The adherer effect

 

As if trying to pull meaning out of the medical literature weren’t difficult enough as it is, a new study demonstrates yet another obstacle to easy understanding: the adherer effect.

We’ve all seen the headlines.  Statins improve bone health.  Statins prevent cancer.  Statins make us smarter.  Low-fat diets improve longevity.  All these headlines and others like them are followed by articles describing studies seeming to show that subjects taking certain medications (usually statin drugs, it seems) or following a particular diet have improvements in health and/or longevity.  The promise of these articles is that if we all take the medication or follow the lifestyle choice, we, too, will reduce our risk of [fill in the blank] or live longer.  But will we?

Maybe so.  But not for the reason most people think.

The adherer effect demonstrates that people who adhere to medical or lifestyle regimens end up with better outcomes than those who don’t…even if the regimens are nothing but placebo.

I mentioned this phenomenon in an earlier post.

Almost thirty years ago a study was published in the New England Journal of Medicine looking at this very idea. [The adherer effect]  The study that inspired the article didn’t start out looking at this idea, but one of the investigators noted a key piece of the data and published on it.  The study was looking at clofibrate, a pre-statin cholesterol lowering drug,  and all cause mortality.  Subjects were randomized into two groups – those in one group got the drug, those in the other got the placebo.  After the subjects were on either the drug or the placebo for five years, researchers calculated the mortality from the number of deaths in each group.  Turned out that the five-year mortality of those on clofibrate was 20.0 percent whereas the five-year mortality of those on the placebo was 20.9 percent, or essentially the same.  Taking the drug was no different than taking the placebo, i.e., the drug was worthless. Had one of the researchers not looked a little closer, that would have been the end of the story.

When the data were looked at from the perspective of how many people actually took the drug as prescribed, the researcher discovered that those subjects who took at least 80 percent or more of their clofibrate had a five year mortality of only 15.0 percent, substantially less than the overall five-year mortality.  Those who took their clofibrate sporadically had a five-year mortality of 24.6 percent, significantly higher than those who took it as directed, a piece of data that would seem to confirm the efficacy of clofibrate.  Right?  Not necessarily.  Let’s look at compliance with the placebo.

Turns out that those subjects on the placebo who regularly took their placebo had a five-year mortality of 15.1 percent while those who took their placebo sporadically had a five-year mortality of 28.3 percent.  What this study really showed was that there is something intrinsic to people who religiously take their medicine that makes them live longer.  There was no difference between the drug and placebo in either those who took them regularly or those who took them sporadically, but there was a huge difference in mortality between those who took either drug or placebo on schedule and those who didn’t.

Gary Taubes discussed this same study and the adherer effect in  a long article he wrote for the New York Times Magazine a few years ago:

A still more subtle component of healthy-user bias has to be confronted. This is the compliance or adherer effect. Quite simply, people who comply with their doctors’ orders when given a prescription are different and healthier than people who don’t. This difference may be ultimately unquantifiable. The compliance effect is another plausible explanation for many of the beneficial associations that epidemiologists commonly report, which means this alone is a reason to wonder if much of what we hear about what constitutes a healthful diet and lifestyle is misconceived.

The lesson comes from an ambitious clinical trial called the Coronary Drug Project that set out in the 1970s to test whether any of five different drugs might prevent heart attacks. The subjects were some 8,500 middle-aged men with established heart problems. Two-thirds of them were randomly assigned to take one of the five drugs and the other third a placebo. Because one of the drugs, clofibrate, lowered cholesterol levels, the researchers had high hopes that it would ward off heart disease. But when the results were tabulated after five years, clofibrate showed no beneficial effect. The researchers then considered the possibility that clofibrate appeared to fail only because the subjects failed to faithfully take their prescriptions.

As it turned out, those men who said they took more than 80 percent of the pills prescribed fared substantially better than those who didn’t. Only 15 percent of these faithful “adherers” died, compared with almost 25 percent of what the project researchers called “poor adherers.” This might have been taken as reason to believe that clofibrate actually did cut heart-disease deaths almost by half, but then the researchers looked at those men who faithfully took their placebos. And those men, too, seemed to benefit from adhering closely to their prescription: only 15 percent of them died compared with 28 percent who were less conscientious. “So faithfully taking the placebo cuts the death rate by a factor of two,” says David Freedman, a professor of statistics at the University of California, Berkeley. “How can this be? Well, people who take their placebo regularly are just different than the others. The rest is a little speculative. Maybe they take better care of themselves in general. But this compliance effect is quite a big effect.”

In the same blog post of mine I linked to above, I wrote about another study showing the adherer effect, showing graphically how potent the phenomenon is.

Previously, the study of the adherer effect has been a secondary finding in studies of various drug regimens, but now comes a paper in which the adherer effect is the primary focus of the investigation.  Based on the data in this recent paper, the effect is robust and should be accounted for in the analysis of any data generated when subjects following a particular treatment are compared to those who don’t.

The authors lay out the problem:

The healthy-user effect [the adherer effect] is a hypothetical source of confounding bias that is thought to affect observational studies of drugs, diets, screening procedures, and other health-related behaviors. This bias presumes that patients who initiate and adhere to preventive therapies are more likely to engage in behaviors consistent with a healthy lifestyle than are patients who do not initiate or adhere to such treatments. Aspects of a healthy lifestyle could include diet, exercise, moderation of alcohol, and avoidance of risky behaviors. These characteristics, which are unmeasured in typical pharmacoepidemiological databases, may be associated with morbidity and mortality outcomes in observational studies. Thus, failure to adjust for them can lead to bias in studies of preventive therapies.

The healthy-user bias has been suggested as an explanation for the discrepancy between several experimental and observational studies, including studies of the effects of long-term use of estrogen therapy and vitamin E. It has also been discussed as a potential source of bias in observational studies of the effectiveness of influenza vaccines in the elderly  and the association between use of 3-hydroxy-3-methylglutaryl coenzyme A reductase inhibitors (statins) and reduced risk of hip fracture,  Alzheimer disease,  sepsis,  cancer,  and mortality.  This bias has also been observed in randomized controlled trials in which adherence to placebo was found to be associated with decreased mortality.  Although long suspected as a source of bias, a paucity of empirical data exists on the healthy-user effect.

Here’s how the study was set up.

It was really pretty simple.  The researchers looked at a group of patients who had been prescribed one of a variety of statin drugs and followed their compliance by looking at how many times these subjects picked up their medicines in the year following their prescription.  The typical statin prescription was for 60 days worth of the medication, and all subjects had available to them a full year’s worth of medicines.  The researchers grouped subjects into two groups: one group who took the trouble to go get over 120 day’s worth of the medication (the “more adherent”) and one group of subjects who were dispensed under 120 days of meds (the “less adherent”).

All subjects entered into the study were evaluated after the one year baseline study period during which their effort to follow their prescribed statin regimen sorted them into the categories of more adherent or less adherent.  The researchers were looking to see which subjects – the adherers or the non-adherers – would develop problems that had nothing to do with the statin drugs.

We evaluated a spectrum of events after the 1-year baseline period to assess the healthy-adherer bias. The outcomes were grouped into 4 broad categories: accident events, screening events, other events not expected to be associated with statin exposure, and other events for which a possible association with statin exposure could be expected. We included inpatient and outpatient events as well as primary and secondary diagnoses.

When the data on these 141,086 subjects was crunched, it turned out that the more adherent subjects had significantly fewer accidents, especially motor vehicle and workplace accidents.  The more adherent also had a lower likelihood of developing other disorders that were not likely to be attributed to the effect of the statin drugs.

In other words, whatever characteristic it was that made subjects hang in there with their statin prescriptions also made them less likely to indulge in risky behaviors and less likely to develop all kinds of medical problems.  Why?  Probably because these people were simply more health conscious, kept themselves in better shape, and didn’t act impulsively.

The real take-home message from this study is that the adherer effect significantly affects the outcome of drug and lifestyle intervention studies.  If you see a study that says those subjects using statin drugs developed 20 percent fewer problems (of whatever kind are being studied) than those who don’t use statins, you can be sure that the adherer effect is at work.  This adherer effect is why randomized, double-blind, placebo-controlled studies are needed to determine the efficacy of any drug, and even then the adherer effect should be controlled for.

There is a big note, enclosed in a box and titled Clinical Perspective, at the end of this study that exhorts doctors to consider this adherer effect when looking at data from observational studies.  Here is the note in full.

Clinicians need to read observational studies reporting surprising benefits of drug therapy with a healthy skepticism. Observational studies of preventive medications and health behaviors are susceptible to various sources of bias, including the so-called healthy-user and healthy-adherer biases. In this article, evidence of the healthy-adherer effect is demonstrated by showing that adherence to statins is associated with a reduction in the risk of accidents (eg, workplace or motor vehicle), outcomes that would not be expected to be affected by a statin. The approximate magnitude of the adherer effect was a 15% relative risk reduction. The most likely explanation for this association is that good adherence to statin therapy is a marker for other healthy behaviors, most of which cannot be accounted for in this type of study. In keeping with this explanation, the study also shows that adherence predicts a 7% to 17% increased incidence of medical screening procedures (eg, fecal occult blood testing, mammography). Risk of myocardial infarction, which has been demonstrated to be reduced by statin therapy in randomized placebo-controlled trials, was found in this study to be reduced by 28%. This observed relative reduction must be interpreted as reflecting a combination of the healthy-adherer effect and the drug effect. Clinicians can also learn from this study that patients who follow their advice are also likely to have other healthy behaviors and a lower risk of adverse events.

It is unfortunate, but I doubt that many doctors (or researchers, for that matter) will consider the adherer effect when they read these studies.  I would bet that we will continue to see studies reported as if the positive effects found were a function of the drug or lifestyle regimen studied and not the adherer effect.

To me the saddest part of this study was the statistic that of the 141,086 subjects in this study, 49 percent were women.  The randomized, double-blind, placebo-controlled studies of statins have never shown a benefit in terms of decreased all-cause mortality in women of any age.  Which means that over 70,000 women in this study took a drug that would do them no good, but which could well cause them significant and harmful side effects.

In this study, those who dropped out of their statin regimen because of intolerable side effects would be considered to be less adherent or non adherers.  My guess is that many of these ‘non adherers’ who dropped out because of side effects were really ‘adherers’ by nature.  Had these drop outs due to side effects been controlled for, I would bet that the difference between the less adherent and the more adherent would have been much larger than the data showed.

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35 thoughts on “The adherer effect

  1. However it may just be possible that the benefit the long term adherer’s obtained from statin use actually derived from the ability of statins either to raise Vitamin D levels or to act in a Vitamin D sparing capacity.
    I thought this editorial very amusing.
    Statins and Vitamin D
    The diet-cholesterol-heart hypothesis dominated medicalthinking for the latter half of the 20th century and it still persists. The diet component has so many inconsistencies that it is unsustainable. It continues in popular folklore and government dietary policies but it seems to
    have been quietly dropped by most cholesterol-hear researchers. The original cholesterol-heart studies were undisputed at the time but the evidence is now no quite so clear.

    Increased Levels of 25 Hydroxyvitamin D and 1,25-Dihydroxyvitamin D After Rosuvastatin Treatment: A Novel Pleiotropic Effect of Statins?This study has shown an effect of rosuvastatin on vitamin D metabolism, with an increase in both 25-hydroxyvitamin D and 1,25-dihydroxyvitamin D. This may be an important pleiotropic effect whereby rosuvastatin reduces mortality in patients with coronary artery disease.

    This is what makes these studies so difficult to interpret perfectly. The researchers used the incidence of accidents, which would not seem to be a function of vitamin D levels, as the main benchmark for the adherer effect. But I would bet that those with higher vitamin D levels have slightly higher cognitive ability and probably quicker reaction times, both of which would likely lead to fewer accidents. But who knows.

    In case you haven’t seen it, here’s a post I did a couple of years ago on statins and vitamin D.

  2. Ineresting post. Could it be that people who are more compliant are generally more cognizant that they have a medical condition? And therefore pay more attention to preventive advice? and actually seek it?

    Much of what is blared at us is good advice: get more (and better) sleep, drink more water, avoid stress, get adequate exercise, etc. People who take their medicine regularly probably adhere to these behaviors more regularly.

    If the powers that be would advocate low-carb, more people wold probably follow it.

  3. Dr. Mike,

    In an unrelated note. I noticed that you Metabosol in your product page, is this a replacement to Pentabosol? How many servings per can? I am ready to give it try to get get rid of the last stubborn fat.

    Yep. No artificial sweeteners. 60 per can.

  4. Sorry for this being completely unrelated- I couldnt find an email address, and really wanted to ask a quick question;

    I’ve been following a ‘primal’ diet for 4 days now (getting back on track), low carb (around 80 grams)- and for day 1,2 and now 4 i’ve been extremely nauseous. Day 3 was alright, and happened to be my higher carb day (150?).
    So I’m thinking it might be a sort of detox effect, since I dropped 5 pounds in those 4 days.. But I’m getting quite worried, and was hoping you could give me some speculation.

    Diet consists of eggs, chicken, beef, salmon, herring, tuna, broccoli, green salad, red cabbage, tomatoes, bell peppers, a carrot, some onions, an apple, a cup of blueberries, almonds, almond butter, olive oil, coconut oil, butter- and a little bit of cheese + 1 cup of yoghurt as my cheats on day 3.

    I’m practically ready to go hang my head over the toilet :S

    I can’t imagine what it is without a whole lot more information, but I can guess that it’s probably not a detox phenomenon.

  5. The adherer effect definitely works for me. A quiet ale (330 ml of low carb beer) and then a Shiraz or two, every night. Never been healthier. Oh, and I do swim about 6km a week and eat low carb and take my D3, etc., etc., if that is of any relevance.

  6. I tried to put this question on a previous post but I don’t think it went through – what is the best way to increase total cholesterol levels? Mine measured recently at 149 (59 HDL and <45 Tri). According to your charts in Protein Power, this is the lower end of optimal. I'm not low carbing persay, but I do eat a lot of grass fed beef, cook primarily with lard and butter and use some olive oil.

    What else can I do?

  7. There is a saying where I originated from ” If Socialism was created by scientists rather than politicians, they would try it on dogs first! Not to delve in political debate but I dont understand how Obama is approaching healthcare reform. When I was a young boy I was always facinated with the power of destruction. My mother would tell me stories how conspiqious I was as a child. My favorite thing to do on the beach was to patiently wait for boys and girls finish building sand castle. Then I would sneak on them and just destroy it. I was always amazed at how long it takes to build smng and how fast you can destroy it. I understand that health care is in need of reform but it should be a thoughtful and gradual process not a hasty political move. Couldnt help but bring it up.

    Adherer affect is indeed a phenomenen but a true one. I, too, have found a correlation between people who adhere religiously to the prescibed diet or lifestyle oor treatment or whatever are those who do well in all other areas of life.

  8. Hi Mike,

    Surely in a simple drug trial such as the clofibrate one, part of the adherence effect is still a placebo effect outcome, as the placebo effect only becomes apparent if the subject believes they are taking the drug, and believes the drug is of benefit – and this belief is only tenable if they are actually taking it. If it is sitting in the cupboard, not many people are going to think it will cure them anyway!

    The other side of this, especially as it relates to statins is a bit of a double edged sword for us is it not? If adherers get a benefit over and above the placebo from the drug, might this not suggest they are benefiting from more closely following the mainstream medical advice on diet? I’m sure we choose to seek another explanation … in this case yet another placebo result – ie those that believe that they are doing everything possible will benefit from that belief whether it is drug, diet or both – in which case we are still ahead of the game in both departments!

    Cheers,

    Malcolm

  9. This effect seems to demonstrate that faith and ritual are powerful medicine – if you believe enough and commit enough, good things follow.

  10. Hi again Mike,

    Off topic this time, but I think it is past time you instigated a new award (in the tradition of Reckless and Blackburn) but this time for reckless research and especially egregious advice in the area of diabetes – which I think you will agree kills more people, or certainly shortens more lives (pretty much the same thing!) than either of the other no doubt ‘worthy’ award recipients combined.

    I will suggest a contender, although if permitted a joint ticket of bodies like ‘our’ Diabetes Australia, Diabetes UK and the American Diabetes Association would be a hands down winner most years.

    This research (funded by Diabetes UK) is worthy in that it sets out to see what happens when you feed diabetic menopausal women two bars of chocolate every day for a year. It gets extra points from the fact the study group’s super chocolate bar is fortified with soy. But surely the judge (that’s you!) will be further swayed by the fact that all study participants must have been on statins for at least a year.

    https://www.uea.ac.uk/mac/comm/media/press/2008/apr/Do+compounds+in+chocolate+reduce+heart+disease+risk+in+women+with+diabetes%3F

    Peter Curtis appears to be the spokesperson. I’m sure he would be delighted if the award bore his name.

    http://www.uea.ac.uk/med/People/Research+Associate/Peter+Curtis

    Cheers,

    Malcolm

    Hmmm. You’re right. Perhaps we should create an award in his name.

  11. I haven’t heard you mention the adherer effect when you talk about people who have had good luck with the high protein diet.

    I’m sure it’s in play. People who can commit to any healthful regimen for any length of time seem to be more healthy. When the low-carb (or high-protein) diet has been compared to the low-fat one, however, those adherers to the low-carb do better than the adherers to the low-fat. They probably both do better than the non-adherers to either one.

  12. I’m confused as to how this adherer effect is any different than the placebo effect. If you know that you aren’t taking your pills on a decent schedule, then there’s going to be some doubt creeping in and it would lessen the placebo effect. But if you know that you took those pills religiously (sugar or with the drug) – then the placebo effect would be in full force. So how is the adherer effect different than the placebo effect?

    There is a major difference, but I’m not going to get into it in the comments.

  13. I think the “healthy user” and “healthy adherer” effects are the effects of creation through thought. People who take their drugs are people who value their own health and well being. Logically, it would follow that they believe they are deriving a health benefit from whatever treatment they are on, whether real or placebo. That belief in a better health outcome translates into thoughts about better health, and the body responds to those positive thoughts. In essence, your thoughts create your reality, and perception is everything. What you think about yourself and your health has a big effect on the physical body.

  14. The adherer effect is likely a combination of an IQ effect plus the personality factor conscientiousness, which is correlated with IQ. Linda Gottfredson has written extensively about this, e.g.: “Intelligence predicts health and longevity, but why?”

    http://www.udel.edu/educ/gottfredson/reprints/2004currentdirections.pdf

    “Life, death, and intelligence”

    http://www.udel.edu/educ/gottfredson/reprints/2004LifeDeathIntelligence.pdf

    Nice papers. Thanks for posting.

  15. I wonder how much of the adherer affect is an indication of lthe evel of mental decline, i.e. non-adherers are in some early stage of cognitive impairment, so are more likely to forget to take a pill, etc. Even slightly diminished capacity leads to more accidents and is possibly a symptom of early cv disease. I’m not a doctor – just an observer of the healthcare of my 81 yo mother.

  16. I just wonder if the adherer effect is somehow coupled to faith and hope? I would guess that the adherers do so because they genuinely believe that they will derive some benefit from following the regimen … i.e. faith and hope. Now I don’t pretend to understand how faith and hope work … how a positive outlook and a belief in something bigger than yourself can provide benefits for many. However, there is a hypothesis out there that says that faith is an evolutionary tool. That early humans who had faith derived benefit from it because it allowed them to band together (via a common cause) and this group cooperation allowed them to live longer against the tough elements that they faced … hence allowing them to pass these “faith” genes along. Sounds interesting anyway.

  17. Is the adherer effect a teachable/learnable phenomenon?

    Has anyone done research on attempting to teach adherence?

    Curious,
    Ben Fury

    I don’t know, but I wondered the same thing myself.

  18. I wonder if the adherer effect applies to dietary regimens as well? Some studies have shown that vegetarians live longer than non-vegetarians, but perhaps that’s the adherer bias at work. How about those who stick religiously to low-carb diets — are they also subject to this effect?

    Speaking of religion, people who attend services regularly supposedly live longer, healthier lives than the control group. Adherer effect?

    Maybe it’s just that people with good self-control do better in life than those with worse self-control. That’s not a big leap.

    BTW, I am a low-carber myself, but I’m also a contrarian.

    I’m sure it applies to diet as well. Those who adhere to almost any diet seem to do better than those who don’t.

  19. Quoth Vadim:

    I dont understand how Obama is approaching healthcare reform.

    Pay close attention to the rhetoric. He’s not really talking about health care; he’s talking about “health insurance reform.” When you consider that his $650-million-dollar campaign was paid for largely by the financial industry, of which the insurance industry is a subset, you will have a clearer idea of what his approach is, and just how much and what type of “reform” we are likely to get.

  20. Dr. Eades wrote: “If you see a study that says those subjects using statin drugs developed 20 percent fewer problems (of whatever kind are being studied) than those who don’t use statins, you can be sure that the adherer effect is at work.”

    Wouldn’t the study need to be designed to sort out the more-adherent from the less-adherent in both the control and experimental groups to make this conclusion? Otherwise, all you’d have is a good hunch, not true evidence, right?

    In order to do make the study accurately reflect the effects of the drug, you would have to single out those subjects who actually took the study drug as prescribed, and not just those randomized into the group of subjects given the drug because a significant number of them won’t take it in accordance with the study protocol.

  21. @Naomi:

    This is just speculation, but it could be gluten or casein withdrawal. Wheat contains gluteomorphines and dairy contains casomorphins. These latch onto specific morphine receptors in your brain creating a sense of pleasure. Many people experience withdrawal symptoms upon giving them up. You can read more about it in Full of It: The shocking truth about gluten; The brain grain connection by Rodney Ford MD MBBS FRACP. Or you can just use google. Hope you feel better soon.

  22. I’m with Michael, I like to get my resveratrol right from the source in red wine. I understand there are other potential sources, but I’m kind of attached to this one. I’m an adherer.

    Me, too. I wonder if there is any resveratrol in Jameson. :-)

  23. I think I might be familiar with the “adherer effect” as it relates to my 88 yo mom who got a stroke in 2006. As you know, once one has committed the sin of having a stroke or heart attack, the doctors bombard him/her with a load of drugs that come with those nasty drug side effects. My mom had to “adhere” to taking those drugs for the rest of her life or else the doctor threatened to not be her doctor anymore and doctors in her town weren’t taking new patients. So my mom “adhered” to the doctors instructions and faithfully took her drugs which included 20 mgs of a statin, a thyroid drug, a beta blocker and a drug for CHF. The CHF developed after taking the statin. Her “adherence” to her drugs made it impossible for her to operate any motor vehicles or get into any kind of accidents because all she could do each day was sit in her living room and waste away. Within 6 weeks after being on the statin she began repeating her questions. From a very ambulatory person, her muscles wasted away and she literally became a cripple. Yes, her “adherence” turned her into a model puppet patient alright just like the medical system wanted. She had abnormally low cholesterol levels, she suffered from constipation, she had a constant hacking cough, her memory loss worsened, she became a cripple and she wasn’t her normal self anymore. “Adherence” keeps the patient just sick enough so that he or she “adheres” to the desires of a controlling medical system.

    A sad story and one that is all-too common. Forced adherence isn’t really the adherer effect, though.

  24. Reference the date of the release on the 2 bars of chocolate a day study – it wasn’t by any chance April 1st. Quite amazing really. Maybe they could run another one where participants eat 12 spoonfuls or sugar every day, as this is a low fat food. Or they could advocate high carb low fat diets for diabetics (and everyone else) …… oh, hang on, they do……… Based on what evidence you might well ask.

  25. I finally got around to making your wife’s mayonnaise. Never in my wildest dreams did I think I would be tempted to eat mayonnaise by the spoonful, but today it happened. Now if you could just get her to post a ranch dressing recipe. In the meantime, I’ll try the Caesar. Thank you, thank you.

    I have trouble getting her to post anything right now. She’s swamped with work on the multiple projects we’ve got going right now. The Caesar is great – you won’t be disappointed. I told her of your comment, and she said she would work on a ranch dressing recipe. Don’t hold your breath, though, for anything, any time soon.

  26. I wonder what role conformity plays in the adherer effect. Conformists are more likely to follow the rules, do what is expected of them etc., making them good adherers. What impact could this have on mortality rates in cultures that encourage conformity — Is it possible Japan’s longer life expectancy is due to conformity, adherence… not diet.

  27. I blame widespread ignorance/evasion of the adhearer effect, like so many other things, on philosophy. Specifically, modern philosophy. So much of today’s conventional wisdom about so many aspects of life is created around the idea that man is not primarily a conceptual being. The “rational animal” – to quote Aristotle.

    Everyone is always looking for some explanation that allows them to not have to use their mind’s fully. They are told repeatedly that philosophizing is one thing, living is another. So when it comes to living, is it really any wonder that most people will swallow just about anything with an appearance of credibility? They never bother to examine to see if it contradicts basic philosophical axioms.

    It seems the only way anyone can get any rational philosophical ideas into the culture nowadays is to disguise them in scientific jargon. I’m glad that the adhearer effect is out there – it’s true – but if people were taught how to think properly before they were taught how to practice a particular profession, erroneous conclusions would not be so common.

    To me, who, fortunately, came to appreciate the central role that ideas play in all parts of the human experience at a relatively young age, the suspicion that someone who is undisciplined about their health in the first place would be undisciplined about improving it seems obvious. Omitting factors beyond their control, it was a lack of respect for reality that got them to where they are so, most likely, it’s going to be a lack of respect for it that will keep them there.

  28. I feel like a lazy schlub. Now that I’ve got a good mayo recipe, I can certainly figure out my own ranch dressing. Again, thanks much.

  29. In many studies, there are high percentages of people who don’t adhere” — folks whom doctors dismiss as “non-compliant.”

    I am a very noncompliant patient, because I tend to have severe adverse events from almost all medications.

    I would argue that persons who make a deliberate decision to be non-compliant, based on side-effects, may be better attuned to their bodies, and they should be studied more seriously, and not scorned.

    Because I refuse to take most meds, I end up doing a lot of Seth Roberts-type self-experimentation, and I learn things that are not discovered in typical studies funded by BigPharma.

    I have learned that, for me at least, a careful diet has much more beneficial results than any drugs.

    Of course, that lesson will never be discussed in any BigPharma literature.

  30. A few years ago the Canadian Council on Animal Care pointed out that most medical research is not “good science” from an analytical statistics viewpoint. Any decent statistics program could do a two way Analysis of Variance with the 4 groups – this would easily test whether results are due to the drug or to adherence. It could also analyze the non-adherent people into true non-adherents and those who dropped because of side effects. But most medical researchers are statistically illiterate.

    True. But you would never know it from the way they blather on about it.

  31. Very interesting post. I wonder if forced adherence would increase life span/health? My mother uses a pillbox from MedMinder (http://www.medminder.com) to increase her adherence – she takes Statins and a host of other medication. I watch like a hawk and make sure that she takes all her medication. It would be interesting to put have my dad use the box as well for his vitamins and see if making him an adherer helps reduce his perpetual minor health complaints and general sense of being.

    Do a study of it and let me know.

  32. Donation of Blood Is Associated with Reduced Risk of Myocardial Infarction: The Kuopio Ischaemic Heart Disease Risk Factor Study
    Now could this be the Adherer effect?
    The type of people who regularly give blood being those who are concerned about health and have particular attitudes that are helpful in promoting good health.
    Or
    Lowering of body iron stores by blood letting and oxidation resistance of serum lipoproteins
    These observations indicate that the reduction of body iron stores by venesection can increase the oxidation resistance of serum VLDL/LDL in regularly smoking men.

    The finding that blood donor are replicated here
    A historical cohort study of the effect of lowering body iron through blood donation on incident cardiac events.
    Frequent and long-term whole blood donation is associated with a lower risk of cardiovascular events.

    It could be a little adherer effect, but blood donation brings about many healthful changes, so I don’t think the adherer effect is all that’s at work.