear what you're saying,but for me, anyway, I need that
external like requirement, or Ijust don't get it done Because
there's like you know, you havea couple races a year, you train
(05:34):
up for it, and then there'salways like I need a little
break for a month or somethingright, like I kind of let things
go, and then it's like, oh, yougot another race in six months,
josh, like you got to prepagain, and so for me, like that
is, especially with, like, thefear of death in water, is like
enough of a motivator to likeshow up and do the the training
sessions.
But yeah, if so, that's for me.
Dr. Adam Sadowski (05:54):
But yeah, if you're able to just get it done
and that was your motivator,then you're good man also it's a
very expensive sport, and so itis for the most part I was just
kind of of you know winging it,like I have a lot of like used
stuff and just like buying stuffon the very, very cheap.
Yeah.
And then I was like, well, ifI'm actually going to do a race,
(06:14):
the race itself is going tocause cost upwards of a grand,
and then to get all this otherequipment and like working
equipment and stuff like that,it's gonna cost a pretty penny.
and then when I, you know,calculated all out, I was like I
would much rather fly firstclass round trip around the
world vacation for two weekswith, like, my best friends and
(06:35):
like, live it up, then endure,you know, eight hours of pain in
one day, just to get a littlepiece of plastic that says you
can do, just to say you did it,yeah, yeah.
Dr. Joshua Goldenberg (06:48):
And then the classic line for triathlon
is like oh, did you win the raceMe?
Like no, no, I finished therace.
Yeah, oh well, did you come inlike there?
No, I was like 130th in my agegroup, you know.
Yeah.
But well, well did I.
Briefly did I, speaking ofcheap equipment, I told you
about what happened with my bikeon my first try, right, my
(07:11):
first one and only try.
Yeah.
Yeah, yeah.
So I think the having decentequipment matters.
Like you can't really wing itand it's just like some things,
like everything else that I'vedone in terms of this, I always
just get the cheap stuff or likewhatever, like I don't know
that it really matters, and butI think here like yeah, ok, you
(07:32):
don't have to buy like the$10,000 bike, but you should
probably buy a nice bike, right,right, if you're going to, and
then you should probably protectit when you travel and all that
jazz.
Dr. Adam Sadowski (07:41):
Anyway, this has nothing to do with what
we're talking and yeah well, andalso like just for anyone out
there who's like also kind ofgoing through anything similar,
like it just quit, like it'sit's okay, like I feel like
there's this you know thing andwith society of like, if you
quit, yeah quitting is okay well, no, no, not that quitting is
okay.
Well, it is okay, but that likeif you quit, you failed oh yeah
(08:03):
it's like I didn't failanything.
I was like doing something thatI just wanted to kind of like
fool around with and see if Iliked it, and at the time it was
something that I really enjoyeddoing, and then I didn't like
doing it.
So I'm not going to do a sunkcost fallacy where you're just
going to keep investing intosomething that you're either not
enjoying or just's just afailure, with the hopes that,
(08:26):
well, I'm already down this far,let me just keep.
At some point it's got to turnaround.
No cut your losses and like,move on.
And so like I mean, I stillwent for a run today, I still do
things I enjoy.
Dr. Joshua Goldenberg (08:39):
It doesn't necessarily have to be,
you know, grueling hours on a tobe, you know, grueling hours on
a on top of an already hectic,you know, work schedule.
Yeah well, dude, you weretraining for half iron man,
right?
So that's like crazy hours,yeah, so that totally makes
sense to me.
What did I want to say aboutthat?
Oh, yeah, well, it's also.
It's not well, I don't thinkyou failed at all, but it's like
or cutting your losses.
(09:00):
I don't think there are anylosses, but um, the.
The other thing is like it's,it's what you're like, what are
the outcomes that you'veselected, right?
Is it to get that metal at theend of a finish line, that like
that piece of metal thatprobably cost them two dollars,
right?
Or is it to stay fit andhealthy, or to prove that you're
able to accomplish somethingphysically?
And if it's the latter two,like, yeah, nailed it, yeah,
(09:23):
check, and so like, yeah.
So I think it depends on likewhat, the what the outcome
measure is right.
So, to bring this back toclinical trials, it's like what
is the, what is the clinicallymeaningful outcome here?
Right?
Like what's the outcome thatthat's meaningful to you?
And you could even argue that,like to extend this obnoxiously,
you can even argue that likethe metal, or doing the actual
(09:45):
race is just a surrogate outcometo like.
Yeah, health and wellness, youknow but I don't know.
Dr. Adam Sadowski (09:53):
I just feel like, you know, looking back to,
it's kind of silly of like, heyAdam, let's go hang out.
It's like, oh no, hold on, Ihave to go sit on a saddle for
three hours watching Netflix,but you go ahead, go have fun.
Dr. Joshua Goldenberg (10:05):
Yeah, fair enough.
I think it sounds like you'vemade the wise, smart decision
and you've proven that you canpull it off, which I think is
impressive.
Dr. Adam Sadowski (10:13):
And I got better at three things.
You know, I got better atrunning, I got better at
swimming, I got better at biking.
I'm going on.
I still go on bike rides, butlike they're more leisurely with
friends, let's go checksomething out.
It's still fun to do thosethings, but not with the mindset
of, oh, I'm doing this becauseI have to do it for triathlon
training, it's more so.
Oh, I'm doing it because it's anight day, let's go on a bike
(10:36):
ride.
Dr. Joshua Goldenberg (10:37):
Yeah, we should just call this podcast
the Triathlon Podcast at thispoint.
But the one of the things Iliked about switching to
actually getting a propertrainer this year is that I used
to just like go out and likeput in those hours, thinking
that that's what I needed to do.
And I think that, um, what shehas me on now is like, okay, you
do 30, 40 minutes of likesomething every day and then you
(11:00):
do your long ride, you knowwith a, you know with a brick or
whatever, like you do at theend, but on the weekends and
obviously that builds up as youget closer to the race.
Yeah, I think it was just doingthose continuous long runs
every time was like so drainingfor me and to just like, oh yeah
, I'm just working out for 3040minutes a day, like that seems
totally doable.
And then, yeah, there is thisone long thing on the weekend
and as you get closer to raceday, it gets like more and more
(11:22):
owners, so it takes up more andmore of your day plus recovery
time.
That's hard on families andlife and all that.
I think my total minutes oftraining is lower now but I feel
better about it, like it's lessof a drag, I guess, okay,
should we talk about science nowand medicine?
Yeah, we can.
(11:42):
Okay, sort of.
So you know, we're only 10minutes 20 seconds in.
So, speaking of biking,speaking of knees, speaking of
knee pain, we are going to talkabout a.
You see how I did that.
That's professionalism, rightthere.
It's a really nice transition.
Just note that.
Dr. Adam Sadowski (12:00):
We're talking about migraines today.
People.
Dr. Joshua Goldenberg (12:02):
Shoot did So my friend Adam here sent us
this article on krill oil forknee pain and because of his
contrary nature I'm suspiciousthat he sent it because it was a
negative trial and he likes tobe contrary about integrative
medicine.
Is that true?
Or did you just see it and sentit before you saw the results?
Dr. Adam Sadowski (12:25):
I wouldn't label it as a contrarian.
I would label it as I'm askeptic of a lot of things, and
I think that there's too muchdirect to consumer nonsense out
there, and so I really wantpeople to question things when
they see things, especiallysince at a lot of these
integrative events there's a lotof lab testing industry,
(12:46):
there's a lot of supplementsalesmen, and I want people to
actually understand what theevidence is for what they're
using these supplements for, andnot just taking it because some
sort of fancy paper by someonewho's wearing a suit and tie,
who isn't actually a researcher,is telling you this is the next
best thing and it's nodifferent than a pharmaceutical
(13:09):
rep doing the exact same thing.
And so I think that really weneed to question that and
recognize that that is a bigthing in the integrative
evidence space that no one wantsto talk about, and so I will
happily talk about it.
Dr. Joshua Goldenberg (13:23):
Excellent .
I have to admit, it's reallybeen weird, ever since we've
been friends, to have someonemore on that wing of things than
I am.
I feel like most of my well,all of my career in natural
medicine, I feel like I've beenthat contrarian.
What did you say?
Oh, not contrarian, curmudgeon,oh wait, no, no, you said
(13:44):
critical thinker.
Okay, so I feel like I've beenthat one, but to have someone
outflank me is impressive.
Um, but at this point, like Ithink I sent you something the
other day.
I was like what we should dothis?
Like, um, colored noiseanalysis.
Now, I was serious.
I was just like no, I wasserious about that.
I was like you know, the whitenoise versus brown noise, versus
(14:04):
pink noise, there might be someneat studies, like whatever,
and you know, just an immediateresponse no, like that's
ridiculous.
Like adam, you haven't evenread it.
This could be a thing.
You're like no, that's tooweird, forget it anyway, all
right, so we're going to talkabout this study.
So, let's talk about this study.
Um, okay, pulling up here aboutthis study.
Okay, pulling up here, allright.
(14:25):
So this was a JAMA paper, whichwas, you know, always nice,
real JAMA, jama, jama, not JAMA.
One of its myriad offspring,and this just came out this year
.
Do you want to set it up?
You want me to set it up?
What's the rationale for?
Well, no, you don't read theintroduction.
Did you read the introduction?
This?
Dr. Adam Sadowski (14:44):
time.
Yeah, I actually read theintroduction.
I also read the discussion.
Whoa.
I did because I wanted to seehow it compared to the three
other trials that they talkedabout in the introduction.
Dr. Joshua Goldenberg (14:55):
Yes, yes, exactly the whole time, the
entire time.
Once I got to the results, Iwas like good study, good study,
good study, good study got theresults like huh, surprising,
surprising, surprising.
And all that was going throughmy head was well, how did you
mess this up?
What were the other trials thatset this up?
And yeah, and I think they dida good job of that in the
discussion.
So that's your foreshadowing.
So set us up what was therationale for this study design.
Dr. Adam Sadowski (15:16):
Yeah, yeah, and just with that thought
process, you and I are literallythe same person.
It's kind of scary, no, I agreeon many levels.
Yeah, but yeah.
So basically, kneeosteoarthritis affects a lot of
people.
Actually, in the paper theyquoted, 654 million people above
the age of 40 have kneeosteoarthritis.
(15:37):
They also said that there's nomedical therapies that improve
the natural history of it,meaning once it's set in stone,
it kind of is this progressiveissue.
And so there's this also from amechanism of action standpoint.
You know, reducing inflammationmay reduce pain, may improve
outcomes in people withosteoarthritis.
(15:58):
In omega-3s there's evidencethat it reduces inflammation and
because we love mechanism ofaction, if you can reduce the
inflammation with something,then therefore we should have
improved knee osteoarthritis.
On top of that, krill oil, asopposed to fish oil, has
improved bioavailability, sothere's better uptake of it, and
(16:20):
it contains an antioxidantcalled astaxanthin which also
can help from, you know,inflammation, free radicals,
yada, yada, yada.
And then they had three priorrandomized clinical control
trials that showed daily krilloil reduced some aspects of knee
pain in individuals with kneeosteoarthritis.
(16:41):
However, compared to this trial, none of those trials included
individuals with effusionsynovitis.
So essentially, that jointspace having some inflammation
of that synovial fluid, thelubrication within the joints.
So this way you're not, they'renot grinding on each other.
I think of it as like breakfluid basically.
(17:03):
Mm-hmm.
Uh, they none of them actuallylike break fluid.
Basically None of them actuallymeasured that and that can be
used as a surrogate marker forthe structural progression of
knee osteoarthritis.
Yeah, and so what?
Go ahead.
Dr. Joshua Goldenberg (17:17):
No, I was just going to say like it's
kind of nice right.
So obviously the clinicallyimportant outcome is the pain.
But you know, I always getnervous about subjectively
reported outcomes, and so it'skind of neat that, even though
the effusion synovitis is asurrogate marker, it is like a
surrogate marker for anobjective response like
(17:37):
progression, and so I don't know, I kind of I love when you have
these.
Okay, yeah, the subjectivelyreported outcome is the
clinically important one, butyou pair it with something
objective at the same time.
So I just love that.
Dr. Adam Sadowski (17:49):
Right.
And then I do want to talkabout those three trials without
giving away the findings ofthis paper, so I do want to go
into that next.
Mm-hmm of this paper, so I dowant to go into that next.
But the whole aim of this paperwas to look at two grams per
day of krill oil versusidentical placebo, and the
placebo that they used in thispaper was a mixture of random
(18:10):
oils, including the quoteunquote bad seed oils that
everybody's scared of, eventhough there's really a lack of
evidence to support that Watch acurmudgeon, yep.
Are curmudgeons, are they?
Do you think they're seacreatures which would be fitting
for this podcast?
Dr. Joshua Goldenberg (18:29):
They might be sea creatures.
Dr. Adam Sadowski (18:31):
Yeah, that's very fitting.
Dr. Joshua Goldenberg (18:33):
Okay, but yes that's what I envision.
I envision someone on thebottom of the ocean, sort of
like an angry mumbling.
What is it?
Spongebob, squarepants,plankton, plankton, just like
fuming about things, about theresearch evidence, literature.
Yeah, great, anyway, that's you.
Dr. Adam Sadowski (18:52):
Yes, that's me, and so this was a randomized
clinical controlled triallooking at two grams per day of
krill oil versus placebo, as Isaid, on the primary outcome of
a knee pain over 24 weeks inpeople with knee osteoarthritis
who had significant knee painand effusion synovitis.
And when we actually comparethe other three trials, which
(19:14):
they do talk about in thediscussion, they were of smaller
trials and they used differentamounts of krill oil.
One small trial looked at 300milligrams of krill oil versus
two grams in this one, so 2,000milligrams in this one.
That trial was also only 30days, whereas this one is 24
(19:37):
weeks.
Another trial did look at twograms per day, but they only
included 50 people with mildknee pain and they also had
other comorbidities associatedwith that as well, so they
couldn't necessarily say that itwas due to knee osteoarthritis.
(19:58):
Interestingly, in one paper withthe 300 milligrams per day of
krill oil, that significantlydecreased C-reactive protein,
whereas in the other one thatlooked at two grams per day of
krill oil had no change inC-reactive protein.
So for anyone who remembers thisShilajat paper that we talked
about, we did talk about how itwas really interesting to see a
(20:22):
dose-response relationship wherea higher dose of the Shilajat
improved the bone mineraldensity as well as all of the
inflammatory markers associated,relative to both placebo and a
lower dose.
But so we're not seeing thathere.
So there's some inconsistencies.
And then there was a thirdrandomized controlled trial that
(20:43):
looked at four grams per dayand that did seem to improve in
individuals with moderate kneeosteoarthritis over 26 weeks.
However, in that trial they didnot have people specifically
with the synovitis as in thiscase, and they also had a little
bit of a difference in the EPAand DHA content, but it seemed
(21:09):
like those were just more sothings to note but didn't really
change much of the results thatwe'll see in this paper change
much of the results that we'llsee in this paper Thoughts.
Dr. Joshua Goldenberg (21:25):
Yeah, I think I think you know to your
point like this.
So this study was done in thecontext of okay, we have studies
that show benefit of krill oilin populations like this, not
exactly like this, even at muchlower doses we're seeing benefit
.
And we have like as low as 300milligrams, as high as four
grams, and we're going to shootfor two grams.
So it doesn't seem like theyintentionally undershot the dose
(21:46):
or any reason like that, right.
So it seems like, you know, itseems reasonable, and even the I
think they even even theplacebo comparators were similar
to at least one of the othertrials.
So it does seem like they setthis up based on an expectation
that we have evidence that thisworks and so let's try it.
Sort of a very rigorous, largerstudy, very rigorous design.
Dr. Adam Sadowski (22:10):
This is also a larger dose than what we're
seeing in over-the-counterproducts, because I did look at
popular name brand fish oilsupplements and krill oil
supplements, a lot of which areused in the integrative space
with sort of this you know ideathat oh, it's not over the
counter, so therefore it's asuperior product and the dosing
(22:31):
on those are significantlyunderdosed compared to what's
being studied in this trial.
Dr. Joshua Goldenberg (22:37):
Well, yeah, I mean, I guess it depends
on, like, how many you take,Like I know, for I don't know
how you use them, but Iregularly.
Will you know if I do?
I don't really do fish oils,but when I do, or when I have,
it's usually been the gramlevels right, Like two grams a
day would not be, it would notbe crazy for me.
So I feel like it's a hefty butnot crazy dose.
So I feel like it's a hefty butnot crazy dose.
(22:58):
But yeah, anyway, Um, okay.
Dr. Adam Sadowski (22:59):
And also can we just plug in one thing real
quick about fish oil.
Dr. Joshua Goldenberg (23:02):
Sure.
Yeah.
Dr. Adam Sadowski (23:08):
For those who are giddy about super high
doses of fish oil.
So when I say super high, I'msaying at least four grams per
day.
There is an association therewith AFib.
So it's not.
Dr. Joshua Goldenberg (23:15):
It's not a benign a hundred percent
benign.
Dr. Adam Sadowski (23:19):
It's not.
It's not a benign, 100 percentbenign.
It's not.
It's not a benign thing.
You can cause harm with highdose fish oil, so please be
careful, and this is not medicaladvice.
Dr. Joshua Goldenberg (23:27):
Yeah, that was.
My mom just sent me that NewYork Times article about that,
that's.
I think that's the next thingwe should, we should look at.
Look, the thing is we don't dothis for money.
This is pro bono and, quitehonestly, the mothership kind of
ekes it out every month or so,right?
So we do this because we careabout this, we think it's
(23:47):
important, we think thatintegrating evidence-based
medicine and integrativemedicine is essential, and there
just aren't other resources outthere.
The moment we find somethingthat does it better, we'll
probably drop it.
We're busy folks, but right nowthis is what's out there.
Unfortunately, that's it, andso we're going to keep on
fighting that good fight.
And if you believe in that, ifyou believe in intellectual
(24:10):
honesty in the profession andintegrative medicine and being
an integrative provider andbringing that into the
integrative space, please helpus, and you can help us by
becoming a member on Dr JournalClub.
If you're in need of continuingeducation credits, take our
NANSEAC approved courses.
We have ethics courses,pharmacy courses, general
courses.
Interact with us on socialmedia, listen to the podcast,
(24:31):
rate our podcast, tell yourfriends.
These are all ways that you cansort of help support the cause.
So let's jump into the methods.
Just some things to highlight.
One of the things I reallyliked they had the entire trial
protocol and the entirestatistical analysis plan
available online.
I feel like they're being likesuper transparent.
(24:53):
Not just that they had, likeyou know, a Prospero well, not
Prospero, but not just like abasic clinicaltrialsgov
registration.
It was like the straight upentire protocol and the analysis
plan.
Dr. Adam Sadowski (25:04):
Honestly, I've been very impressed with
research coming out of Australia.
I'm not surprised that that iswhat happened.
A lot of the Australians do areally good job with when it
comes to the reporting ofoutcomes in the papers and
whatnot.
Dr. Joshua Goldenberg (25:18):
Huh, yeah , no, that's cool, I haven't.
I hadn't noticed that I'm notseeing a lot out of Australia
besides SIBO stuff.
Actually, like they FODMAPstuff is really big out of the
Monash University down there,but okay, so, yeah, so, really,
like you said, very transparent,very good methods.
We talked about the population.
(25:39):
You had to be 40 years of older.
Symptomatic knee pain you hadto have like significant knee
pain, like 40 points or higheron 100 point scale.
So these aren't people where itwas just marginal knee pain.
And I think the biggestdifference between this
population and the other trialswas A it was all people with
knee arthritis, osteoarthritisspecifically, and not a mix.
And also that they all havethis effusion synovitis.
(26:02):
And I was wondering, like, doyou?
I mean it's not like I guessyou would argue that that makes
it more severe.
Yeah, yeah, right.
Dr. Adam Sadowski (26:13):
And so if you were to see a response, then
you should see a response, right?
So if you kind of think aboutit like as a secondary
prevention type of population,you would expect to see a larger
magnitude of effect.
Dr. Joshua Goldenberg (26:25):
Right, and that's the only thing I
could think of, like trying toplay devil's advocate was well,
maybe they were so extreme, Likesometimes, when disease is so
progressed you know you justcan't reverse it and maybe
that's what we're seeing here,is that you have these anatomic
evidence of severity of diseasethat's just no longer reversible
(26:47):
, Whereas if it wasn't thatextreme it would.
I don't know, could just bethat it doesn't work, but we'll
see.
So that was one thing.
One question I had, because Ithink this is the only study
that actually had that as aninclusion criteria, that they
had to actually have thissynovitis.
Dr. Adam Sadowski (27:00):
Yeah, and that was one of the
differentiating factors betweenthis and the other three
randomized controlled trials.
Dr. Joshua Goldenberg (27:05):
Yep, yep.
So as we try to compare andcontrast, so remember, like, if
you have disparate results, itcould just be that like, well,
the early studies were wrong,like that happens or not wrong,
but just like randomly positiveright, especially smaller trials
.
But again, it could be that thepopulations are just very
different as well, and so that'salways something that you have
to sort of consider.
So I thought they did a goodjob with randomization, with
(27:27):
treatment assignment, withblinding.
I was all pretty happy with allthat.
You know, one thing that comesup when I hear you know people
complain about integrativemedicine trials, I hear you know
people complain aboutintegrative medicine trials,
about oils or about integrative.
You know, anything is the is becareful about the placebo.
And like, what is the placebo?
Is it truly inactive or not?
(27:47):
So, like you said, this wasvegetable oil, it did have olive
oil, so it did have things thatyou know you might suggest
would be negative, but also ithas olive oil.
So what about the argument that?
Well, maybe the placebo itselfhad a benefit here, although the
point, because it's maybeanti-inflammatory.
However, it doesn't have anyEPA, dha, and maybe that's what
(28:11):
you're measuring here.
Dr. Adam Sadowski (28:13):
It also has corn oil, which everyone loses
their mind over.
So I don't, I really, I really,you know, if you're gonna, if
you have one good oil, then youhave three other not good oils.
I feel like it all cancels out.
And I'm not gonna lose sleepover the fact that these contain
olive oil yeah, okay, fairenough.
Dr. Joshua Goldenberg (28:31):
So adam's not losing sleep over it.
I'm not like I don't know, likeI I always wonder about this
sort of thing and I feel likethere's always this battle
between well, you can find onething that explains a negative
result, and it can soundrational, but at a certain point
you look just like.
Dr. Adam Sadowski (28:49):
But then you can't argue anymore that seed
oils are pro-inflammatory.
Dr. Joshua Goldenberg (28:53):
Yeah, I mean.
So there's that, and thenthere's, you know, also, you
just can't truly prove a fullnegative right, like you can
always find something that if itwas done differently it would
be positive, and so I feel likeat a certain point you just have
to say on net that this lookedlike an excellent study, well
designed, decent placebo, youknow, and if you're comparing it
to just taking some seed oils,it seems as if krill oil doesn't
(29:17):
add much to that.
Dr. Adam Sadowski (29:20):
We can put it that way, I guess I mean I
would also say like okay, wellthen, go compare, go get funding
.
To say, the difference betweenour study in the previous study
was that they had a mixed oiland so we're going to use
straight up canola oil.
Right, right, the canola oilstudy.
No one's going to fund that.
That doesn't make any sense.
Dr. Joshua Goldenberg (29:39):
Yeah Well , interesting, I wonder.
Actually I don't know whofunded this one.
They'll look at the bottom.
I forgot to check the funding.
Dr. Adam Sadowski (29:44):
It was publicly funded.
And then the Krill Oil Companygave them product for free but
had no role in the methods datacollection, whether or not they
were going to publish or not, soit was publicly funded.
Dr. Joshua Goldenberg (30:03):
Cool yeah , and I just want to point out
like that is totally okay andnormal it's a multi-million
dollar study probably and youknow, someone donates some krill
oil like that's not going toinfluence things, but to like,
so that people say, well then,why, why do you get it donated?
Because, pragmatically, whenyou do these studies, you need
all the quality assurancedocuments and certificates for
safety, and so you need to beworking with the company that
makes the product to providethose analysis to give to your
(30:25):
ethics board.
And also, when you'remanufacturing a placebo, it has
to match as much as possibleright for blinding, and so the
usually the best way to do thatis to have the facility that
makes the actual product alsomake the placebo, so that
everything else is kind of thesame.
So, again, that's totallyreasonable, I think.
So, yeah, okay, so we have okay.
(30:46):
Another thing I wanted to pointout we did have a lot of dropout
right.
So you have 262 peoplerandomized, half to crow oil,
half to placebo.
They did a good analysis, liketheir primary analysis was.
You know, everyone that wasrandomized, but I think they
lost, like what, 24 people inone group it looks like 23 and
(31:07):
another, which is a significantpercentage of the total.
Dr. Adam Sadowski (31:12):
I think it's easier to look at it from a
percentage standpoint.
I think it was like 15% and 17%in both groups and overall only
85% of people completed thetrial.
So I do think, from a you know,bias standpoint, that is
something that has to be takeninto account, especially as they
did not use an intention totreat analysis.
Dr. Joshua Goldenberg (31:32):
I want to ask you about that.
Like, that seems like a.
I mean 24 weeks it's a longtime and I guess 15% doesn't
sound so crazy, but still thatseems to be a lot of people to
just drop out of the study andat least it's balanced, right.
And if we look at the reasonsfor dropout here, they say
(31:53):
dropped out for adverse.
So seven dropped out for anadverse event in one group
versus eight in the other.
That seems balanced.
Perceived lack of efficacy fourin one group, six in another.
Six cannot be contacted.
So it seems like balanced asfar as the number of people that
dropped out and the reason.
So it doesn't appear on its facethat the intervention itself
was driving dropouts.
(32:14):
So that's what you worry aboutfrom a bias perspective.
You just kind of wonder, well,if you're just missing this many
data points, maybe it's not abias issue, but maybe it's like
you're just you know it'll,you're not going to see the
effect as well, right, you'rejust kind of losing your power.
So yeah, I don't know Anythoughts on like why they had
such a large, relatively largedropout.
Is it just the length of time,you think, or maybe just the
(32:35):
people running the trial?
I mean they were run throughdifferent.
You know, I think clinics, butI think primary clinics.
Dr. Adam Sadowski (32:43):
Yeah, I mean it may have just been a time
issue.
I'm really not sure, becausewhen we even look at the
adherence rates, they were sohigh 99% in the krill oil group
and 96% in the placebo group.
So you know, the adherence totreatment for those who were
taking it was so high.
It would have been interestingto see what was the adherence
rate in those who dropped out.
Like, did they also have a highadherence rate and then just,
(33:06):
for whatever reason, dropped outof the study?
Or yeah, I don't know.
It's a shame that that happenedand kind of a bummer that they
didn't do it in ITT.
Dr. Joshua Goldenberg (33:16):
Yeah, right, so they did.
So they sort of did intentionto treat, but they didn't do
like a sensitivity analysis, Iguess across it, but it was an.
It was a null finding anyways,as we'll talk about, so I guess
it's less of an issue, okay.
And then primary outcomes wasthe 24 week change in self
reported knee pain.
So I like that the primaryoutcome, even though it's
subjective, is clinicallyrelevant.
(33:37):
I loved that they predefinedtheir minimal clinically
important improvement.
Did you see me like in yourmind doing a little jig when you
read that?
Because I was like, yeah, I did, I did.
Yeah, I was beyond thrilled andthey actually picked the right
number.
So, like there's a lot of newresearch on minimally important
differences, we used to thinkthe VAS scale, okay, it's like
(34:01):
10 points, right, you just do10%.
But actually it depends to doit properly.
Like you need to look at, youneed to actually ask the
population that's relevant toyou.
So you know, find a group ofpeople that have knee arthritis
and ask them like what's theminimal difference that would
matter to you?
And and they use the 15.
And most of the studies thatI've seen, whether it's shoulder
(34:21):
pain or knee pain or somethinglike that.
It's somewhere between like 13and 18, or something like this,
so 15 sounded really totallylegitimate.
They had that.
Initially.
They had a lot of secondaryoutcomes, including the change
in effusion syncytitis, and then, like I think, up to like 60
other secondary outcomes.
That's the other thing.
Like they definitely wentfishing, like they had lots of
(34:41):
things they looked at, but theywere so upfront and honest about
it so that I feel like I wasn'ttoo worried.
Dr. Adam Sadowski (34:48):
Yeah, I mean.
They even said, due to thelarge number of secondary
outcomes, results for secondaryoutcomes should be considered
exploratory.
So they straight up said likehey, yeah, we're looking at a
bunch of stuff, please don'tlook into it.
Really, what that means iswe're setting up future trials
and future research questions.
That's pretty standard.
Dr. Joshua Goldenberg (35:06):
Yep, yep, yep and it's like so I always
wonder with this sort of thingif it was the peer reviewers, if
it was the referees that, like,required them to temper their
thoughts about secondaryoutcomes.
But just basically readingbetween the lines here, I feel
like these authors were, likeyou said, super legit.
Probably was their originallanguage and yeah.
So it's okay to explore andhave exploratory outcomes.
(35:27):
Just don't pass them off aswhat you intended to see, and I
think they did a good job ofthat.
Dr. Adam Sadowski (35:36):
I think too, if they had 60 secondary
outcomes to look at.
They really are, are trying tobe as thorough with this as
possible, and so even if there'slike the slightest noise of a
positive secondary outcome, youknow they're going to go down
exploring that.
Dr. Joshua Goldenberg (35:47):
Exactly and they saw a couple things
that didn't really make senseand we're probably just like
random.
Oh, the other thing I reallyliked about the MCID is the
minimal important difference.
They set them as well for labvalues, which is so cool and you
rarely see.
We did that with our paper acouple years ago on on low carb
(36:07):
diets and, as far as I know, wewere like the first people to do
that.
We had like a big discussionabout should we do this?
Should we apply this concept tolab values?
Can you do that?
What's your justification?
I mean, I'm sure we weren't thefirst, but we didn't know of
anyone else and it's neat to seeother people doing that now and
actually using very similarthresholds to what we used,
which I think is kind of cool.
So, yeah, it's this idea thatyou know.
(36:29):
You just have to start settingthese thresholds that matter one
way or another, and that isanalogous in labs.
It's obviously not patientimportant, because you can't
tell the difference, but it isclinically important and they
actually use these.
People are great man.
They actually use differentlanguaging around that right, so
that you have the minimallyclinically important improvement
(36:49):
, which is a very specificphraseology there, versus the
minimal clinically importantdifference for the labs.
Yeah, they did a great job.
They clearly were well versedin MCIDs and all that.
Yeah, I like these authors.
I don't know any of them.
I don't recognize any of thosenames, but I'm impressed as well
.
Alrighty, what else did youwant to talk about?
That's pretty much everything Iwanted to talk about on results
(37:12):
, besides some comments onadherence.
Anything you want to touch onfirst?
Dr. Adam Sadowski (37:17):
No, that was it, and we already talked about
the adherence too.
Dr. Joshua Goldenberg (37:20):
Yeah, and the adherence right, the
adherence was excellent, youknow.
The other thing I'd say is theylooked at, not just at counting
pills, which is what almosteverybody does Like.
Okay, return the bottles whenyou're done.
Let's count up how many areleft to figure out how adherent
you were.
But they actually had abiomarker for omega-3 as well,
which I thought was great.
So they had like proof that notonly were you taking the omegas
(37:43):
, but it was getting into yourbloodstream and bioavailable
enough to have an impact, whichis it's really nice when you can
have that biomarker as well,alrighty.
Dr. Adam Sadowski (37:57):
So let's talk results.
You want to walk us through theresults?
Sure, so the primary outcome,which again was the change in
knee pain based on the visualanalog score.
And so again, that visualanalog score goes from zero to
100.
100 is maximal pain, zero is nopain.
In order to be included in thestudy you had to have a score of
at least 40.
And when we look at ourdemographic table, score of at
(38:22):
least 40.
And when we look at ourdemographic table, the average
knee pain for the two groups wasa 48 in the in the krill oil
group and a 50 in the placebogroup.
So basically the same.
And then when we look at theprimary outcome, so the change
in that there was no differencebetween the two groups.
From baseline to 24 weeks itchanged by 20 points.
It went down by 20 points inthe krill oil group versus 20
points in the placebo group.
(38:44):
Absolutely no difference.
Dr. Joshua Goldenberg (38:47):
Yeah, so both improved significantly.
But there is no differencebetween placebo and krill oil
there.
It's not too surprising to seea clinically important
improvement from baseline toendpoint.
In general like not when you'recomparing across groups, but
just because this issubjectively reported outcome
(39:07):
they know they're gettingsomething and so when you ask
them how they're feeling, likethey're going to report feeling
better, right, Like that's just,that's the placebo effect.
So it isn't crazy to think that, yeah, you would drop 20 points
when you're in a study, whenyou're taking something.
But that's, of course, why wedo these placebo comparisons,
because the drop with the krillwas exactly the same as the
placebo group.
Dr. Adam Sadowski (39:28):
Right.
And then when we look at thesecondary outcomes, of the 60
secondary outcomes that werelooked at, two were different,
58 were no different.
Of those two, one favored krilloil and it improved
triglycerides at the 12-weekmark but not the 24-week mark.
(39:48):
So it didn't really do anythingthere.
And then when we looked ateffusion synovitis volume at 24
weeks, the placebo groupactually improved that over the
krill oil group.
Dr. Joshua Goldenbe (40:00):
Interesting right.
Dr. Adam Sadowski (40:02):
To all the corn oil haters it improved
inflammation.
Dr. Joshua Goldenberg (40:06):
Yeah, that was interesting, and they
kind of talk about when I guesswe could talk about that in the
discussion.
Like they kind of talked aboutwhy that, why in the world the
placebo would improve it, and Ithink they just kind of
concluded at the end that it wasprobably a random, random
result.
Yeah, alrighty, so that's thatprobably a random, random result
.
Yeah, alrighty, so that's,that's basically it.
Ladies and gentlemen, um, Ilet's look at the anything.
(40:27):
I think we discussed most ofthe discussion as we went
through.
Um, I want to see if there'sanything else here I want to
talk about.
Yeah, so, basically in thediscussion they're going through
, they're like okay, why didn'twe see an effect here?
Like the dose was you know rightbetween these two studies that
we've seen that showed benefit?
There was.
There were studies that showedbenefit of exactly two grams a
(40:48):
day.
They all had knee pain, theywere improving.
So like, what's the difference?
And I think, at least in myreading, the only major
difference if you assume thatdose is not responsible, then
because you were seeing effectsat like two grams and 300
milligrams in other studies wasthe population.
Like it wasn't.
The other populations were moremixed.
Maybe they had some rheumatoidarthritis, maybe they had knee
(41:11):
pain that wasn't necessarilyosteoarthritis knee pain, and
then also they didn't have thissynovitis piece, and so those
seem to be the most like if it'snot truly negative, and those
initial results are true, andthis is true too then that was
the take home that I had, thatit's like, well, maybe it's the
difference in the populationshere that if we're really
(41:32):
talking about a knee arthritiswhere you're having synovitis,
then it's just not gonna helpyou essentially.
Dr. Adam Sadowski (41:43):
Yeah, yeah, yeah, yeah.
I don't have anything else toadd to that.
Dr. Joshua Goldenberg (41:45):
Cool, I think that's everything just
going through here.
Yeah, that's everything as well.
They also looked at adverseevents.
There wasn't any majordifference between groups there
and they talk about how, um,what they saw with the placebo,
that's the placebo thing.
So that's the placebo thing.
So that's another thing Iwanted to highlight.
So and I thought I think Italked about this earlier so
they have this study of twograms a day showing benefit,
(42:07):
right.
So that's what?
Again, that's what they'redoing and they're like, okay,
well, maybe you know you messedup the placebo pill.
Maybe the placebo pill wasactually beneficial and that's
why you're not seeing adifference.
But again, they use a placebopill they claim very similar to
that used in the study that hadthe two grams that showed
benefit, right?
So again, in theory, it's notthat either.
(42:31):
So, yeah, I think, at the endof the day, if you've got knee
arthritis and you've gotsynovitis, krill oil is probably
not going to help more thanplacebo, according to the
findings of this study.
And I think that's pretty muchwhat I want to say about this
paper.
Anything else you want to add?
(42:51):
Is it practice changing for you?
No, well, I mean, I don't.
I just, I'm such a specializedpopulation that I don't I don't
really see people for arthritis.
I'm such a specializedpopulation that I don't really
see people for arthritis,although I have to say my
laziness, because I see peoplewith basically one condition
small intestinal bacterialovergrowth.
If they happen to mentionarthritis, pain here or there, I
(43:13):
will often say lazy things likeoh well, you might consider
some fish oil or something likethat acryl oil, and so maybe
this will be practice changing.
Maybe I'll kind of check thatreflex a little, a little bit
more.
How about you You're?
You see patients like thisevery day, probably.
Dr. Adam Sadowski (43:28):
Uh, I mean I, I see knee osteoarthritis a lot
, um, I see people on omegathrees.
I have not yet seen anyonespecifically using krill oil for
anything, but I, you know, I, Igo to conferences, I see, I see
the salesmen and saleswomenyeah, we've got this thing
against salesmen.
So I always just yeah, I alwaysjust roll my eyes.
(43:50):
Here's what I would say.
I would say I, I would notconsider it.
Um, if someone was already onit, I'd be like you know, if you
don't want to be on it or youdon't know why, it's fine to
discontinue, but I personallywould not be making the
recommendation to start this.
Dr. Joshua Goldenberg (44:08):
Yeah, and and you know, to your earlier
point, like there might even bea little bit of a harm there
with AFib signal.
So we should, maybe we shoulddo that paper next to continue
with the curmudgeon theme, justbecause, like, sometimes it's
like okay, yeah, like it'soverblown and over promoted, and
when you look at good qualitystudies there's nothing there
and usually it's just like okay,but it's benign.
(44:28):
You're probably fine if youwant to stick with it, right,
but that's not always the casewhen you do have these harm
signals.
So I am curious personally tokind of look at that a little
bit more.
Maybe we'll do that next weekor something like that.
Dr. Adam Sadowski (44:40):
Also, I wouldn't say I'm a curmudgeon.
I really do think I'm just ahealthy skeptic because so many
people are.
They want to believe thesethings work.
Introducer (44:48):
But if we?
Dr. Adam Sadowski (44:48):
don't have the data to support it.
We have to stop.
We have to challenge our biases.
If we don't challenge ourbiases, things don't change,
things don't evolve and you getleft behind.
I'm sorry, but if you want theprofession to change, if you
want to be a better provider,you have to challenge your
biases and everything.
Dr. Joshua Goldenberg (45:08):
Yeah, yeah, it's true, it's true, I
think.
You know, I just I feel like I'mjust steeped in this assumption
, cultural assumption, that fishoil, omegas, like that they
work, and I don't know wherethat comes from.
I think that just comes from,like that's the societal milieu.
And you know, you hear somepapers or you hear your
(45:28):
professors in school and youknow, and then I just never was
in a field where I wasprescribing it a lot, right, and
so I never really looked intoit much, and so it is kind of
interesting to actually look atthese papers and be like, no,
not really, and oh, you know,there might even be harm signals
here.
So, you're right, it isimportant to question these
things.
I guess it's.
(45:49):
I guess you can't, so you can'tquestion everything, and so,
yeah, I think I think you justquestion the things that are
high value and also that you seeevery day, right, so, like for
you, I think it makes sense tobe doing, to be looking at that
and to have these conversations.
And I'm curious, dear listeners, because I think that, um,
there'll probably be a lot ofhate mail after this one, I
(46:11):
would suspect, and they're goingto be giving us good papers.
Dr. Adam Sadowski (46:14):
So, yeah, so with your hate mail, but then
good, but like then, I'm gladthat's happening.
Send a good paper, send goodpapers.
Dr. Joshua Goldenberg (46:23):
Yeah, send good papers, yeah, yeah.
So here's, here's, the otherthing is okay.
So we have this our own.
Our own tendency is to be to becritical of everything and to
just assume it's all randomness,right, that, at least that's my
tendency, and that most of thehigher quality, larger studies
will basically show that almostnothing works.
But you know where I go withthis evidence nihilism thing.
(46:45):
However, I also want to own thefact that I'm not an expert in
fish oil research.
I haven't looked at a lot offish oil studies and it could
very well be that this is anexception to the rule, and in
fact, this study followedapparently three studies that
were positive.
I don't know if they're welldone.
One of them at least had over200 participants, I don't know.
But I also want to own the factthat it could be that we're
(47:07):
looking at a true subgroupphenomenon where populations
with osteoarthritis of the knee,where you have the synovitis is
just not going to benefit it'stoo far gone, or something like
that Whereas more mild casesmaybe it does.
I don't know.
Is that an apologist for thekrill oil?
Possibly you should look at mydisclosures.
I just got a huge new tri bikefrom Big Krill and I call it my
(47:32):
Big Krill, big Grill, and soanyway, but yeah, but I think
that's.
The other thing is that, andthis is okay, well, okay, I want
to go on this tangent a littlebit longer.
When you're in the evidenceevaluation world like I am most
of the time, you know, doingsystematic reviews, teaching
critical eval it's so easy forme to like say, ah, this is just
randomness, yada, yada, yada,and maybe that's good to have
(47:54):
that distance.
And then, whenever it's a it's aclinical question about a
clinical field that is very dearto my heart, that I like know
well and know the literature,I'm always much more skeptical
of people's attempts to like poo, poo it, and I think that's a
natural inclination.
But I also feel like I don'tknow there's like benefits of
(48:14):
being removed and looking atsomething purely from a methods
perspective, but also there'sobvious harms.
Right, like you're not acontent expert, you don't
necessarily know the literaturewell, and that's one of the
things I like about doingsystematic reviews is like you
always include content expertsin your team for exactly this
reason.
Right, you've got yourmethodologists, but you also
have your content experts tolike keep you honest or keep you
(48:36):
from being like overly critical, I guess.
Anyway, thoughts on that, or isthat just me rambling?
Dr. Adam Sadowski (48:43):
no, I get where you're coming from.
Um, I always kind of used to bethe opposite, where I was like
oh, supplement in jama, bet youit's going to be a negative
trial, because, like 99 of thetime, it's a negative trial yeah
, right to now where I'm.
I mean that was a very likeemotional response because I'm
in the integrative profession.
(49:04):
It feels like an attack on me.
Yeah.
To now me being okay, it's anegative trial.
Let's actually see if it'ssomething to be up in arms about
.
Were there huge flaws or wasthis just a really well done
trial?
And we're just upset about ouremotion, and the more I look at
(49:24):
it, it's usually the latterrather than the former.
Now, of course, there's alwaysgoing to be instances of the
former and you know, I thinkpeople also have to realize that
because we're so in theintegrative space, we're looking
at integrative things and so Ikeep saying this doesn't work,
this doesn't work, et cetera, etcetera.
There's inadequate evidence tothings.
The opposite is not also true,that that means that all
(49:49):
medications work.
We're critical of all things.
It's just that we just sohappen to be in the integrative
space.
So we're looking at thesethings and if they're not
working, we're going to say thatthey're not working or not
providing the magnitude ofeffect that we want it to.
And it's very sobering.
Dr. Joshua Goldenberg (50:10):
And I think that people need to come
to that conclusion as well.
Yeah, I think that's well said,right, because of our area of
interest, this is what we talkabout, but, as longtime
listeners will know, we'reequally critical of a lot of
different interventions and tendtowards the evidence nihilism
position for all of medicine.
We were excited for Shiljatyeah, that was a surprise.
(50:30):
That was kind of cool.
Yeah, every once in a while yousee it.
Or Kirk Heumann was showingsome pretty cool stuff too.
We did that one paper on.
Dr. Adam Sadowski (50:38):
Yeah, we're shills for Shiljat Big Shiljat
jack.
Come sponsor us.
So how is that?
Dr. Joshua Goldenberg (50:49):
I thought it was sheila jeet.
How do we print we don't know,no one will know.
Nobody will know, no one willknow.
No one knows.
Unknown, unknown.
It's one of those.
It's like uh oh, you'reprobably too young for that.
You know the um.
How many licks does it take toget to the center of a tootsie
pop roll or whatever?
Dr. Adam Sadowski (51:00):
I'm old enough for that.
Yeah, with a little with theowl, with the owl, yeah, yeah,
yeah with the owl, with the owlright.
Dr. Joshua Goldenberg (51:06):
Some things are just unknown, right?
So anyway, um so interestingcan't.
Dr. Adam Sadowski (51:15):
I think between now and the next podcast
, one of us needs to get aTootsie Roll Pop and find the
answer.
Dr. Joshua Goldenberg (51:21):
Yeah fair enough, I'll put Theo on it.
I think he'll be thrilled.
He's all hopped up.
Today was his last day ofkindergarten and so I went in
for the kindergarten party andso they brought in like pizza
and cupcakes and like juiceboxes and I had already packed
him a cupcake in his lunch forhis like last day, so like the
(51:42):
kid.
Well, the entire class arehopped up on sugar, like
literally bouncing around theclassroom jumping on each other,
and I'm just look, did theyalso?
What was that?
Dr. Adam Sadowski (51:53):
did they also come.
Everybody get a free sample ofozempic.
Dr. Joshua Goldenberg (51:57):
Here's your cupcake and ozempic well,
it or or like a benzo orsomething to calm the freak down
.
It was, it was totally nuts andI just I was like I turned into
something.
Other parents and I was like Iam just so glad that he's got
two more hours here before hecomes home, because he's gonna
have to, like, burn off thissugar crash with his
kindergarten teacher not me,although he'll probably be a
(52:19):
half asleep in a coma by thetime I get him isn't it kind of
funny how we go from like kidsbeing hopped up on sugar to then
we just transition to caffeineas adults?
Oh yeah, I'm hopped up oncaffeine right now, right, so
it's like you know I I havenothing to say about this.
All right, ladies and gentlemen, we will talk to you later.
(52:40):
Adam, it is wonderful to talkto you.
I missed you.
I'm so glad we were back onthis thing likewise my friend
all right, take care bye thankyou, everybody.
Please do us a favor and letthem know about the podcast and,
(53:01):
if you have a little bit ofextra time, even just a few
seconds, if you could rate usand review us on Apple Podcast
or any other distributor, itwould be greatly appreciated.
It would mean a lot to us andhelp get the word out to other
people that would really enjoyour content.
Thank you, hey y'all.
This is Josh.
You know we talked about somereally interesting stuff today.
I think one of the things we'regoing to do that's relevant.
There is a course we have on DrJournal Club called the EBM Boot
(53:24):
Camp.
That's really meant forclinicians to sort of help them
understand how to criticallyevaluate the literature, etc.
Etc.
Some of the things that we'vebeen talking about today.
Go ahead and check out the shownotes link.
We're going to link to itdirectly.
I think it might be of interest.
Don't forget to follow us onsocial and interact with us on
social media at DrJournalClubDrJournalClub on Twitter, we're
(53:46):
on Facebook, we're on LinkedIn,etc.
Etc.
So please reach out to us.
We always love to talk to ourfans and our listeners.
If you have any specificquestions you'd like to ask us
about research evidence, being aclinician, etc.
Don't hesitate to ask.
Introducer (54:00):
And then, of course, if you have any topics that
you'd like us to cover on thepod, please let us know as well.
Thank you for listening to theDoctor Journal Club podcast, the
show that goes under the hoodof evidence-based integrative
medicine.
We review recent researcharticles, interview
evidence-based medicine thoughtleaders and discuss the
(54:22):
challenges and opportunities ofintegrating evidence-based and
integrative medicine.
Be sure to visit www.
d rjournalclub.
com to learn more.
Welcome to the Dr Journal Club podcast, the show
that goes under the hood ofevidence-based integrative
medicine.
We review recent researcharticles, interview
evidence-based medicine thoughtleaders and discuss the
challenges and opportunities ofintegrating evidence-based and
integrative medicine.
Continue your learning afterthe show at www.
(00:23):
d rjournalclub.
com.
Dr. Joshua Goldenberg (00:31):
Please bear in mind that this is for
educational and entertainmentpurposes only.
Talk to your doctor beforemaking any medical decisions,
changes etc.
Everything we're talking aboutthat's to teach you guys stuff
and have fun.
We are not your doctors.
Also, we would love to answeryour specific questions on
drjournalclub.
com.
You can post questions andcomments for specific videos,
(00:55):
but go ahead and email usdirectly at josh at
drjournalclub.
com.
That's josh at drjournalclub.
com.
Send us your listener questionsand we will discuss it on our
pod.
Hello and welcome to the DrJournal Club podcast, where I've
(01:15):
missed my podcasting partnerlately.
It's good to have you back, sir, I have to say.
Dr. Adam Sadowski (01:20):
Hello, hello, hello.
How are you?
Dr. Joshua Goldenberg (01:23):
Good, good, you were well missed.
I do have to say I don't knowif you listened to the last um,
the last pod, but I I had a odeto I owe to you in the middle.
It's like, oh, this is soboring.
I just it was so weird talkingto myself about the, the paper,
I just felt like it was uhspeaking out into the ether like
the the old days, or somethinglike that that's probably gonna
(01:45):
have the the most views or themost downloads to watch yeah,
they're like hey, everyone,adam's not on this one, take a,
take a listen.
Yeah, although it's funny, likeyou get into your rhythm and
then you just start talking andit feels normal, but at first
you're like I'm talking tonobody.
This is very, very strangeright and I was realizing like
(02:07):
we've done this for a long time,like it was kind of weird at
that point because you know,basically I think we've been
doing this for a year and a half, something like that,
definitely over a year sincelast october, I think oct.
Dr. Adam Sadowski (02:21):
Because I remember it was the fall or the
winter of my final year ofresidency and I just remember us
talking about studies and wewere like let's just you know we
already talked about all ofthis.
Why don't we just share it withothers?
Dr. Joshua Goldenberg (02:39):
Yeah, let's just basically still do it
.
Dr. Adam Sadowski (02:42):
And then literally the next week week.
We just started doing that.
Dr. Joshua Goldenberg (02:47):
Yeah, and it's been fun.
Man, it's getting easier andeasier to podcast, I have to say
, and now there's liketechnology that we can remove
filler words and all this jazz,but anyway.
So how are you?
Briefly, how are you in life?
It's been a while.
The listeners haven't heardfrom you in like months and
months and months and months.
How are you doing?
(03:07):
What are you doing?
The rumor on the street is youare no longer training for
triathlon.
Is that true?
Is that a blatant lie?
Are you back on the saddle?
What is going on?
Dr. Adam Sadowski (03:17):
The rumors are semi-true.
Overall, life is great, butwith the triathlon training and
working as a full-time clinicianand doing a lot of other
extracurricular things andwanting to also have a life,
it's that last piece that'sgonna get you every time yeah
and it was just a culmination ofthings and just honestly
(03:41):
started feeling really burnt outwith it.
Uh, when I first started Iactually just truly enjoyed the
training component of it andreally just liked going to every
training session, and then thatonly recently really um,
started to dwindle to the pointwhere I then just hated every
single training session I wasdoing and then I was like, why
(04:03):
am I actually doing this?
I'm not a professional triathlon, you know triathlete if it's
not fun, you gotta stop yeah andI was like I'm not trying to
prove this to anyone and I knowI can do all of the events
because I I've, you know, I'vedone every single event on its
own and I have done combinationsof it.
(04:24):
I've just never done the fullthing, like at an actual iron
man event.
And then I was like, well, youknow, if I, if I know I can do
all these things, that wasreally kind of the internal
motivating factor of it.
I was like, well, can I even doit check?
I don't need to prove it toanyone else.
And then why do I have to bringit on a very specific day,
(04:47):
right at a very specific time,when it at first is like, hey, I
feel really good today, likelet's just go, versus let me go
to a race event and have all thestuff that I'm used to be, all
these like weird variables inthe way of like you know a
different hotel room and likesleeping at a different hour and
like you know nutrition's notthe room, and like sleeping at a
different hour and like youknow nutrition is not the same
(05:09):
versus like, hey, I just woke up, felt really good and went for
it.
Dr. Joshua Goldenberg (05:11):
Yeah, no, that makes sense.
I mean, you, you hit your goals, so now you just got to find
new, new goals, to have newthings to hit from her.
For, like, that's the thing Ilike about having some sort of
like I hear what you're saying,but for me, anyway, I need that
external like requirement, or Ijust don't get it done Because
there's like you know, you havea couple races a year, you train
(05:34):
up for it, and then there'salways like I need a little
break for a month or somethingright, like I kind of let things
go, and then it's like, oh, yougot another race in six months,
josh, like you got to prepagain, and so for me, like that
is, especially with, like, thefear of death in water, is like
enough of a motivator to likeshow up and do the the training
sessions.
But yeah, if so, that's for me.
Dr. Adam Sadowski (05:54):
But yeah, if you're able to just get it done
and that was your motivator,then you're good man also it's a
very expensive sport, and so itis for the most part I was just
kind of of you know winging it,like I have a lot of like used
stuff and just like buying stuffon the very, very cheap.
Yeah.
And then I was like, well, ifI'm actually going to do a race,
(06:14):
the race itself is going tocause cost upwards of a grand,
and then to get all this otherequipment and like working
equipment and stuff like that,it's gonna cost a pretty penny.
and then when I, you know,calculated all out, I was like I
would much rather fly firstclass round trip around the
world vacation for two weekswith, like, my best friends and
(06:35):
like, live it up, then endure,you know, eight hours of pain in
one day, just to get a littlepiece of plastic that says you
can do, just to say you did it,yeah, yeah.
Dr. Joshua Goldenberg (06:48):
And then the classic line for triathlon
is like oh, did you win the raceMe?
Like no, no, I finished therace.
Yeah, oh well, did you come inlike there?
No, I was like 130th in my agegroup, you know.
Yeah.
But well, well did I.
Briefly did I, speaking ofcheap equipment, I told you
about what happened with my bikeon my first try, right, my
(07:11):
first one and only try.
Yeah.
Yeah, yeah.
So I think the having decentequipment matters.
Like you can't really wing itand it's just like some things,
like everything else that I'vedone in terms of this, I always
just get the cheap stuff or likewhatever, like I don't know
that it really matters, and butI think here like yeah, ok, you
(07:32):
don't have to buy like the$10,000 bike, but you should
probably buy a nice bike, right,right, if you're going to, and
then you should probably protectit when you travel and all that
jazz.
Dr. Adam Sadowski (07:41):
Anyway, this has nothing to do with what
we're talking and yeah well, andalso like just for anyone out
there who's like also kind ofgoing through anything similar,
like it just quit, like it'sit's okay, like I feel like
there's this you know thing andwith society of like, if you
quit, yeah quitting is okay well, no, no, not that quitting is
okay.
Well, it is okay, but that likeif you quit, you failed oh yeah
(08:03):
it's like I didn't failanything.
I was like doing something thatI just wanted to kind of like
fool around with and see if Iliked it, and at the time it was
something that I really enjoyeddoing, and then I didn't like
doing it.
So I'm not going to do a sunkcost fallacy where you're just
going to keep investing intosomething that you're either not
enjoying or just's just afailure, with the hopes that,
(08:26):
well, I'm already down this far,let me just keep.
At some point it's got to turnaround.
No cut your losses and like,move on.
And so like I mean, I stillwent for a run today, I still do
things I enjoy.
Dr. Joshua Goldenberg (08:39):
It doesn't necessarily have to be,
you know, grueling hours on a tobe, you know, grueling hours on
a on top of an already hectic,you know, work schedule.
Yeah well, dude, you weretraining for half iron man,
right?
So that's like crazy hours,yeah, so that totally makes
sense to me.
What did I want to say aboutthat?
Oh, yeah, well, it's also.
It's not well, I don't thinkyou failed at all, but it's like
or cutting your losses.
(09:00):
I don't think there are anylosses, but um, the.
The other thing is like it's,it's what you're like, what are
the outcomes that you'veselected, right?
Is it to get that metal at theend of a finish line, that like
that piece of metal thatprobably cost them two dollars,
right?
Or is it to stay fit andhealthy, or to prove that you're
able to accomplish somethingphysically?
And if it's the latter two,like, yeah, nailed it, yeah,
(09:23):
check, and so like, yeah.
So I think it depends on likewhat, the what the outcome
measure is right.
So, to bring this back toclinical trials, it's like what
is the, what is the clinicallymeaningful outcome here?
Right?
Like what's the outcome thatthat's meaningful to you?
And you could even argue that,like to extend this obnoxiously,
you can even argue that likethe metal, or doing the actual
(09:45):
race is just a surrogate outcometo like.
Yeah, health and wellness, youknow but I don't know.
Dr. Adam Sadowski (09:53):
I just feel like, you know, looking back to,
it's kind of silly of like, heyAdam, let's go hang out.
It's like, oh no, hold on, Ihave to go sit on a saddle for
three hours watching Netflix,but you go ahead, go have fun.
Dr. Joshua Goldenberg (10:05):
Yeah, fair enough.
I think it sounds like you'vemade the wise, smart decision
and you've proven that you canpull it off, which I think is
impressive.
Dr. Adam Sadowski (10:13):
And I got better at three things.
You know, I got better atrunning, I got better at
swimming, I got better at biking.
I'm going on.
I still go on bike rides, butlike they're more leisurely with
friends, let's go checksomething out.
It's still fun to do thosethings, but not with the mindset
of, oh, I'm doing this becauseI have to do it for triathlon
training, it's more so.
Oh, I'm doing it because it's anight day, let's go on a bike
(10:36):
ride.
Dr. Joshua Goldenberg (10:37):
Yeah, we should just call this podcast
the Triathlon Podcast at thispoint.
But the one of the things Iliked about switching to
actually getting a propertrainer this year is that I used
to just like go out and likeput in those hours, thinking
that that's what I needed to do.
And I think that, um, what shehas me on now is like, okay, you
do 30, 40 minutes of likesomething every day and then you
(11:00):
do your long ride, you knowwith a, you know with a brick or
whatever, like you do at theend, but on the weekends and
obviously that builds up as youget closer to the race.
Yeah, I think it was just doingthose continuous long runs
every time was like so drainingfor me and to just like, oh yeah
, I'm just working out for 3040minutes a day, like that seems
totally doable.
And then, yeah, there is thisone long thing on the weekend
and as you get closer to raceday, it gets like more and more
(11:22):
owners, so it takes up more andmore of your day plus recovery
time.
That's hard on families andlife and all that.
I think my total minutes oftraining is lower now but I feel
better about it, like it's lessof a drag, I guess, okay,
should we talk about science nowand medicine?
Yeah, we can.
(11:42):
Okay, sort of.
So you know, we're only 10minutes 20 seconds in.
So, speaking of biking,speaking of knees, speaking of
knee pain, we are going to talkabout a.
You see how I did that.
That's professionalism, rightthere.
It's a really nice transition.
Just note that.
Dr. Adam Sadowski (12:00):
We're talking about migraines today.
People.
Dr. Joshua Goldenberg (12:02):
Shoot did So my friend Adam here sent us
this article on krill oil forknee pain and because of his
contrary nature I'm suspiciousthat he sent it because it was a
negative trial and he likes tobe contrary about integrative
medicine.
Is that true?
Or did you just see it and sentit before you saw the results?
Dr. Adam Sadowski (12:25):
I wouldn't label it as a contrarian.
I would label it as I'm askeptic of a lot of things, and
I think that there's too muchdirect to consumer nonsense out
there, and so I really wantpeople to question things when
they see things, especiallysince at a lot of these
integrative events there's a lotof lab testing industry,
(12:46):
there's a lot of supplementsalesmen, and I want people to
actually understand what theevidence is for what they're
using these supplements for, andnot just taking it because some
sort of fancy paper by someonewho's wearing a suit and tie,
who isn't actually a researcher,is telling you this is the next
best thing and it's nodifferent than a pharmaceutical
(13:09):
rep doing the exact same thing.
And so I think that really weneed to question that and
recognize that that is a bigthing in the integrative
evidence space that no one wantsto talk about, and so I will
happily talk about it.
Dr. Joshua Goldenberg (13:23):
Excellent .
I have to admit, it's reallybeen weird, ever since we've
been friends, to have someonemore on that wing of things than
I am.
I feel like most of my well,all of my career in natural
medicine, I feel like I've beenthat contrarian.
What did you say?
Oh, not contrarian, curmudgeon,oh wait, no, no, you said
(13:44):
critical thinker.
Okay, so I feel like I've beenthat one, but to have someone
outflank me is impressive.
Um, but at this point, like Ithink I sent you something the
other day.
I was like what we should dothis?
Like, um, colored noiseanalysis.
Now, I was serious.
I was just like no, I wasserious about that.
I was like you know, the whitenoise versus brown noise, versus
(14:04):
pink noise, there might be someneat studies, like whatever,
and you know, just an immediateresponse no, like that's
ridiculous.
Like adam, you haven't evenread it.
This could be a thing.
You're like no, that's tooweird, forget it anyway, all
right, so we're going to talkabout this study.
So, let's talk about this study.
Um, okay, pulling up here aboutthis study.
Okay, pulling up here, allright.
(14:25):
So this was a JAMA paper, whichwas, you know, always nice,
real JAMA, jama, jama, not JAMA.
One of its myriad offspring,and this just came out this year
.
Do you want to set it up?
You want me to set it up?
What's the rationale for?
Well, no, you don't read theintroduction.
Did you read the introduction?
This?
Dr. Adam Sadowski (14:44):
time.
Yeah, I actually read theintroduction.
I also read the discussion.
Whoa.
I did because I wanted to seehow it compared to the three
other trials that they talkedabout in the introduction.
Dr. Joshua Goldenberg (14:55):
Yes, yes, exactly the whole time, the
entire time.
Once I got to the results, Iwas like good study, good study,
good study, good study got theresults like huh, surprising,
surprising, surprising.
And all that was going throughmy head was well, how did you
mess this up?
What were the other trials thatset this up?
And yeah, and I think they dida good job of that in the
discussion.
So that's your foreshadowing.
So set us up what was therationale for this study design.
Dr. Adam Sadowski (15:16):
Yeah, yeah, and just with that thought
process, you and I are literallythe same person.
It's kind of scary, no, I agreeon many levels.
Yeah, but yeah.
So basically, kneeosteoarthritis affects a lot of
people.
Actually, in the paper theyquoted, 654 million people above
the age of 40 have kneeosteoarthritis.
(15:37):
They also said that there's nomedical therapies that improve
the natural history of it,meaning once it's set in stone,
it kind of is this progressiveissue.
And so there's this also from amechanism of action standpoint.
You know, reducing inflammationmay reduce pain, may improve
outcomes in people withosteoarthritis.
(15:58):
In omega-3s there's evidencethat it reduces inflammation and
because we love mechanism ofaction, if you can reduce the
inflammation with something,then therefore we should have
improved knee osteoarthritis.
On top of that, krill oil, asopposed to fish oil, has
improved bioavailability, sothere's better uptake of it, and
(16:20):
it contains an antioxidantcalled astaxanthin which also
can help from, you know,inflammation, free radicals,
yada, yada, yada.
And then they had three priorrandomized clinical control
trials that showed daily krilloil reduced some aspects of knee
pain in individuals with kneeosteoarthritis.
(16:41):
However, compared to this trial, none of those trials included
individuals with effusionsynovitis.
So essentially, that jointspace having some inflammation
of that synovial fluid, thelubrication within the joints.
So this way you're not, they'renot grinding on each other.
I think of it as like breakfluid basically.
(17:03):
Mm-hmm.
Uh, they none of them actuallylike break fluid.
Basically None of them actuallymeasured that and that can be
used as a surrogate marker forthe structural progression of
knee osteoarthritis.
Yeah, and so what?
Go ahead.
Dr. Joshua Goldenberg (17:17):
No, I was just going to say like it's
kind of nice right.
So obviously the clinicallyimportant outcome is the pain.
But you know, I always getnervous about subjectively
reported outcomes, and so it'skind of neat that, even though
the effusion synovitis is asurrogate marker, it is like a
surrogate marker for anobjective response like
(17:37):
progression, and so I don't know, I kind of I love when you have
these.
Okay, yeah, the subjectivelyreported outcome is the
clinically important one, butyou pair it with something
objective at the same time.
So I just love that.
Dr. Adam Sadowski (17:49):
Right.
And then I do want to talkabout those three trials without
giving away the findings ofthis paper, so I do want to go
into that next.
Mm-hmm of this paper, so I dowant to go into that next.
But the whole aim of this paperwas to look at two grams per
day of krill oil versusidentical placebo, and the
placebo that they used in thispaper was a mixture of random
(18:10):
oils, including the quoteunquote bad seed oils that
everybody's scared of, eventhough there's really a lack of
evidence to support that Watch acurmudgeon, yep.
Are curmudgeons, are they?
Do you think they're seacreatures which would be fitting
for this podcast?
Dr. Joshua Goldenberg (18:29):
They might be sea creatures.
Dr. Adam Sadowski (18:31):
Yeah, that's very fitting.
Dr. Joshua Goldenberg (18:33):
Okay, but yes that's what I envision.
I envision someone on thebottom of the ocean, sort of
like an angry mumbling.
What is it?
Spongebob, squarepants,plankton, plankton, just like
fuming about things, about theresearch evidence, literature.
Yeah, great, anyway, that's you.
Dr. Adam Sadowski (18:52):
Yes, that's me, and so this was a randomized
clinical controlled triallooking at two grams per day of
krill oil versus placebo, as Isaid, on the primary outcome of
a knee pain over 24 weeks inpeople with knee osteoarthritis
who had significant knee painand effusion synovitis.
And when we actually comparethe other three trials, which
(19:14):
they do talk about in thediscussion, they were of smaller
trials and they used differentamounts of krill oil.
One small trial looked at 300milligrams of krill oil versus
two grams in this one, so 2,000milligrams in this one.
That trial was also only 30days, whereas this one is 24
(19:37):
weeks.
Another trial did look at twograms per day, but they only
included 50 people with mildknee pain and they also had
other comorbidities associatedwith that as well, so they
couldn't necessarily say that itwas due to knee osteoarthritis.
(19:58):
Interestingly, in one paper withthe 300 milligrams per day of
krill oil, that significantlydecreased C-reactive protein,
whereas in the other one thatlooked at two grams per day of
krill oil had no change inC-reactive protein.
So for anyone who remembers thisShilajat paper that we talked
about, we did talk about how itwas really interesting to see a
(20:22):
dose-response relationship wherea higher dose of the Shilajat
improved the bone mineraldensity as well as all of the
inflammatory markers associated,relative to both placebo and a
lower dose.
But so we're not seeing thathere.
So there's some inconsistencies.
And then there was a thirdrandomized controlled trial that
(20:43):
looked at four grams per dayand that did seem to improve in
individuals with moderate kneeosteoarthritis over 26 weeks.
However, in that trial they didnot have people specifically
with the synovitis as in thiscase, and they also had a little
bit of a difference in the EPAand DHA content, but it seemed
(21:09):
like those were just more sothings to note but didn't really
change much of the results thatwe'll see in this paper change
much of the results that we'llsee in this paper Thoughts.
Dr. Joshua Goldenberg (21:25):
Yeah, I think I think you know to your
point like this.
So this study was done in thecontext of okay, we have studies
that show benefit of krill oilin populations like this, not
exactly like this, even at muchlower doses we're seeing benefit
.
And we have like as low as 300milligrams, as high as four
grams, and we're going to shootfor two grams.
So it doesn't seem like theyintentionally undershot the dose
(21:46):
or any reason like that, right.
So it seems like, you know, itseems reasonable, and even the I
think they even even theplacebo comparators were similar
to at least one of the othertrials.
So it does seem like they setthis up based on an expectation
that we have evidence that thisworks and so let's try it.
Sort of a very rigorous, largerstudy, very rigorous design.
Dr. Adam Sadowski (22:10):
This is also a larger dose than what we're
seeing in over-the-counterproducts, because I did look at
popular name brand fish oilsupplements and krill oil
supplements, a lot of which areused in the integrative space
with sort of this you know ideathat oh, it's not over the
counter, so therefore it's asuperior product and the dosing
(22:31):
on those are significantlyunderdosed compared to what's
being studied in this trial.
Dr. Joshua Goldenberg (22:37):
Well, yeah, I mean, I guess it depends
on, like, how many you take,Like I know, for I don't know
how you use them, but Iregularly.
Will you know if I do?
I don't really do fish oils,but when I do, or when I have,
it's usually been the gramlevels right, Like two grams a
day would not be, it would notbe crazy for me.
So I feel like it's a hefty butnot crazy dose.
So I feel like it's a hefty butnot crazy dose.
(22:58):
But yeah, anyway, Um, okay.
Dr. Adam Sadowski (22:59):
And also can we just plug in one thing real
quick about fish oil.
Dr. Joshua Goldenberg (23:02):
Sure.
Yeah.
Dr. Adam Sadowski (23:08):
For those who are giddy about super high
doses of fish oil.
So when I say super high, I'msaying at least four grams per
day.
There is an association therewith AFib.
So it's not.
Dr. Joshua Goldenberg (23:15):
It's not a benign a hundred percent
benign.
Dr. Adam Sadowski (23:19):
It's not.
It's not a benign, 100 percentbenign.
It's not.
It's not a benign thing.
You can cause harm with highdose fish oil, so please be
careful, and this is not medicaladvice.
Dr. Joshua Goldenberg (23:27):
Yeah, that was.
My mom just sent me that NewYork Times article about that,
that's.
I think that's the next thingwe should, we should look at.
Look, the thing is we don't dothis for money.
This is pro bono and, quitehonestly, the mothership kind of
ekes it out every month or so,right?
So we do this because we careabout this, we think it's
(23:47):
important, we think thatintegrating evidence-based
medicine and integrativemedicine is essential, and there
just aren't other resources outthere.
The moment we find somethingthat does it better, we'll
probably drop it.
We're busy folks, but right nowthis is what's out there.
Unfortunately, that's it, andso we're going to keep on
fighting that good fight.
And if you believe in that, ifyou believe in intellectual
(24:10):
honesty in the profession andintegrative medicine and being
an integrative provider andbringing that into the
integrative space, please helpus, and you can help us by
becoming a member on Dr JournalClub.
If you're in need of continuingeducation credits, take our
NANSEAC approved courses.
We have ethics courses,pharmacy courses, general
courses.
Interact with us on socialmedia, listen to the podcast,
(24:31):
rate our podcast, tell yourfriends.
These are all ways that you cansort of help support the cause.
So let's jump into the methods.
Just some things to highlight.
One of the things I reallyliked they had the entire trial
protocol and the entirestatistical analysis plan
available online.
I feel like they're being likesuper transparent.
(24:53):
Not just that they had, likeyou know, a Prospero well, not
Prospero, but not just like abasic clinicaltrialsgov
registration.
It was like the straight upentire protocol and the analysis
plan.
Dr. Adam Sadowski (25:04):
Honestly, I've been very impressed with
research coming out of Australia.
I'm not surprised that that iswhat happened.
A lot of the Australians do areally good job with when it
comes to the reporting ofoutcomes in the papers and
whatnot.
Dr. Joshua Goldenberg (25:18):
Huh, yeah , no, that's cool, I haven't.
I hadn't noticed that I'm notseeing a lot out of Australia
besides SIBO stuff.
Actually, like they FODMAPstuff is really big out of the
Monash University down there,but okay, so, yeah, so, really,
like you said, very transparent,very good methods.
We talked about the population.
(25:39):
You had to be 40 years of older.
Symptomatic knee pain you hadto have like significant knee
pain, like 40 points or higheron 100 point scale.
So these aren't people where itwas just marginal knee pain.
And I think the biggestdifference between this
population and the other trialswas A it was all people with
knee arthritis, osteoarthritisspecifically, and not a mix.
And also that they all havethis effusion synovitis.
(26:02):
And I was wondering, like, doyou?
I mean it's not like I guessyou would argue that that makes
it more severe.
Yeah, yeah, right.
Dr. Adam Sadowski (26:13):
And so if you were to see a response, then
you should see a response, right?
So if you kind of think aboutit like as a secondary
prevention type of population,you would expect to see a larger
magnitude of effect.
Dr. Joshua Goldenberg (26:25):
Right, and that's the only thing I
could think of, like trying toplay devil's advocate was well,
maybe they were so extreme, Likesometimes, when disease is so
progressed you know you justcan't reverse it and maybe
that's what we're seeing here,is that you have these anatomic
evidence of severity of diseasethat's just no longer reversible
(26:47):
, Whereas if it wasn't thatextreme it would.
I don't know, could just bethat it doesn't work, but we'll
see.
So that was one thing.
One question I had, because Ithink this is the only study
that actually had that as aninclusion criteria, that they
had to actually have thissynovitis.
Dr. Adam Sadowski (27:00):
Yeah, and that was one of the
differentiating factors betweenthis and the other three
randomized controlled trials.
Dr. Joshua Goldenberg (27:05):
Yep, yep.
So as we try to compare andcontrast, so remember, like, if
you have disparate results, itcould just be that like, well,
the early studies were wrong,like that happens or not wrong,
but just like randomly positiveright, especially smaller trials
.
But again, it could be that thepopulations are just very
different as well, and so that'salways something that you have
to sort of consider.
So I thought they did a goodjob with randomization, with
(27:27):
treatment assignment, withblinding.
I was all pretty happy with allthat.
You know, one thing that comesup when I hear you know people
complain about integrativemedicine trials, I hear you know
people complain aboutintegrative medicine trials,
about oils or about integrative.
You know, anything is the is becareful about the placebo.
And like, what is the placebo?
Is it truly inactive or not?
(27:47):
So, like you said, this wasvegetable oil, it did have olive
oil, so it did have things thatyou know you might suggest
would be negative, but also ithas olive oil.
So what about the argument that?
Well, maybe the placebo itselfhad a benefit here, although the
point, because it's maybeanti-inflammatory.
However, it doesn't have anyEPA, dha, and maybe that's what
(28:11):
you're measuring here.
Dr. Adam Sadowski (28:13):
It also has corn oil, which everyone loses
their mind over.
So I don't, I really, I really,you know, if you're gonna, if
you have one good oil, then youhave three other not good oils.
I feel like it all cancels out.
And I'm not gonna lose sleepover the fact that these contain
olive oil yeah, okay, fairenough.
Dr. Joshua Goldenberg (28:31):
So adam's not losing sleep over it.
I'm not like I don't know, likeI I always wonder about this
sort of thing and I feel likethere's always this battle
between well, you can find onething that explains a negative
result, and it can soundrational, but at a certain point
you look just like.
Dr. Adam Sadowski (28:49):
But then you can't argue anymore that seed
oils are pro-inflammatory.
Dr. Joshua Goldenberg (28:53):
Yeah, I mean.
So there's that, and thenthere's, you know, also, you
just can't truly prove a fullnegative right, like you can
always find something that if itwas done differently it would
be positive, and so I feel likeat a certain point you just have
to say on net that this lookedlike an excellent study, well
designed, decent placebo, youknow, and if you're comparing it
to just taking some seed oils,it seems as if krill oil doesn't
(29:17):
add much to that.
Dr. Adam Sadowski (29:20):
We can put it that way, I guess I mean I
would also say like okay, wellthen, go compare, go get funding
.
To say, the difference betweenour study in the previous study
was that they had a mixed oiland so we're going to use
straight up canola oil.
Right, right, the canola oilstudy.
No one's going to fund that.
That doesn't make any sense.
Dr. Joshua Goldenberg (29:39):
Yeah Well , interesting, I wonder.
Actually I don't know whofunded this one.
They'll look at the bottom.
I forgot to check the funding.
Dr. Adam Sadowski (29:44):
It was publicly funded.
And then the Krill Oil Companygave them product for free but
had no role in the methods datacollection, whether or not they
were going to publish or not, soit was publicly funded.
Dr. Joshua Goldenberg (30:03):
Cool yeah , and I just want to point out
like that is totally okay andnormal it's a multi-million
dollar study probably and youknow, someone donates some krill
oil like that's not going toinfluence things, but to like,
so that people say, well then,why, why do you get it donated?
Because, pragmatically, whenyou do these studies, you need
all the quality assurancedocuments and certificates for
safety, and so you need to beworking with the company that
makes the product to providethose analysis to give to your
(30:25):
ethics board.
And also, when you'remanufacturing a placebo, it has
to match as much as possibleright for blinding, and so the
usually the best way to do thatis to have the facility that
makes the actual product alsomake the placebo, so that
everything else is kind of thesame.
So, again, that's totallyreasonable, I think.
So, yeah, okay, so we have okay.
(30:46):
Another thing I wanted to pointout we did have a lot of dropout
right.
So you have 262 peoplerandomized, half to crow oil,
half to placebo.
They did a good analysis, liketheir primary analysis was.
You know, everyone that wasrandomized, but I think they
lost, like what, 24 people inone group it looks like 23 and
(31:07):
another, which is a significantpercentage of the total.
Dr. Adam Sadowski (31:12):
I think it's easier to look at it from a
percentage standpoint.
I think it was like 15% and 17%in both groups and overall only
85% of people completed thetrial.
So I do think, from a you know,bias standpoint, that is
something that has to be takeninto account, especially as they
did not use an intention totreat analysis.
Dr. Joshua Goldenberg (31:32):
I want to ask you about that.
Like, that seems like a.
I mean 24 weeks it's a longtime and I guess 15% doesn't
sound so crazy, but still thatseems to be a lot of people to
just drop out of the study andat least it's balanced, right.
And if we look at the reasonsfor dropout here, they say
(31:53):
dropped out for adverse.
So seven dropped out for anadverse event in one group
versus eight in the other.
That seems balanced.
Perceived lack of efficacy fourin one group, six in another.
Six cannot be contacted.
So it seems like balanced asfar as the number of people that
dropped out and the reason.
So it doesn't appear on its facethat the intervention itself
was driving dropouts.
(32:14):
So that's what you worry aboutfrom a bias perspective.
You just kind of wonder, well,if you're just missing this many
data points, maybe it's not abias issue, but maybe it's like
you're just you know it'll,you're not going to see the
effect as well, right, you'rejust kind of losing your power.
So yeah, I don't know Anythoughts on like why they had
such a large, relatively largedropout.
Is it just the length of time,you think, or maybe just the
(32:35):
people running the trial?
I mean they were run throughdifferent.
You know, I think clinics, butI think primary clinics.
Dr. Adam Sadowski (32:43):
Yeah, I mean it may have just been a time
issue.
I'm really not sure, becausewhen we even look at the
adherence rates, they were sohigh 99% in the krill oil group
and 96% in the placebo group.
So you know, the adherence totreatment for those who were
taking it was so high.
It would have been interestingto see what was the adherence
rate in those who dropped out.
Like, did they also have a highadherence rate and then just,
(33:06):
for whatever reason, dropped outof the study?
Or yeah, I don't know.
It's a shame that that happenedand kind of a bummer that they
didn't do it in ITT.
Dr. Joshua Goldenberg (33:16):
Yeah, right, so they did.
So they sort of did intentionto treat, but they didn't do
like a sensitivity analysis, Iguess across it, but it was an.
It was a null finding anyways,as we'll talk about, so I guess
it's less of an issue, okay.
And then primary outcomes wasthe 24 week change in self
reported knee pain.
So I like that the primaryoutcome, even though it's
subjective, is clinicallyrelevant.
(33:37):
I loved that they predefinedtheir minimal clinically
important improvement.
Did you see me like in yourmind doing a little jig when you
read that?
Because I was like, yeah, I did, I did.
Yeah, I was beyond thrilled andthey actually picked the right
number.
So, like there's a lot of newresearch on minimally important
differences, we used to thinkthe VAS scale, okay, it's like
(34:01):
10 points, right, you just do10%.
But actually it depends to doit properly.
Like you need to look at, youneed to actually ask the
population that's relevant toyou.
So you know, find a group ofpeople that have knee arthritis
and ask them like what's theminimal difference that would
matter to you?
And and they use the 15.
And most of the studies thatI've seen, whether it's shoulder
(34:21):
pain or knee pain or somethinglike that.
It's somewhere between like 13and 18, or something like this,
so 15 sounded really totallylegitimate.
They had that.
Initially.
They had a lot of secondaryoutcomes, including the change
in effusion syncytitis, and then, like I think, up to like 60
other secondary outcomes.
That's the other thing.
Like they definitely wentfishing, like they had lots of
(34:41):
things they looked at, but theywere so upfront and honest about
it so that I feel like I wasn'ttoo worried.
Dr. Adam Sadowski (34:48):
Yeah, I mean.
They even said, due to thelarge number of secondary
outcomes, results for secondaryoutcomes should be considered
exploratory.
So they straight up said likehey, yeah, we're looking at a
bunch of stuff, please don'tlook into it.
Really, what that means iswe're setting up future trials
and future research questions.
That's pretty standard.
Dr. Joshua Goldenberg (35:06):
Yep, yep, yep and it's like so I always
wonder with this sort of thingif it was the peer reviewers, if
it was the referees that, like,required them to temper their
thoughts about secondaryoutcomes.
But just basically readingbetween the lines here, I feel
like these authors were, likeyou said, super legit.
Probably was their originallanguage and yeah.
So it's okay to explore andhave exploratory outcomes.
(35:27):
Just don't pass them off aswhat you intended to see, and I
think they did a good job ofthat.
Dr. Adam Sadowski (35:36):
I think too, if they had 60 secondary
outcomes to look at.
They really are, are trying tobe as thorough with this as
possible, and so even if there'slike the slightest noise of a
positive secondary outcome, youknow they're going to go down
exploring that.
Dr. Joshua Goldenberg (35:47):
Exactly and they saw a couple things
that didn't really make senseand we're probably just like
random.
Oh, the other thing I reallyliked about the MCID is the
minimal important difference.
They set them as well for labvalues, which is so cool and you
rarely see.
We did that with our paper acouple years ago on on low carb
(36:07):
diets and, as far as I know, wewere like the first people to do
that.
We had like a big discussionabout should we do this?
Should we apply this concept tolab values?
Can you do that?
What's your justification?
I mean, I'm sure we weren't thefirst, but we didn't know of
anyone else and it's neat to seeother people doing that now and
actually using very similarthresholds to what we used,
which I think is kind of cool.
So, yeah, it's this idea thatyou know.
(36:29):
You just have to start settingthese thresholds that matter one
way or another, and that isanalogous in labs.
It's obviously not patientimportant, because you can't
tell the difference, but it isclinically important and they
actually use these.
People are great man.
They actually use differentlanguaging around that right, so
that you have the minimallyclinically important improvement
(36:49):
, which is a very specificphraseology there, versus the
minimal clinically importantdifference for the labs.
Yeah, they did a great job.
They clearly were well versedin MCIDs and all that.
Yeah, I like these authors.
I don't know any of them.
I don't recognize any of thosenames, but I'm impressed as well
.
Alrighty, what else did youwant to talk about?
That's pretty much everything Iwanted to talk about on results
(37:12):
, besides some comments onadherence.
Anything you want to touch onfirst?
Dr. Adam Sadowski (37:17):
No, that was it, and we already talked about
the adherence too.
Dr. Joshua Goldenberg (37:20):
Yeah, and the adherence right, the
adherence was excellent, youknow.
The other thing I'd say is theylooked at, not just at counting
pills, which is what almosteverybody does Like.
Okay, return the bottles whenyou're done.
Let's count up how many areleft to figure out how adherent
you were.
But they actually had abiomarker for omega-3 as well,
which I thought was great.
So they had like proof that notonly were you taking the omegas
(37:43):
, but it was getting into yourbloodstream and bioavailable
enough to have an impact, whichis it's really nice when you can
have that biomarker as well,alrighty.
Dr. Adam Sadowski (37:57):
So let's talk results.
You want to walk us through theresults?
Sure, so the primary outcome,which again was the change in
knee pain based on the visualanalog score.
And so again, that visualanalog score goes from zero to
100.
100 is maximal pain, zero is nopain.
In order to be included in thestudy you had to have a score of
at least 40.
And when we look at ourdemographic table, score of at
(38:22):
least 40.
And when we look at ourdemographic table, the average
knee pain for the two groups wasa 48 in the in the krill oil
group and a 50 in the placebogroup.
So basically the same.
And then when we look at theprimary outcome, so the change
in that there was no differencebetween the two groups.
From baseline to 24 weeks itchanged by 20 points.
It went down by 20 points inthe krill oil group versus 20
points in the placebo group.
(38:44):
Absolutely no difference.
Dr. Joshua Goldenberg (38:47):
Yeah, so both improved significantly.
But there is no differencebetween placebo and krill oil
there.
It's not too surprising to seea clinically important
improvement from baseline toendpoint.
In general like not when you'recomparing across groups, but
just because this issubjectively reported outcome
(39:07):
they know they're gettingsomething and so when you ask
them how they're feeling, likethey're going to report feeling
better, right, Like that's just,that's the placebo effect.
So it isn't crazy to think that, yeah, you would drop 20 points
when you're in a study, whenyou're taking something.
But that's, of course, why wedo these placebo comparisons,
because the drop with the krillwas exactly the same as the
placebo group.
Dr. Adam Sadowski (39:28):
Right.
And then when we look at thesecondary outcomes, of the 60
secondary outcomes that werelooked at, two were different,
58 were no different.
Of those two, one favored krilloil and it improved
triglycerides at the 12-weekmark but not the 24-week mark.
(39:48):
So it didn't really do anythingthere.
And then when we looked ateffusion synovitis volume at 24
weeks, the placebo groupactually improved that over the
krill oil group.
Dr. Joshua Goldenbe (40:00):
Interesting right.
Dr. Adam Sadowski (40:02):
To all the corn oil haters it improved
inflammation.
Dr. Joshua Goldenberg (40:06):
Yeah, that was interesting, and they
kind of talk about when I guesswe could talk about that in the
discussion.
Like they kind of talked aboutwhy that, why in the world the
placebo would improve it, and Ithink they just kind of
concluded at the end that it wasprobably a random, random
result.
Yeah, alrighty, so that's thatprobably a random, random result
.
Yeah, alrighty, so that's,that's basically it.
Ladies and gentlemen, um, Ilet's look at the anything.
(40:27):
I think we discussed most ofthe discussion as we went
through.
Um, I want to see if there'sanything else here I want to
talk about.
Yeah, so, basically in thediscussion they're going through
, they're like okay, why didn'twe see an effect here?
Like the dose was you know rightbetween these two studies that
we've seen that showed benefit?
There was.
There were studies that showedbenefit of exactly two grams a
(40:48):
day.
They all had knee pain, theywere improving.
So like, what's the difference?
And I think, at least in myreading, the only major
difference if you assume thatdose is not responsible, then
because you were seeing effectsat like two grams and 300
milligrams in other studies wasthe population.
Like it wasn't.
The other populations were moremixed.
Maybe they had some rheumatoidarthritis, maybe they had knee
(41:11):
pain that wasn't necessarilyosteoarthritis knee pain, and
then also they didn't have thissynovitis piece, and so those
seem to be the most like if it'snot truly negative, and those
initial results are true, andthis is true too then that was
the take home that I had, thatit's like, well, maybe it's the
difference in the populationshere that if we're really
(41:32):
talking about a knee arthritiswhere you're having synovitis,
then it's just not gonna helpyou essentially.
Dr. Adam Sadowski (41:43):
Yeah, yeah, yeah, yeah.
I don't have anything else toadd to that.
Dr. Joshua Goldenberg (41:45):
Cool, I think that's everything just
going through here.
Yeah, that's everything as well.
They also looked at adverseevents.
There wasn't any majordifference between groups there
and they talk about how, um,what they saw with the placebo,
that's the placebo thing.
So that's the placebo thing.
So that's another thing Iwanted to highlight.
So and I thought I think Italked about this earlier so
they have this study of twograms a day showing benefit,
(42:07):
right.
So that's what?
Again, that's what they'redoing and they're like, okay,
well, maybe you know you messedup the placebo pill.
Maybe the placebo pill wasactually beneficial and that's
why you're not seeing adifference.
But again, they use a placebopill they claim very similar to
that used in the study that hadthe two grams that showed
benefit, right?
So again, in theory, it's notthat either.
(42:31):
So, yeah, I think, at the endof the day, if you've got knee
arthritis and you've gotsynovitis, krill oil is probably
not going to help more thanplacebo, according to the
findings of this study.
And I think that's pretty muchwhat I want to say about this
paper.
Anything else you want to add?
(42:51):
Is it practice changing for you?
No, well, I mean, I don't.
I just, I'm such a specializedpopulation that I don't I don't
really see people for arthritis.
I'm such a specializedpopulation that I don't really
see people for arthritis,although I have to say my
laziness, because I see peoplewith basically one condition
small intestinal bacterialovergrowth.
If they happen to mentionarthritis, pain here or there, I
(43:13):
will often say lazy things likeoh well, you might consider
some fish oil or something likethat acryl oil, and so maybe
this will be practice changing.
Maybe I'll kind of check thatreflex a little, a little bit
more.
How about you You're?
You see patients like thisevery day, probably.
Dr. Adam Sadowski (43:28):
Uh, I mean I, I see knee osteoarthritis a lot
, um, I see people on omegathrees.
I have not yet seen anyonespecifically using krill oil for
anything, but I, you know, I, Igo to conferences, I see, I see
the salesmen and saleswomenyeah, we've got this thing
against salesmen.
So I always just yeah, I alwaysjust roll my eyes.
(43:50):
Here's what I would say.
I would say I, I would notconsider it.
Um, if someone was already onit, I'd be like you know, if you
don't want to be on it or youdon't know why, it's fine to
discontinue, but I personallywould not be making the
recommendation to start this.
Dr. Joshua Goldenberg (44:08):
Yeah, and and you know, to your earlier
point, like there might even bea little bit of a harm there
with AFib signal.
So we should, maybe we shoulddo that paper next to continue
with the curmudgeon theme, justbecause, like, sometimes it's
like okay, yeah, like it'soverblown and over promoted, and
when you look at good qualitystudies there's nothing there
and usually it's just like okay,but it's benign.
(44:28):
You're probably fine if youwant to stick with it, right,
but that's not always the casewhen you do have these harm
signals.
So I am curious personally tokind of look at that a little
bit more.
Maybe we'll do that next weekor something like that.
Dr. Adam Sadowski (44:40):
Also, I wouldn't say I'm a curmudgeon.
I really do think I'm just ahealthy skeptic because so many
people are.
They want to believe thesethings work.
Introducer (44:48):
But if we?
Dr. Adam Sadowski (44:48):
don't have the data to support it.
We have to stop.
We have to challenge our biases.
If we don't challenge ourbiases, things don't change,
things don't evolve and you getleft behind.
I'm sorry, but if you want theprofession to change, if you
want to be a better provider,you have to challenge your
biases and everything.
Dr. Joshua Goldenberg (45:08):
Yeah, yeah, it's true, it's true, I
think.
You know, I just I feel like I'mjust steeped in this assumption
, cultural assumption, that fishoil, omegas, like that they
work, and I don't know wherethat comes from.
I think that just comes from,like that's the societal milieu.
And you know, you hear somepapers or you hear your
(45:28):
professors in school and youknow, and then I just never was
in a field where I wasprescribing it a lot, right, and
so I never really looked intoit much, and so it is kind of
interesting to actually look atthese papers and be like, no,
not really, and oh, you know,there might even be harm signals
here.
So, you're right, it isimportant to question these
things.
I guess it's.
(45:49):
I guess you can't, so you can'tquestion everything, and so,
yeah, I think I think you justquestion the things that are
high value and also that you seeevery day, right, so, like for
you, I think it makes sense tobe doing, to be looking at that
and to have these conversations.
And I'm curious, dear listeners, because I think that, um,
there'll probably be a lot ofhate mail after this one, I
(46:11):
would suspect, and they're goingto be giving us good papers.
Dr. Adam Sadowski (46:14):
So, yeah, so with your hate mail, but then
good, but like then, I'm gladthat's happening.
Send a good paper, send goodpapers.
Dr. Joshua Goldenberg (46:23):
Yeah, send good papers, yeah, yeah.
So here's, here's, the otherthing is okay.
So we have this our own.
Our own tendency is to be to becritical of everything and to
just assume it's all randomness,right, that, at least that's my
tendency, and that most of thehigher quality, larger studies
will basically show that almostnothing works.
But you know where I go withthis evidence nihilism thing.
(46:45):
However, I also want to own thefact that I'm not an expert in
fish oil research.
I haven't looked at a lot offish oil studies and it could
very well be that this is anexception to the rule, and in
fact, this study followedapparently three studies that
were positive.
I don't know if they're welldone.
One of them at least had over200 participants, I don't know.
But I also want to own the factthat it could be that we're
(47:07):
looking at a true subgroupphenomenon where populations
with osteoarthritis of the knee,where you have the synovitis is
just not going to benefit it'stoo far gone, or something like
that Whereas more mild casesmaybe it does.
I don't know.
Is that an apologist for thekrill oil?
Possibly you should look at mydisclosures.
I just got a huge new tri bikefrom Big Krill and I call it my
(47:32):
Big Krill, big Grill, and soanyway, but yeah, but I think
that's.
The other thing is that, andthis is okay, well, okay, I want
to go on this tangent a littlebit longer.
When you're in the evidenceevaluation world like I am most
of the time, you know, doingsystematic reviews, teaching
critical eval it's so easy forme to like say, ah, this is just
randomness, yada, yada, yada,and maybe that's good to have
(47:54):
that distance.
And then, whenever it's a it's aclinical question about a
clinical field that is very dearto my heart, that I like know
well and know the literature,I'm always much more skeptical
of people's attempts to like poo, poo it, and I think that's a
natural inclination.
But I also feel like I don'tknow there's like benefits of
(48:14):
being removed and looking atsomething purely from a methods
perspective, but also there'sobvious harms.
Right, like you're not acontent expert, you don't
necessarily know the literaturewell, and that's one of the
things I like about doingsystematic reviews is like you
always include content expertsin your team for exactly this
reason.
Right, you've got yourmethodologists, but you also
have your content experts tolike keep you honest or keep you
(48:36):
from being like overly critical, I guess.
Anyway, thoughts on that, or isthat just me rambling?
Dr. Adam Sadowski (48:43):
no, I get where you're coming from.
Um, I always kind of used to bethe opposite, where I was like
oh, supplement in jama, bet youit's going to be a negative
trial, because, like 99 of thetime, it's a negative trial yeah
, right to now where I'm.
I mean that was a very likeemotional response because I'm
in the integrative profession.
(49:04):
It feels like an attack on me.
Yeah.
To now me being okay, it's anegative trial.
Let's actually see if it'ssomething to be up in arms about
.
Were there huge flaws or wasthis just a really well done
trial?
And we're just upset about ouremotion, and the more I look at
(49:24):
it, it's usually the latterrather than the former.
Now, of course, there's alwaysgoing to be instances of the
former and you know, I thinkpeople also have to realize that
because we're so in theintegrative space, we're looking
at integrative things and so Ikeep saying this doesn't work,
this doesn't work, et cetera, etcetera.
There's inadequate evidence tothings.
The opposite is not also true,that that means that all
(49:49):
medications work.
We're critical of all things.
It's just that we just sohappen to be in the integrative
space.
So we're looking at thesethings and if they're not
working, we're going to say thatthey're not working or not
providing the magnitude ofeffect that we want it to.
And it's very sobering.
Dr. Joshua Goldenberg (50:10):
And I think that people need to come
to that conclusion as well.
Yeah, I think that's well said,right, because of our area of
interest, this is what we talkabout, but, as longtime
listeners will know, we'reequally critical of a lot of
different interventions and tendtowards the evidence nihilism
position for all of medicine.
We were excited for Shiljatyeah, that was a surprise.
(50:30):
That was kind of cool.
Yeah, every once in a while yousee it.
Or Kirk Heumann was showingsome pretty cool stuff too.
We did that one paper on.
Dr. Adam Sadowski (50:38):
Yeah, we're shills for Shiljat Big Shiljat
jack.
Come sponsor us.
So how is that?
Dr. Joshua Goldenberg (50:49):
I thought it was sheila jeet.
How do we print we don't know,no one will know.
Nobody will know, no one willknow.
No one knows.
Unknown, unknown.
It's one of those.
It's like uh oh, you'reprobably too young for that.
You know the um.
How many licks does it take toget to the center of a tootsie
pop roll or whatever?
Dr. Adam Sadowski (51:00):
I'm old enough for that.
Yeah, with a little with theowl, with the owl, yeah, yeah,
yeah with the owl, with the owlright.
Dr. Joshua Goldenberg (51:06):
Some things are just unknown, right?
So anyway, um so interestingcan't.
Dr. Adam Sadowski (51:15):
I think between now and the next podcast
, one of us needs to get aTootsie Roll Pop and find the
answer.
Dr. Joshua Goldenberg (51:21):
Yeah fair enough, I'll put Theo on it.
I think he'll be thrilled.
He's all hopped up.
Today was his last day ofkindergarten and so I went in
for the kindergarten party andso they brought in like pizza
and cupcakes and like juiceboxes and I had already packed
him a cupcake in his lunch forhis like last day, so like the
(51:42):
kid.
Well, the entire class arehopped up on sugar, like
literally bouncing around theclassroom jumping on each other,
and I'm just look, did theyalso?
What was that?
Dr. Adam Sadowski (51:53):
did they also come.
Everybody get a free sample ofozempic.
Dr. Joshua Goldenberg (51:57):
Here's your cupcake and ozempic well,
it or or like a benzo orsomething to calm the freak down
.
It was, it was totally nuts andI just I was like I turned into
something.
Other parents and I was like Iam just so glad that he's got
two more hours here before hecomes home, because he's gonna
have to, like, burn off thissugar crash with his
kindergarten teacher not me,although he'll probably be a
(52:19):
half asleep in a coma by thetime I get him isn't it kind of
funny how we go from like kidsbeing hopped up on sugar to then
we just transition to caffeineas adults?
Oh yeah, I'm hopped up oncaffeine right now, right, so
it's like you know I I havenothing to say about this.
All right, ladies and gentlemen, we will talk to you later.
(52:40):
Adam, it is wonderful to talkto you.
I missed you.
I'm so glad we were back onthis thing likewise my friend
all right, take care bye thankyou, everybody.
Please do us a favor and letthem know about the podcast and,
(53:01):
if you have a little bit ofextra time, even just a few
seconds, if you could rate usand review us on Apple Podcast
or any other distributor, itwould be greatly appreciated.
It would mean a lot to us andhelp get the word out to other
people that would really enjoyour content.
Thank you, hey y'all.
This is Josh.
You know we talked about somereally interesting stuff today.
I think one of the things we'regoing to do that's relevant.
There is a course we have on DrJournal Club called the EBM Boot
(53:24):
Camp.
That's really meant forclinicians to sort of help them
understand how to criticallyevaluate the literature, etc.
Etc.
Some of the things that we'vebeen talking about today.
Go ahead and check out the shownotes link.
We're going to link to itdirectly.
I think it might be of interest.
Don't forget to follow us onsocial and interact with us on
social media at DrJournalClubDrJournalClub on Twitter, we're
(53:46):
on Facebook, we're on LinkedIn,etc.
Etc.
So please reach out to us.
We always love to talk to ourfans and our listeners.
If you have any specificquestions you'd like to ask us
about research evidence, being aclinician, etc.
Don't hesitate to ask.
Introducer (54:00):
And then, of course, if you have any topics that
you'd like us to cover on thepod, please let us know as well.
Thank you for listening to theDoctor Journal Club podcast, the
show that goes under the hoodof evidence-based integrative
medicine.
We review recent researcharticles, interview
evidence-based medicine thoughtleaders and discuss the
(54:22):
challenges and opportunities ofintegrating evidence-based and
integrative medicine.
Be sure to visit www.
d rjournalclub.
com to learn more.
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