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How can you recognize sound health information on the internet from quackery? In the most surreal case of cognitive disconnect, the federal agency in charge of regulating fraudulent health claims on the internet, and promoting and protecting public health, has entered a partnership that will lead consumers to a website with some of the very same spurious health claims it is busily trying to shut down…

First the news

Last night on CBS evening news with Katie Couric, medical correspondent Dr. Jon LaPook reported a special consumer advisory on how consumers can protect themselves from bad medical information on the internet. With a sea of bad medical advice online, people are being harmed and even dying after being duped by phony and useless remedies. Viewers were warned that there are a lot of people trying to take advantage of patients, especially surrounding cancer, with bogus information. [Internet cancer fraud was covered in June.]

The FDA cracks down on fraudulent claims and has sent out 35 warning letters, citing more than 260 products. “But officials say it's almost impossible to keep up with a marketplace so vast,” reported Dr. LaPook. According to Dr. Jason Woo with the U.S. Food and Drug Administration: “We are constantly scouring the internet for illegal companies. Unfortunately, as soon as we can shut them down, more pop up.”

CBS news then offered a few basic rules for consumers when searching for medical information online. First, if it claims to cure cancer, click out. Beware of phrases like “scientific breakthrough” or products claiming to be natural and safe. Beware of anecdotal information from testimonials or blogs. Finally: “Look for sites like WebMD that are reviewed by health professionals.”

In the minds of viewers, the FDA and WebMD were linked, along with CBS’s endorsement of WebMD. Why was only WebMD recommended by CBS?

It wouldn’t be, perhaps, that WebMD has an agreement with CBS News, under which it provides branded content and resources to CBS Evening New, The Early Show and CBSNews.com? As part of the relationship, CBS News works closely with WebMD to produce regular, co-branded medical and health news segments.

Viewers heard nothing about that, nor about a new collaborative deal between WebMD and the FDA.

A new deal

Yesterday, the FDA announced the first-ever partnership between a government health agency and a private health media company. FDA Consumer Health Information will be a new feature on WebMD’s website and its magazine, and in turn, the FDA’s website will directly link to WebMD’s content.

President and chief executive officer of WebMD, Wayne Gattinella, said: “This important partnership is consistent with WebMD’s longstanding mission of providing Americans access to credible and relevant health information. "This partnership will further empower people to make decisions that affect their health, he said in a WebMD press release. “We have witnessed a tremendous move to health and wellness that is playing a role in all aspects of consumers’ lives,” he said. “This partnership between WebMD and the FDA is an important collaboration that further bridges that intersection of health, wellness and prevention.”

“We are enthusiastic about this collaboration with WebMD because it will enable us to reach more consumers with accurate, science based information that can help them improve their health,” said Commissioner of Food and Drugs Andrew C. von Eschenbach, M.D. He said it will enable the FDA to present content it feels is “extremely important for consumers to be aware of” as they make important healthcare decisions. “This is just the first of what may be many such partnerships. We are fortunate to have as our first partner one that can bring to the table such extraordinary expertise as WebMD has.”

The terms of the partnership are outlined in the Memorandum of Understanding which notes that WebMD’s website gets more than 40 million unique users every month, which will expand the FDA’s reach from its current 6 million visitors. While getting health and safety alerts to consumers faster is beneficial, there’s more to it than that. The FDA will provide a minimum of 50 articles which will be featured on WebMD, along with access to the FDA’s full catalog of Consumer Updates. The FDA content will be “free of advertisements, to avoid implying FDA's endorsement or support for a particular product, service or website.”

Dr. von Eschenbach told Medical Marketing and Media that the content FDA develops for WebMD will be tailored to WebMDs audience, but doesn’t constitute an exclusive relationship with WebMD. He added that the deal “should no be construed as FDA putting a seal of approval on WebMD.” [CBS news appears to be making the endorsement.]

But, the FDA page is embedded within the WebMD frame, with all of the links to regular WebMD content, leaving the clear impression to consumers that WebMD content has the legitimacy of being FDA-approved.

A WebMD spokesperson told MMM that no cash considerations were made regarding the partnership, which exists solely as a content exchange. That, along with the fact that the FDA page on WebMD will be free from advertising, may leave consumers believing there are no financial reasons or other incentives for WebMD to collaborate with the FDA and therefore, the information is even more likely to be credible.

Understanding private-public partnerships

The third quarter Securities and Exchange Commission Form 10-Q filed by WebMD provided information that suggested some reasons why WebMD might seek such a partnership. [See below* for a description of WebMD and the company’s products and services.] In explaining it potential liabilities, WebMD wrote:

Most of our revenue is derived from the healthcare industry and could be affected by changes affecting healthcare spending. We are particularly dependent on pharmaceutical, biotechnology and medical device companies for our advertising and sponsorship revenue. If we are unable to provide content and services that attract and retain users to The WebMD Health Network on a consistent basis, our advertising and sponsorship revenue could be reduced. Our ability to compete for user traffic on our public portals depends upon our ability to make available a variety of health and medical content, decision-support applications and other services that meet the needs of a variety of types of users, including consumers, physicians and other healthcare professionals, with a variety of reasons for seeking information. Our ability to do so depends, in turn, on: our ability to hire and retain qualified authors, journalists and independent writers; our ability to license quality content from third parties; and our ability to monitor and respond to increases and decreases in user interest in specific topics…

WebMD needs content, especially free content, supplied without any editorial labor on their part. Coming from the highest medical authority in the country also means little liability. WebMD adds:

The WebMD Health Network provides services involving advertising and promotion of prescription and over-the-counter drugs and medical devices. If the FDA or the Federal Trade Commission (FTC) finds that any information on The WebMD Health Network or in WebMD the Magazine violates FDA or FTC regulations, they may take regulatory or judicial action against us and/or the advertiser or sponsor of that information. State attorneys general may also take similar action based on their state’s consumer protection statutes. Any increase or change in regulation of drug or medical device advertising and promotion could make it more difficult for us to contract for sponsorships and advertising. Members of Congress, physician groups and others have criticized the FDA’s current policies, and have called for restrictions on advertising of prescription drugs to consumers and increased FDA enforcement. We cannot predict what actions the FDA or industry participants may take in response to these criticisms. It is also possible that new laws would be enacted that impose restrictions on such advertising. Our advertising and sponsorship revenue could be materially reduced by additional restrictions on the advertising of prescription drugs and medical devices to consumers, whether imposed by law or regulation or required under policies adopted by industry members.

With WebMD in partnership with the FDA, how likely will the FDA turn around and take regulatory action against WebMD for promoting drugs and medical devices… or for fraudulent health claims? WebMD’s SEC filing goes on to describe other ways it is vulnerable, should changes in public policies increase privacy protections for consumers or restrict industry-sponsored continuing medical education for medical professionals:

We face potential liability related to the privacy and security of personal information we collect from or on behalf of users of our services. Privacy of personal health information, particularly personal health information stored or transmitted electronically, is a major issue in the United States. The Privacy Standards under the Health Insurance Portability and Accountability Act of 1996 (or HIPAA) establish a set of basic national privacy standards for the protection of individually identifiable health information by health plans, healthcare clearinghouses and healthcare providers (referred to as covered entities) and their business associates. Only covered entities are directly subject to potential civil and criminal liability under the Privacy Standards. Accordingly, the Privacy Standards do not apply directly to us. However, portions of our business, such as those managing employee or plan member health information for employers or health plans, are or may be business associates of covered entities and are bound by certain contracts and agreements to use and disclose protected health information in a manner consistent with the Privacy Standards. Depending on the facts and circumstances, we could potentially be subject to criminal liability for aiding and abetting or conspiring with a covered entity to violate the Privacy Standards. We cannot assure you that we will adequately address the risks created by the Privacy Standards. In addition, we are unable to predict what changes to the Privacy Standards might be made in the future or how those changes could affect our business. Any new legislation or regulation in the area of privacy of personal information, including personal health information, could also affect the way we operate our business and could harm our business…

Government regulation and industry initiatives could adversely affect the volume of sponsored online CME programs implemented through our Web sites or require changes to how Medscape offers CME . CME activities may be subject to government regulation by Congress, the FDA, the Department of Health and Human Services, the federal agency responsible for interpreting certain federal laws relating to healthcare, and by state regulatory agencies. Medscape and/or the sponsors of the CME activities that Medscape accredits may be subject to enforcement actions if any of these CME activities are deemed improperly promotional, potentially leading to the termination of sponsorships.

WebMD content

CBS News correctly reported that WebMD’s content is peer-reviewed by health professionals. As WebMD explains on its About WebMD page:

The WebMD content staff blends award-winning expertise in medicine, journalism, health communication and content creation to bring you the best health information possible. Our esteemed colleagues at MedicineNet.com are frequent contributors to WebMD and comprise our Medical Editorial Board. Our Independent Medical Review Board continuously reviews the site for accuracy and timeliness.

CBS mistakenly equated peer-reviewed content with sound content. You’re seeing samples in this post of WebMD pages that have appeared over the past 24 hours. WebMD’s Live Well with Vitamins and Supplements Center tells readers about natural herbs and supplements for revving up their libido naturally; boosting energy and mood with supplements and vitamins, fortifying their memory with supplements; and supplements from apple cider vinegar to black cohosh. Tummy trimming secrets are featured on the Health and Diet page, a story on what men think is hot is featured on the Women’s Health page features, while the Men’s Health page headlines with six great sex tips all men should know. Credible medical information or tabloid content? You decide.

A sampling of the typical stories that have appeared recently on WebMD would make the FDA’s warning letter hit list:

Pomegranate Juice May Clear Clogged Arteries — WebMD tells readers: “Antioxidants in pomegranate juice may fight hardening of the arteries…the antioxidant-rich juice may also reverse the progression of this disease.”

Pomegranate: The Wellness Fruit — Another WebMD feature from “Eating Well” tells readers: “This antioxidant-rich superfood may help protect against arthritis, diabetes and a long list of other diseases.”

The New Powerfoods — A WebMD Men’s Health feature tells readers to “spike your diet with these… goji berries are packed with the phytochemicals beta-carotene and zeaxanthin, which studies have shown reduce the risk of lung and bladder cancers… Goji berries are also unique among fruits for their ability to reduce LDL (bad) cholesterol and raise HDL (good) cholesterol… Rooibos tea is made from a root, and packed with even more digestion-enhancing phytochemicals and disease-fighting antioxidants. A Japanese study found that it might even help prevent allergies and fight cancer… studies have suggested that consuming [flaxseed] oil may increase one's risk of prostate cancer.” And alligator meat is the new heart-healthy meat.

'Superfoods' Everyone Needs — WebMD tells readers: “Experts say dozens of easy-to-find 'superfoods' can help ward off heart disease, cancer, cholesterol, and more. Imagine a superfood — not a drug — powerful enough to help you lower your cholesterol, reduce your risk of heart disease and cancer, and, for an added bonus, put you in a better mood. Did we mention that there are no side effects?”

The FDA has also issued warning letters for years against companies marketing pomegranate, goji, super juices and teas for fraud. As reviewed here, here and here, not only has every sound randomized controlled clinical trial of antioxidant vitamins since 1945 disproven claims for superfoods and juices. Nor does science support claims for the ability of a special food to prevent cancers or heart disease.

Black Cohosh — WebMD tells readers: “For centuries, the roots of the North American black cohosh plant have been used for various ailments. Black cohosh is now a popular remedy for the symptoms of menopause. This has been especially true since the risks of a standard treatment for menopause — hormone therapy — were publicized in 2002. Black cohosh is most often used to control the symptoms of menopause, such as: headaches, hot flashes, mood changes, sleep problems, heart palpitations, night sweats, vaginal dryness”

This is another product the FDA has issued warning letters to purveyors making these very same claims. Health agencies around the world have also cautioned consumers about risks associated with black cohosh, including warnings from the Australian Therapeutic Goods Administration surrounding liver damage and acute hepatitis and Britain's Medicines and Healthcare Regulatory Agency now requires black cohosh products come with a warning about the potential for liver damage.

Apple Cider Vinegar — WebMD tells readers: “Apple cider vinegar is the natural product of fermenting crushed apples. Vinegar has been used as a health tonic for thousands of years for many different ailments. Several studies have found that vinegar — including apple cider vinegar — may lower blood sugar levels. This could have benefits for people with diabetes. Some types of vinegar have also been shown to make people feel fuller. This could support the traditional use of apple cider vinegar for weight loss. Animal and laboratory studies have found evidence that apple cider vinegar might help lower cholesterol and blood pressure, improve heart health, and slow the growth of some cancer cells. However, this research is only in its early stages. It’s too soon to say whether the same results will be seen in people.” In the next paragraph it provides: “Apple Cider Vinegar Dose & Instructions for Use.”

This urban legend was covered here. Even the National Center for Complementary and Alternative Medicine (NCCAM), a division of the National Institutes of Health specifically tasked to investigate natural or unconventional modalities, has found no studies to support vinegar.

Obese Kids Have Middle-Aged Arteries — WebMD tells readers: “Study Shows Obese and Overweight Children Have as Much Plaque Buildup as 40-Year-Olds.”

No it didn’t, as was reviewed here .

Vitamin B₁₂ Boasts Brain Benefits — WebMD tells readers: “Simple Dietary Changes May Help Ward Off Brain Volume Loss in Old Age.”

The study behind this false claim was covered here .

Acupuncture Cuts Ails of Breast Cancer Drugs — WebMD tells readers: “Acupuncture eases the hot flashes and night sweats common in women taking tamoxifen and Arimidex…"Acupuncture is a way to help regulate the body and enhance what it would normally do…’Obviously people are recognizing the benefit,’ Walker says. ‘Women need to talk to their insurance companies and push them to cover the cost.’”

The study behind this media claim was an abstract read at a meeting and the study failed to meet basic scientific principles of a fair test or biological plausibility, as covered here.

“4 Steps to Living 14 Years Longer” — WebMD promised readers could shed 14 years off their age in four easy steps.

This claim and the study behind it was covered here .

Dairy Foods Help Burn Fat, Speed Weight Loss… lose those extra pounds and burn fat without cutting back drastically on calories

The FTC cracked down on bogus weight loss claims that any food or supplement can healthfully cause significant weight loss without cutting calories.

Cinnamon helps type 2 diabetes — WebMD tells readers: “Cinnamon can improve glucose and cholesterol levels in the blood. For people with type 2 diabetes, and those fighting high cholesterol, it's important information. Researchers have long speculated that foods, especially spices, could help treat diabetes. In lab studies, cinnamon, cloves, bay leaves, and turmeric have all shown promise in enhancing insulin's action…”

These bogus claims of cinnamon and the randomized controlled clinical trial evidence was covered here.

Trans Fats May Increase Infertility — WebMD tells readers that a new Harvard study linked ovulation-related fertility problems in women to transfats.

As covered here, this study had actually found that the more total fat women ate, the less likely they were to have problems conceiving and that each quintele of higher fat intake was associated with an improved ability to conceive. Plus, the type of fat made no difference.

Red Meat May Up Breast Cancer Risk— WebMD told readers, including healthcare professionals for continuing education credit: “Eating more than one serving of red meat every day may double a woman's risk of developing some forms of breast cancer.”

In actuality, as covered here, this Nurses Health Study was unable to find any tenable link between red meat intake and premenopausal breast cancers.

Weight Loss Cuts Prostate Cancer Risk — WebMD told readers, including healthcare professionals for continuing education credit: “Men who lose weight may be less likely to get aggressive prostate cancer, while obesity may increase a man's risk... Men who lose weight may reduce their risk of prostate cancer.”

As was reviewed here, this study found no association between the men’s body mass index or weight change and their overall risk for prostate cancer. In fact, the obese men had about 10% lower overall incidence of prostate cancers and the risk steadily dropped as BMIs increased. And the men who gained 10 pounds had a 20% lower risk for the most deadly, metastatic forms of cancer, with the men gaining 20 pounds having a lower risk than the men who hadn’t gained an ounce.

Now, this WebMD content can be accessed from the FDA Consumer Health Information page, created to assist the FDA in reaching more consumers with “accurate, science based information that can help them improve their health.”

Toto, I've a feeling we're not in Kansas anymore.

© 2008 Sandy Szwarc

* As the largest online health information company, WebMD owns and operates WebMD Health, Medscape, MedicineNet, e-Medicine, e-Medicine Health, RxList and theheart.org. It supplies much of the online health information reaching consumers and found on employer and insurer preventive health and wellness programs. WebMD provides personal health record services to more than 90 large employers, pharmaceutical companies and health plans (Aetna, Cigna and Wellpoint). Information from insurer billing records, clinical laboratories and pharmacy benefit managers is entered automatically, along with any information employees volunteer about their health and lifestyle habits in health assessment questionnaires. WebMD was also awarded a government contract last summer in efforts to develop personal health records for the Centers for Medicare & Medicaid Services using its claims data. These personal health records are being used to identify and target people to receive alerts about certain health factors and reminders of screening and interventions, as well as measure compliance. Medscape, LLC offers accredited CME free to physicians, as well as continuing education credits free to nurses. It also supplies the financial technology and health information applications for large employers, the pharmaceutical industry, health plans and financial institutions. WebMD also has a Weight Loss Clinic and its obesity reference material is offered in collaboration with The Cleveland Clinic. [Click on any images to enlarge.]