Evidence-based policy

As I mentioned a while back, I’ve been doing a bit of running and, unsurprisingly, had knee problems. One response has been to take drinks made of a foul-tasting powder containing glucosamine sulphate and chondritin, which has been widely held out as having promise in relieving symptoms of osteoarthritis. There were some promising case studies, enough to prompt both widespread use, including by me, and a full-scale trial and meta-analysis.

The tests results are now in, and I have mixed feelings in reporting that the both glucosamine sulphate and chondritin appear to be useless. (H/T Neurologica, but link isn’t loading). I was tempted to finish off what was left, on the theory that it might be doing some good anyway, but my commitment to evidence-based policy, along with the fact that the stuff tastes foul, has prevailed.

Out it goes. Now, if anyone can recommend a good broad-spectrum placebo, I’m in the market.

57 thoughts on “Evidence-based policy

  1. Errr ProfQ, might I suggest that in your case the best placebo would be to go swimming instead of running. Everybody’s joints have a ‘last strain by date’, and you’ve reached yours.

  2. I’m doing triathlon, so swimming as well as running and cycling. My knees haven’t reached their use by date yet, I think. I’m alert, not alarmed.

  3. I was interested to see that study as I take glucosamine+chondroitin tablets daily. I’m a rock climber and many in that sport take these both to strengthen joints protectively, and also to speed up recovery from injury. In my case I have early-stage osteoarthitis in a wrist, which feels like it is better (ie less or even no pain) when I’m taking the pills, compared to when I’ve gone off them. I freely admit, in the light of the single study, that this could be a placebo effect, but if placebo’s can reduce pain and increase function, then I’ll keep taking them.

  4. John, I think running is dumb. Its a variant on the idea that if something hurts its gotta be good for you.

    Running harms your knees which do wear out – I think the first commenter is accurate – take up swimming. For 8 years in Thailand I was a member of the Hash House Harriers which ran about 8K twice a week on hard surfaces. At the end of each run vast amounts of beer were consumed.

    I think that the running did me damage in both knees. I have had an arthroscopy in 1 (and it needs a total knee reconstruction) and the other has little grissle left. The beer probably damaged my liver and knocked off many million brain cells but I had more than enough to begin with or – more realistically – I am now just so deteriorated I cannot appreciate the costs and hence the intelligence loss is irrelevant.

    If you must run get yourself the best running shoes available and try to avoid running on hard surfaces.

  5. Now, if anyone can recommend a good broad-spectrum placebo, I’m in the market.

    Beer. Beer makes everything better — it even has non-placebo effects.

  6. Cycling is non-impact and often more practical than swimming. As for the other…

    Now, if anyone can recommend a good broad-spectrum placebo, I’m in the market.

    Try Keynesianism.

  7. Swimming! Nice and gentle and the emphasis is on arms. Join a squad of old masters somewhere (its a bit boring on your own and coaches know how to make it interesting) and make sure lots of lane space and not crowded with wippersnippers.
    Then Yoga. Fish oil. Hot and cold packs to keep swelling down. If things like that fail…hyaluronic knee injections?.

  8. I agree with HC. Being now afflicted with various arthritic conditions caused by degeneration of assorted joints and bones, for which there is no cure and which will only get progressively worse and more painful, I devoutly wish I had quit running 10 years before my body made me.

  9. Squats, lunges, and leg strength work at the gym fixed my knee soreness for half marathon running.

  10. Exercise and drinking alcohol – burning the candle at both ends! Just walk for half an hour daily and reduce your food intake to a natural diet of fresh meat, fruit and veges – no grain – it works.

  11. I lost about 12kg running, so the heart benefits have to be weighed against impacts on the knees. I’m trying for all-round fitness, with a mix of weights, general training, cycling, swimming and running.

  12. Both my dog and I have the same joint problems and the vet recommended glucosamine for the dog.
    It works, or something does and I presume there is no placebo effect for her.
    She is back to sprinting and jumping all over the place.
    My doc showed me the research, dumbed down of course, of the effect of glucosamine on humans.
    Minus the placebo it was zero.
    So I’m not jumping and sprinting all over the place.

  13. I concur with the others concerning quietly dropping the muck, but keep an eye out for further studies, you never know. Meanwhile, swimming, walking and cycling are all easier on the knees than running.

    On the topic of evidence-based policy, I have been trying to work out why morphine and other opiates are so ridiculously limited for chronic pain sufferers – the usual excuses all lack evidence of adequate quality to justify such tight-fistedness.
    A couple of years ago I went to a pain clinic, after an 11 month wait, to find out what I might be able to do about the pain. Exercise and postural stuff goes only so far to reducing pain averaged over a month say, and distraction techniques fail when concerted thinking on something other than the distraction is required. In other words, for chronic pain medication is typically an essential part of the mix of surviving day-to-day, week-to-week, etc.

    The pain clinic gave me a double-blind drug infusion, in which 4 separate classes of medication (well 3 actually as one is a saline placebo) are infused intravenously and trialled by the patient. So far, so good. For me the results confirmed my assessment of each drug including the placebo, for which pain increased. The best drug turned out to be fentanyl, a synthetic opiate. Imagine how surprising it was to be told that the clinic team thought I’d be best not being on medication – except OTC – at all! They told me I was too young to be on an opioid and I didn’t have cancer, so…bad luck! Oh, and there was the risk of addiction, apparently.

    I bring this up because OTC medications such as panadeine and nurofen plus are harder to obtain now, in the sense that the pharmacist has to play 20 questions and take the purchaser’s details. It is claimed that people were running around buying up all these meds and then extracting the codeine to make hillbilly heroin. It has also been claimed that people are guzzling up to 100 a day of nurofen plus in order to get a high.

    Where is the evidence of such rampant transgressions? I know of only one case of someone taking 100 a day and that was from the press release supporting the new restrictions on codeine-containing pain meds.

    Evidence-based policy in chronic pain management is non-existent in Australia, and I make that claim based upon my experience 😛

    In fact, all I see are mysterious regressions in pain medication control towards a temperance and prohibition model. Inscrutable.

  14. You could also try a bit of the Green Fairy.

    It did wonders for Toulouse Lautrec, Baudelaire and Modigliani (and I think it would improve the general disposition of some others in here as well).

    Oscar Wilde said it made his legs feel like they had tulips on them.

  15. JQ,

    Some people swear by fish-oil capsules.

    Personally, I think you’ll have to wait for injectable articular cartilage.

  16. I’m going to concur with others here PrQ.

    If you want to work your heart but not your cartilege and ligaments, swimming is a much better option. Aquarobics isn’t bad either.

    Walking can give you similar benefoits to running without the impact, and yes, stay off compacted surfaces. A treadmill in a gym will hurt you less.

    In between, something like tai chi is a useful part of the suite.

  17. JQ, to much running will ruin your knees. To much cycling will ruin your hips.

    You want to alleviate knee pain get a podiatrist or a sports physio/medico to look at your feet and running style. Insoles may help or a change in running technique. This will delay the inevitable joint replacement. Jog on soft grass, keep your stride low to the ground to reduce impact, avoid steep slopes up and down….. get advice.

    If you want to loose weight its all about tricking your body into loosing weight. You could probably loose weight without many hours of exercise a week and less long term damage and pain to your joints. How much more exercise can you do before you reach your limit. If you stabilise your exercise routine at a high level (or low) your body will fall into a metabolic equilibrium yielding very little weight loss. Fluctutate your exercise routine, eat only what you need keep your metabolism guessing. You will eventually have to innovate when your knees go so start now.

    I’m in my early 40s, I use to run many kms but I stopped 10 years ago for this very reason, I want my knees to last and I hate pain. My exercise routines are no longer then 40 minutes a day( maximum 10 minute jog) and change every eight weeks.

    Glucosamine and chondroiton supplements are useless at least at the moderate and severe levels of joint damage.

    …and some of what PML suggested.

  18. Some free professional advice JQ (glad to be able to reciprocate for a change!).

    What many are saying is true – some variety in activity is good. And if the knees are the problem, they will appreciate some non-running activity. Sudden increases in distance/time/intensity are most likely to provoke problems. Constant running on hard surfaces is likewise problematic. Good shoes – yes, but also change them before they look like they need it. Shock absorbancy is diminished by up to 50% after as little as a few hundred kilometres (though depends on brand, your weight, etc. (and is accelerated by running in rain)).

    The mistake most people make with running is to continually increase their time. An hour isn’t twice as beneficial as 30 mins. If you’re after the health effects, then 20 mins 3-4 times a week is sufficient. More hasn’t been shown to offer greater benefits.

    This next bit is age-dependent. You mentioned the weight loss aspect. Being in the healthy weight range also has health benefits – unless you are over 60. From this point, death rates (from all causes, male and female) are lowest in those in the overweight (not obese) range. Strange but true.

  19. Unless you have really weird biomechanics, you should be able to run at moderate levels injury free. The book all the serious runners think is good is: “The Lore of Running” by Tim Noakes.

    If you want to run happily, don’t increase your mileage quickly. In addition, it’s pretty easy to tell if you have a strange gait by the wear pattern on the bottom of you shoe. Depending on the pattern, you need to choose the right type of shoe — most shoes change your gait one way or another. It’s very likely that you will something wrong with your gait for running, since about 50% of white Europeans pronate too much, and a small percentage supinate. Almost any serious runners can tell you what is wrong just by running behind you and look at the way your feet hit the ground (there must be a running club at UQ, so you can find serious there I guess).

    If you have really serious biomechanical problems, which is unlikely, then can get some custom soft orthotics from a sports podiatrist, which cost about four hundred dollars. These are wonderful (I have them in my cycling shoes — you need different ones for cycling and running, although it’s very unlikely you’d need them for cycling unless you are really super serious about it all and training heaps).

    If you don’t, go to a sports podiatrist and get some soft orthotics if you need them. That will cost about four hundred dollars all up, but will solve all you nee

  20. Sorry about the typos and occasional missing word in that, I have left my normal glasses at work.. It also seems to have chopped, the last bit should be:

    solve all your knee problems.

  21. If you are needing a placebo for the foul taste, then try taking fish oil. It can’t do any harm, right?

    To build up bone density get some wobble board treatment (used by astronauts to reduce the effects of weightlessness on bones) this will improve bone strength without overworking the joint surfaces. You might also try the kangaroo shoes, those springey things that attach to the legs. Guaranteed to improve your distance/time results without impacting your joints so severely (cushioning effect). Then all you have to do is convince the next race organisers that they are fair competition.

    Fn. http://www.buzzle.com/editorials/9-11-2005-76536.asp

  22. Hi John

    I have osteoarthritis in my foot, my Doctor said to me “You can live with that”.

    My husband went out and bought me a “circulation booster”, at the Chemist shop.
    The machine is light in weight and easy to move around, I have it under the computer.

    The pain stopped within 2 days, absolutely magic, I would recommend to everyone.

    Ask Ad Astra about taking stuff, he owns The Political Sword., Ad is a Doctor:



  23. @Donald Oats I’m glad you’ve raised the authoritarian, nanny-state regulations that require a pharmacist to ask for all sorts of personal information when providing non-prescription compound analgesics containing codiene.

    I don’t tell people that I have the Hep C virus because they usually assume that I am an injecting drug user – I was infected in hospital 40 years ago. I’ve been symptom free for decades but as I’d like to be rid of this nasty infection, I decided to start the current treatment, involving weekly injections of Interferon and daily oral Ribavirin, for 6 months.

    These both have unpleasant side effects – flu-like aching anywhere but mainly headaches, nausea, sleeplessness and fatigue. To deal with this I take a compound medication containing paracetamol, codiene and an antihistamine. Never more than 1 at night.

    So I object to having to explain, at a public pharmacy counter, to a young chemist, why I want the product. The other side-effect of Interferon is reduced seratonin levels, making me less tolerant of others crap, so it can be an unpleasant exchange for both of us. And it’s not as if this intrusive measure does anything to control access to codiene for inappropriate use.

  24. If you are doing the triathlon Prof – just make it a biathlon. Shame…. I would have loved (paid good money even) to see someone just like you thrash Budgie Boy! Challenge him in the pool – I dont know as Budgie can swim as well as he runs.

  25. Some of those with fibromylagia (a chronic pain condition) find a mix, but not necessarily all, of the following helpful:

    ? seeing a physiotherapist for exercises
    ? seeing a dietician for advice on foods (salmon can be a good anti-inflamatory for some)
    ? using a TENS machine
    ? doing Tai Chi
    ? taking a couple of paracetamol before bed only when absolutely necessary
    ? thinking positively
    ? pacing activities.

    A friend of my who does a lot of dancing finds a good massage invaluable.

    Hope that at least one of these is of some assistance (MeganK).

  26. John, Daisy has cartrophen injections from the vet and they definitely work. If you get desperate….

  27. Hatha Yoga, preferably in the Iyengar tradition. Not a placebo of course, but over a period of time has – for me – improved alignment and diminished tweaks and nagging pains

  28. I’d just about have to be dying or in agony before I’d take any pharmaceutical. Big Pharma’s modern drugs are pretty much all dangerous long term. Modern medicine and pharmacy has been so corrupted by money (corporate capitalism) that scientific objectivty has gone out the window. Alternative medicine is quakery of course so dont go that way either.

    In most cases you are best off medication free at all times. I’d advise the same for operations. Too dangerous due to modern superbugs sweeping the hospitals. Forget elective surgery and only accept other surgery if you would definitely die without it.

  29. I ought to add my (ex) doctor put me on proton pump inhihibitors for gastric reflux. Within 3 months I had an irregular heart beat which I’ve never had before. Research has linked PPI’s with increased heart trouble.

    So, I stopped the inhibitors, lost 10 kg by walking, gave up coffee and the reflux stopped. My reaction to the irregular heart beat was to exercise harder and harder. I thought, I’ll soon find out if this is benign or not.

    Moral of the story. Most health problems are cureable or ameliorated by exercise and weightloss. Modern medicine will harm you as much as it helps you. Better to die than be kept alive to live a half life on pills.

  30. If you’re in the market for placebos, I strongly recommend homeopathy. Its just water, but you have to pay so much for it that you convince yourself it must be helping! I know lots of people that swear by it.

  31. Aplogies in advance for excessive length …

    Firstly what Fran said: “If you want to work your heart but not your cartilege and ligaments, swimming is a much better option …. Walking can give you similar benefoits to running without the impact, and yes, stay off compacted surfaces …. In between, something like tai chi is a useful part of the suite”

    then what Michael said: “… some variety in activity is good. And if the knees are the problem, they will appreciate some non-running activity. Sudden increases in distance/time/intensity are most likely to provoke problems. Constant running on hard surfaces is likewise problematic …… The mistake most people make with running is to continually increase their time. An hour isn’t twice as beneficial as 30 mins. If you’re after the health effects, then 20 mins 3-4 times a week is sufficient. More hasn’t been shown to offer greater benefits.

    This next bit is age-dependent. You mentioned the weight loss aspect. Being in the healthy weight range also has health benefits – unless you are over 60. From this point, death rates (from all causes, male and female) are lowest in those in the overweight (not obese) range. Strange but true”.

    All good stuff!

    Nassim Nicholas Taleb at http://www.fooledbyrandomness.com/notebook.htm : “… Spent some time with Erwan Le Corre … [who] understands the value of moderate unpredictability, the importance of improvization, and unconstrained exercise — to avoid the “fossilization” of routines. My idea of naturalistic/Paleo fitness: the broadest domain bandwidth, freedom from the captivity & injurious gym machines (resembling Tayloristic methods in working out). So started walking/sprinting on “rough”, fractal sufaces. I am lucky to have a place within walking distance from the best parc for that; along the coastline with close to a mile of rocks. Exhilarating, except for my broken nose.

    Just as chess skills only help you in chess (we know that those who can play chess games from memory don’t have strong memory for other matters), classroom math only helps in classrooms, weight training in gyms almost only helps you in gyms, a specific sport almost only helps you in that specific sport, and walking on smooth Euclidian surfaces causes injuries somewhere deep inside your soul.

    When you run and jump on rocks, your entire brain and body are at work; you stretch your back better than with yoga; every muscle in your body is involved; no two movements will be identical (unlike running in gyms); you become yourself.

    Also I just realized that, in the same vein, broad erudition, when supported by a good mathematical culture, is vastly more robust than any specialization. The wisdom of the ancients was domain-independent”.

    Guy’s a loon but I love him, and the above is very good 🙂

    In short: what they said.

    Personally I enjoy running on soft sand (I’ve done it, because I love it, for thirty years) but if it started to hurt my joints I would cease and desist. I don’t think it will. Walking is better for us than running, in general. Swimming is wonderful – who wouldn’t want to do some of it?! TaiChi and yoga … everybody should be practicing them, regularly, because they connect mind to body and because a billion Chinese and a few hundred million Indians couldn’t be wrong, could they? Try them, don’t try them too hard. They’re a pleasure.

    Finally, as always: “Warning: Don’t take financial, medical, safety, romance, or career advice from cartoonists. Any one of those could get you killed” – Scott Adams http://www.dilbert.com/

  32. I don’t know about glucosamine in humans but my sample was the neighbour’s dog. (Sample size 1!) She started bouncing around like a puppy after 3 weeks of 1000mg of glucosamine a day. I was sceptical of this supplement was another pampered pooch rip off like annual vaccinations but the dog convinced me. I am taking the stuff now!

    Are dogs subject to the placebo effect? It seems to me that a sample of elderly arthritic dogs would make an ideal sample. Researchers could attach a pedometer to the dogs to get a quantitative measure of the dog’s activity with and with glucosamine.

    BTW: My feeling is that dosage matters. Scaling up the dog’s weigh meant that I would have to take 3000 mg per day. Most of the human trials are at dosages well below this.

  33. On the subject of jogging and knees: I believe cross training to maintain core body as well as calf strength will reduce knee injury. Jogging seems to strip of muscle mass from where ever it can so you can find your self with not enough calf strength to run on your toes or maintain posture. This means that knees get a hammering. This seems to be principle behind the barefoot running movement with their over priced “bare foot running shoes”. From what I can see this really should be called the run on your toes movement!

    It is trendy to do triathalons to address this issue. Personally, I find a three hours training-walk up and down Mt Cootha a few times with 15kgs on my back listening to my backlog of podcasts once a week is enough balance out the negative effects of jogging. (The dog loves it as well!)

  34. I haven’t been able to run in many years, which is a pity. “Patello-femoral syndrome” (where syndrome is the catch-all for “modern medicine hasn’t quite worked this one out yet”). The physio said “well we can do a range of things, but more than 90% of people just give up running”, which I did, killing my mature age hockey comeback.

  35. The only placebo with any documented evidence of effect for joint inflammation and analgesia (not degeneration/prevention) is paracetamol (+ caffeine for endurance). A lot of work, some of it reasonably planned, powered, executed and reviewed by fairly reliable people (ie no overt bias, such as vested interest funding) has gone into demonstrating that there is no demonstrable effect (beyond placebo) in human osteoarthritis. Peterm’s comments on dosing is relevant, but so is the point that human joint degeneration is very different from other species – especially quadrupeds (though they do most of the animal work in sheep!). There is bugger all valid (by the same criteria as above) evidence on using glucosamine or chondroitin to prevent pain or degenerative joint disease, but I’m sure it has a strong placebo effect. On a personal level (bugger the studies!), I’ve given both up after trying them to overcome overenthusiam for climbing and running for 30 years (sorry Des!). I still take the EPA though…no evidence, but I did my PhD thesis on it so I’m biased! Slainte.

  36. Here too for barefoot running (thongs = roughly same difference). As long as it’s your idea not something being sold to you, which thought is important. Also: running on concrete whatever you’re wearing is boring and bad for you.

  37. I’ve often thought that a smart pharma company should market Placebin®, which is basically glucose, for doctors to prescribe. 90 percent of punters wouldn’t have a clue…

    Which reminds me, the 21 day contraceptive pill has 7 useless red pills containing lactose, to make up the 28 days. Why lactose, aren’t there lactose intolerant people? And why not iron supplement, surely that would be a timely period (‘scuse the pun) to be taking it?

  38. @jquiggin I enjoyed a similar weight loss a few years ago, after being a fat teenager (the 60s) and then battling to lose weight with various diet and exercise regimes ever since.

    Success was finally achieved through the adoption of a natural diet and the abandonment of any exercise beyond regular bushwalking (usually 10 hours plus weekly), and I’ve maintained good weight and health since, even despite my experience with Hep C treatment, above mentioned.

    Diet remains poorly understood, with the food industries successfully promoting as healthy, whole grain and low fat foods like wholemeal bread and brown rice. It is helpful to look at the hunter/gatherer diet, which sustained humans for about 95% of our time on Earth. They ate fresh meat, fruit and berries, leaves and roots, with minimal contributions from grains and other seeds, and the best diet today is still a diet that closely matches the hunter/gatherer diet.

    Of course, since some of us became farmers and town dwellers, there has been a natural selection in favour of tolerance of a high starch diet based on farmed grains, and clear evidence of this can be seen in the higher incidence of type 2 diabetes which always occurs in indigenous hunter/gatherer populations when they are introduced to our modern diet. We have already culled the most susceptible from our own European and Asian populations over the last few millenia.

    I adopted the natural diet for (what seemed like) a reason unrelated to weight – chronic asthma, hay fever, rhinitis, ear infections and laryngitis, all related to persistent Candida infestation of mucous membranes. (Sounds dreadful I know, but commoner than you think.)

    On the ENT specialist’s advice, I cut my food to fresh meat, fruit and veges only – no grain foods or compound manufactured foods at all. I lost in excess of 10 kg in 3 months and ate as much as I felt like, and felt much more energetic. The yeast infection and the problems it caused all went away, as did the craving for starchy food which I had always had.

    There is a persistent view, even among overweight people who are trying to lose weight, that they know what they need to do, but just don’t have the self discipline or will power to do it. This view is wrong – people don’t know what constitutes a healthy diet that will allow them to achieve a normal weight. They eat a diet high in grain starch and deficient in animal protein, and wonder why they’re still fat, sluggish and constantly hungry.

    If I’m right, the question then arises, can we provide a natural diet to most people? Given our reliance on grain crops to feed the current too-high population, I don’t think we can.

  39. Instead of trying to find something to add, why not try deleting some food types eg wheat. Refined wheat is a common low level inflamatory in some people who are not allergic to gluten.

  40. I do a lot of Zen-running and don’t have any knee problems. Essentially, Zen running entails sitting in the lotus position and envisioning oneself jogging. Zen-work and Zen-sex are variants, but I digress.

  41. You can’t beat running. It’s quick and easy compared with a bike or swimming and also more natural.

    Get your knees warm before running by plenty of flexing without shock, like fast walking or weird looking smooth running to minimise shock for a while.

    Cross training does wonders as many here have recommended, and again pay attention to getting the knees warm before heavy weights.

    I used Natures Way Liquid Glucosamine for several years following a back injury with a Herniated disc and 3 bulging discs. I used it in conjunction with Calcium Orotate as well as fish oil, plus many exercises and inversion bench. Threw everything at the problem and it mostly went away apart from permanently modifying my lifting behaviour to ensure I can continue to operate in my job.

    I still love to run, even with a twinge in the left knee if I don’t warm up properly and because of my back I only run uphill which is far less impact, and walk downhill.

  42. After a patellectomy in my twenties I now, in my fifites, have serious arthritis in that knee. The arthritis is so bad that it can leave me completely unable to walk and is causing serious slow weight gain. My doctor dismissively (but correctly) said “You could try glucosamine, apparently it helps some people” but of course it did nothing so I gave it up after persisting for two months. What does work is his prescription of 100mg of voltaren daily although as we now know that will probably give me a stroke eventually. The stroke will almost certainly be brought on by my hundredth patronising counselling session by a spotty faced pharmacy assistant who apparently by law has to treat me like an imbecilic child/criminal with no understanding of my own health needs.
    The most infuriating thing about these lectures is my suspicion that the legislation mandating them arose from pharmacists’ desire to assert a role in the medical system as something more than shopkeepers. They have now graduated from shopkeeping to low-rent policing. Their quest for credibility would be more plausible if they stopped aggressively promoting not just placebos like glucosamine but also a whole range of products that have no scientific basis whatsoever in their medical claims, including for starters most alternative medicines and dietary supplements and most cosmetics.

  43. I should have said that the liquid Glucosamine is far more digestable and tastes good.
    Running is the best thing for keeping my blood pressure down. If there were mountains around here I’m sure walking would do the same job but there isn’t.

  44. Ian Milliss, try a cortisone injection. Probably did me more good than all the others combined but how would you know for sure.

    Living with constant Pain and it’s consequences could be much more debilitating than the side efffects of cortisone.

  45. Thanks Salient Green that is the next step I think. Constant pain makes you grumpy as my earlier comment demonstrates, but it also sets you on a downward spiral. My weight gain, rising blood pressure etc have all grown from increasing immobility especially because daily walking was my main form of exercise. And I would add that the worst thing about getting older is too much discussion of health problems. JQ can you please refrain from any future health posts?

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