Cupping: How It Works (And How It Doesn’t)

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Good Health By The Cup?

In Tuesday’s newsletter, we asked you for your opinion of cupping (the medical practice), and got the above-depicted, below-described, set of responses:

  • About 40% said “It may help by improving circulation and stimulating the immune system”
  • About 26% said “I have never heard of the medical practice of cupping before this”
  • About 19% said “It is pseudoscience and/or placebo at best, but probably not harmful
  • About 9% said “It is a good, evidence-based practice that removes toxins and stimulates health”
  • About 6% said “It is a dangerous practice that often causes harm to people who need medical help”

So what does the science say?

First, a quick note for those unfamiliar with cupping: it is the practice of placing a warmed cup on the skin (open side of the cup against the skin). As the warm air inside cools, it reduces the interior air pressure, which means the cup is now (quite literally) a suction cup. This pulls the skin up into the cup a little. The end result is visually, and physiologically, the same process as what happens if someone places the nozzle of a vacuum cleaner against their skin. For that matter, there are alternative versions that simply use a pump-based suction system, instead of heated cups—but the heated cups are most traditional and seem to be most popular. See also:

National Center for Complementary and Integrative Health | Cupping

It is a dangerous practice that often causes harm to people who need medical help: True or False?

False, for any practical purposes.

  • Directly, it can (and usually does) cause minor superficial harm, much like many medical treatments, wherein the benefits are considered to outweigh the harm, justifying the treatment. In the case of cupping, the minor harm is usually a little bruising, but there are other risks; see the link we gave just above.
  • Indirectly, it could cause harm by emboldening a person to neglect a more impactful treatment for their ailment.

But, there’s nothing for cupping akin to the “the most common cause of death is when someone gets a vertebral artery fatally severed” of chiropractic, for example.

It is a good, evidence-based practice that removes toxins and stimulates health: True or False?

True and False in different parts. This one’s on us; we included four claims in one short line. But let’s look at them individually:

  • Is it good? Well, those who like it, like it. It legitimately has some mild health benefits, and its potential for harm is quite small. We’d call this a modest good, but good nonetheless.
  • Is it evidence-based? Somewhat, albeit weakly; there are some papers supporting its modest health claims, although the research is mostly only published in journals of alternative medicine, and any we found were in journals that have been described by scientists as pseudoscientific.
  • Does it remove toxins? Not directly, at least. There is also a version that involves making a small hole in the skin before applying the cup, the better to draw out the toxins (called “wet cupping”). This might seem a little medieval, but this is because it is from early medieval times (wet cupping’s first recorded use being in the early 7th century). However, the body’s response to being poked, pierced, sucked, etc is to produce antibodies, and they will do their best to remove toxins. So, indirectly, there’s an argument.
  • Does it stimulate health? Yes! We’ll come to that shortly. But first…

It is pseudoscience and/or placebo at best, but probably not harmful: True or False?

True in that its traditionally-proposed mechanism of action is a pseudoscience and placebo almost certainly plays a strong part, and also in that it’s generally not harmful.

On it being a pseudoscience: we’ve talked about this before, but it bears repeating; just because something’s proposed mechanism of action is pseudoscience, doesn’t necessarily mean it doesn’t work by some other mechanism of action. If you tell a small child that “eating the rainbow” will improve their health, and they believe this is some sort of magical rainbow power imbuing them with health, then the mechanism of action that they believe in is a pseudoscience, but eating a variety of colorful fruit and vegetables will still be healthy.

In the case of cupping, its proposed mechanism of action has to do withbalancing qi, yin and yang, etc (for which scientific evidence does not exist), in combination with acupuncture lore (for which some limited weak scientific evidence exists). On balancing qi, yin and yang etc, this is a lot like Europe’s historically popular humorism, which was based on the idea of balancing the four humors (blood, yellow bile, black bile, phlegm). Needless to say, humorism was not only a pseudoscience, but also eventually actively disproved with the advent of germ theory and modern medicine. Cupping therapy is not more scientifically based than humorism.

On the placebo side of things, there probably is a little more to it than that; much like with acupuncture, a lot of it may be a combination of placebo and using counter-irritation, a nerve-tricking method to use pain to reduce pain (much like pressing with one’s nail next to an insect bite).

Here’s one of the few studies we found that’s in what looks, at a glance, to be a reputable journal:

Cupping therapy and chronic back pain: systematic review and meta-analysis

It may help by improving circulation and stimulating the immune system: True or False?

True! It will improve local circulation by forcing blood into the area, and stimulate the immune system by giving it a perceived threat to fight.

Again, this can be achieved by many other means; acupuncture (or just “dry needling”, which is similar but without the traditional lore), a cold shower, and/or exercise (and for that matter, sex—which combines exercise, physiological arousal, and usually also foreign bodies to respond to) are all options that can improve circulation and stimulate the immune system.

You can read more about using some of these sorts of tricks for improving health in very well-evidenced, robustly scientific ways here:

The Stress Prescription (Against Aging!)

Take care!

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  • Spinach vs Chard – Which is Healthier?

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    Our Verdict

    When comparing spinach to chard, we picked the spinach.

    Why?

    In terms of macros, spinach has slightly more fiber and protein, while chard has slightly more carbs. Now, those carbs are fine; nobody is getting metabolic disease from eating greens. But, by the numbers, this is a clear, albeit marginal, win for spinach.

    In the category of vitamins, spinach has more of vitamins A, B1, B2, B3, B5, B6, B9, E, and K, while chard has more of vitamins C and choline. An even clearer victory for spinach this time.

    When it comes to minerals, spinach has more calcium, copper, iron, magnesium, manganese, phosphorus, selenium, and zinc, while chard has more potassium. Once again, a clear win for spinach.

    You may be wondering about oxalates, in which spinach is famously high. However, chard is nearly 2x higher in oxalates. In practical terms, this doesn’t mean too much for most people. If you have kidney problems or a family history of such, it is recommended to avoid oxalates. For everyone else, the only downside is that oxalates diminish calcium bioavailability, which is a pity, as spinach is (by the numbers) a good source of calcium.

    However, oxalates are broken down by heat, so this means that cooked spinach (lightly steamed is fine; you don’t need to do anything drastic) will be much lower in oxalates (if you have kidney problems, do still check with your doctor/dietician, though).

    All in all, spinach beats chard by most metrics, and by a fair margin. Still, enjoy either or both, unless you have kidney problems, in which case maybe go for kale or collard greens instead!

    Want to learn more?

    You might like to read:

    Make Your Vegetables Work Better Nutritionally ← includes a note on breaking down oxalates, and lots of other information besides!

    Enjoy!

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  • Mammography AI Can Cost Patients Extra. Is It Worth It?

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    As I checked in at a Manhattan radiology clinic for my annual mammogram in November, the front desk staffer reviewing my paperwork asked an unexpected question: Would I like to spend $40 for an artificial intelligence analysis of my mammogram? It’s not covered by insurance, she added.

    I had no idea how to evaluate that offer. Feeling upsold, I said no. But it got me thinking: Is this something I should add to my regular screening routine? Is my regular mammogram not accurate enough? If this AI analysis is so great, why doesn’t insurance cover it?

    I’m not the only person posing such questions. The mother of a colleague had a similar experience when she went for a mammogram recently at a suburban Baltimore clinic. She was given a pink pamphlet that said: “You Deserve More. More Accuracy. More Confidence. More power with artificial intelligence behind your mammogram.” The price tag was the same: $40. She also declined.

    In recent years, AI software that helps radiologists detect problems or diagnose cancer using mammography has been moving into clinical use. The software can store and evaluate large datasets of images and identify patterns and abnormalities that human radiologists might miss. It typically highlights potential problem areas in an image and assesses any likely malignancies. This extra review has enormous potential to improve the detection of suspicious breast masses and lead to earlier diagnoses of breast cancer.

    While studies showing better detection rates are extremely encouraging, some radiologists say, more research and evaluation are needed before drawing conclusions about the value of the routine use of these tools in regular clinical practice.

    “I see the promise and I hope it will help us,” said Etta Pisano, a radiologist who is chief research officer at the American College of Radiology, a professional group for radiologists. However, “it really is ambiguous at this point whether it will benefit an individual woman,” she said. “We do need more information.”

    The radiology clinics that my colleague’s mother and I visited are both part of RadNet, a company with a network of more than 350 imaging centers around the country. RadNet introduced its AI product for mammography in New York and New Jersey last February and has since rolled it out in several other states, according to Gregory Sorensen, the company’s chief science officer.

    Sorensen pointed to research the company conducted with 18 radiologists, some of whom were specialists in breast mammography and some of whom were generalists who spent less than 75% of their time reading mammograms. The doctors were asked to find the cancers in 240 images, with and without AI. Every doctor’s performance improved using AI, Sorensen said.

    Among all radiologists, “not every doctor is equally good,” Sorensen said. With RadNet’s AI tool, “it’s as if all patients get the benefit of our very top performer.”

    But is the tech analysis worth the extra cost to patients? There’s no easy answer.

    “Some people are always going to be more anxious about their mammograms, and using AI may give them more reassurance,” said Laura Heacock, a breast imaging specialist at NYU Langone Health’s Perlmutter Cancer Center in New York. The health system has developed AI models and is testing the technology with mammograms but doesn’t yet offer it to patients, she said.

    Still, Heacock said, women shouldn’t worry that they need to get an additional AI analysis if it’s offered.

    “At the end of the day, you still have an expert breast imager interpreting your mammogram, and that is the standard of care,” she said.

    About 1 in 8 women will be diagnosed with breast cancer during their lifetime, and regular screening mammograms are recommended to help identify cancerous tumors early. But mammograms are hardly foolproof: They miss about 20% of breast cancers, according to the National Cancer Institute.

    The FDA has authorized roughly two dozen AI products to help detect and diagnose cancer from mammograms. However, there are currently no billing codes radiologists can use to charge health plans for the use of AI to interpret mammograms. Typically, the federal Centers for Medicare & Medicaid Services would introduce new billing codes and private health plans would follow their lead for payment. But that hasn’t happened in this field yet and it’s unclear when or if it will.

    CMS didn’t respond to requests for comment.

    Thirty-five percent of women who visit a RadNet facility for mammograms pay for the additional AI review, Sorensen said.

    Radiology practices don’t handle payment for AI mammography all in the same way.

    The practices affiliated with Boston-based Massachusetts General Hospital don’t charge patients for the AI analysis, said Constance Lehman, a professor of radiology at Harvard Medical School who is co-director of the Breast Imaging Research Center at Mass General.

    Asking patients to pay “isn’t a model that will support equity,” Lehman said, since only patients who can afford the extra charge will get the enhanced analysis. She said she believes many radiologists would never agree to post a sign listing a charge for AI analysis because it would be off-putting to low-income patients.

    Sorensen said RadNet’s goal is to stop charging patients once health plans realize the value of the screening and start paying for it.

    Some large trials are underway in the United States, though much of the published research on AI and mammography to date has been done in Europe. There, the standard practice is for two radiologists to read a mammogram, whereas in the States only one radiologist typically evaluates a screening test.

    Interim results from the highly regarded MASAI randomized controlled trial of 80,000 women in Sweden found that cancer detection rates were 20% higher in women whose mammograms were read by a radiologist using AI compared with women whose mammograms were read by two radiologists without any AI intervention, which is the standard of care there.

    “The MASAI trial was great, but will that generalize to the U.S.? We can’t say,” Lehman said.

    In addition, there is a need for “more diverse training and testing sets for AI algorithm development and refinement” across different races and ethnicities, said Christoph Lee, director of the Northwest Screening and Cancer Outcomes Research Enterprise at the University of Washington School of Medicine. 

    The long shadow of an earlier and largely unsuccessful type of computer-assisted mammography hangs over the adoption of newer AI tools. In the late 1980s and early 1990s, “computer-assisted detection” software promised to improve breast cancer detection. Then the studies started coming in, and the results were often far from encouraging. Using CAD at best provided no benefit, and at worst reduced the accuracy of radiologists’ interpretations, resulting in higher rates of recalls and biopsies.

    “CAD was not that sophisticated,” said Robert Smith, senior vice president of early cancer detection science at the American Cancer Society. Artificial intelligence tools today are a whole different ballgame, he said. “You can train the algorithm to pick up things, or it learns on its own.”

    Smith said he found it “troubling” that radiologists would charge for the AI analysis.

    “There are too many women who can’t afford any out-of-pocket cost” for a mammogram, Smith said. “If we’re not going to increase the number of radiologists we use for mammograms, then these new AI tools are going to be very useful, and I don’t think we can defend charging women extra for them.”

    KFF Health News is a national newsroom that produces in-depth journalism about health issues and is one of the core operating programs at KFF—an independent source of health policy research, polling, and journalism. Learn more about KFF.

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  • Natto, Taurine + Black Pepper, And Other Game-Changers

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    It’s Q&A Day at 10almonds!

    Have a question or a request? You can always hit “reply” to any of our emails, or use the feedback widget at the bottom!

    In cases where we’ve already covered something, we might link to what we wrote before, but will always be happy to revisit any of our topics again in the future too—there’s always more to say!

    As ever: if the question/request can be answered briefly, we’ll do it here in our Q&A Thursday edition. If not, we’ll make a main feature of it shortly afterwards!

    So, no question/request too big or small

    ❝Loved the info on nuts; of course I always eat pecans, which didn’t make the list of healthy nuts!❞

    Dear subscriber, pardon the paraphrase of your comment—somehow it got deleted and now exists only in this writer’s memory. However, to address it:

    Pecans are great too! We can’t include everything in every article (indeed, we got another feedback the same day saying the article was too long), but we love when you come to us with stuff for us to look at and write about (seriously, writer here: the more you ask, the easier it makes my job), so let’s talk pecans for a moment:

    Pecans would have been number six on our list if we’d have written more!

    Like many nuts, they’ve an abundance of healthy fats, fiber, vitamins, and minerals.

    They’re particularly good for zinc, which is vital for immune function, healing (including normal recovery after normal exercise), and DNA synthesis (so: anti-aging).

    Pecans are also great for reducing LDL (“bad” cholesterol) and triglycerides (which are also bad for heart health); check it out:

    Pecan-Enriched Diets Alter Cholesterol Profiles and Triglycerides in Adults at Risk for Cardiovascular Disease in a Randomized, Controlled Trial

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  • Ghanaian Red Bean & Sweet Potato Groundnut Stew

    10almonds is reader-supported. We may, at no cost to you, receive a portion of sales if you purchase a product through a link in this article.

    This is a dish popular in principle throughout West Africa. We say “in principle” because that’s a big place, and there is a lot of regional variation. The archetypal peanut stew is from Senegal (as maafe) or Mali (as tigadèguèna), but for its more balanced nutritional profile we’ve chosen one from Ghana—and since there are regional variations within Ghana too, we should specify that this one is from the south.

    If you are allergic to nuts, you can substitute a seed butter (or tahini) for the nut butter, and omit the nuts—this will work in culinary terms and be fine healthwise, but we can’t claim it would be the same dish, having lost its defining ingredient. If your allergy is solely to peanuts, then substituting with any oily nut would work. So, not almonds for example, but cashews or even walnuts would be fine.

    You will need

    • 1½ lbs sweet potatoes, peeled and cut into ½” cubes
    • 2 cups low-sodium vegetable stock
    • 2 cans kidney beans, drained, cooked, and rinsed (or 2 cups same; cooked, drained, and rinsed)
    • 1 can chopped tomatoes
    • ½ cup unsalted dry-roasted peanuts
    • 1 onion, chopped
    • 1 red bell pepper, deseeded and chopped
    • ¼ bulb garlic, finely chopped
    • 2 heaped tbsp unsalted peanut butter, minimal (ideally: no) additives
    • 2 tsp white miso paste
    • 2 tsp grated fresh ginger
    • 1 tsp ground cumin
    • 1 tsp cayenne pepper
    • 1 tsp black pepper
    • ½ tsp MSG or 1 tsp low-sodium salt
    • ½ tsp coarsely ground nigella seeds
    • Extra virgin olive oil

    Method

    (we suggest you read everything at least once before doing anything)

    1) Heat some oil in a sauté pan, or other pan suitable for both frying and fitting the entire stew in. Fry the onions until softened, turn the heat down low, and add the garlic, ginger, red bell pepper, cumin, cayenne, black pepper, and MSG/salt.

    2) Add ¼ cup of the vegetable stock, and the sweet potato, and turn the heat back up, on high for about 30 seconds to get it to temperature, and then take it down to a simmer.

    3) Stir in the miso paste and chopped tomatoes.

    4) Add most of the rest of the vegetable stock, keeping ¼ cup aside. Simmer for about 20 minutes.

    5) Stir in the kidney beans, and simmer for about 30 minutes more—the sweet potato should be soft now; if it isn’t, let it simmer a while longer until it is.

    6) Combine the peanut butter with the remaining ¼ cup vegetable stock, and blend until smooth. Stir it into the stew.

    7) If the stew is looking more like a soup than a stew, take out 1 cup and blend this 1 cup to a purée, adding it back in.

    8) Add half the peanuts unto the stew. Taste, and adjust the seasonings if necessary.

    9) Crush the remaining peanuts using a pestle and mortar; not too much though; you want them broken into bits, not pulverised.

    10) Garnish with the crushed nuts and nigella seeds, and serve.

    Enjoy!

    Want to learn more?

    For those interested in some of the science of what we have going on today:

    Take care!

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  • Citicoline: Better Than Dietary Choline?

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    Citicoline: Better Than Dietary Choline?

    Citicoline, also known as cytidine diphosphate-choline (or CDP-Choline, to its friends, or cytidine 5′-diphosphocholine if it wants to get fancy) is a dietary supplement that the stomach can metabolize easily for all the brain’s choline needs. What are those needs?

    Choline is an essential nutrient. We technically can synthesize it, but only in minute amounts, far less than we need. Choline is a key part of the neurotransmitter acetylcholine, as well as having other functions in other parts of the body.

    As for citicoline specifically… it appears to do the job better than dietary sources of choline:

    ❝Intriguing data, showing that on a molar mass basis citicoline is significantly less toxic than choline, are also analyzed.

    It is hypothesized that, compared to choline moiety in other dietary sources such as phosphatidylcholine, choline in citicoline is less prone to conversion to trimethylamine (TMA) and its putative atherogenic N-oxide (TMAO).

    Epidemiological studies have suggested that choline supplementation may improve cognitive performance, and for this application citicoline may be safer and more efficacious.❞

    ~ Synoradzki & Grieb

    Source: Citicoline: A Superior Form of Choline?

    Great! What does it do?

    What doesn’t it do? When it comes to cognitive function, anyway, citicoline covers a lot of bases.

    Short version: it improves just about every way a brain’s healthy functions can be clinically measured. From cognitive improvements in all manner of tests (far beyond just “improves memory” etc; also focus, alertness, verbal fluency, logic, computation, and more), to purely neurological things like curing tinnitus (!), alleviating mobility disorders, and undoing alcohol-related damage.

    One of the reasons it’s so wide in its applications, is that it has a knock-on effect to other systems in the brain, including the dopaminergic system.

    Long version: Citicoline: pharmacological and clinical review, 2022 update

    (if you don’t want to sit down for a long read, we recommend skimming to the charts and figures, which are very elucidating even alone)

    Spotlight study in memory

    For a quick-reading example of how it helps memory specifically:

    Citicoline and Memory Function in Healthy Older Adults: A Randomized, Double-Blind, Placebo-Controlled Clinical Trial

    Keeping dementia at bay

    For many older people looking to improve memory, it’s less a matter of wanting to perform impressive feats of memory, and more a matter of wanting to keep a sharp memory throughout our later years.

    Dr. Maria Bonvicini et al. looked into this:

    ❝We selected seven studies including patients with mild cognitive impairment, Alzheimer’s disease or post-stroke dementia

    All the studies showed a positive effect of citicoline on cognitive functions. Six studies could be included in the meta-analysis.

    Overall, citicoline improved cognitive status, with pooled standardized mean differences ranging from 0.56 (95% CI: 0.37-0.75) to 1.57 (95% CI: 0.77-2.37) in different sensitivity analyses❞

    Source: Is Citicoline Effective in Preventing and Slowing Down Dementia?-A Systematic Review and a Meta-Analysis

    The researchers concluded “yes”, and yet, called for more studies, and of higher quality. In many such studies, the heterogeneity of the subjects (often, residents of nursing homes) can be as much a problem (unclear whether the results will be applicable to other people in different situations) as it is a strength (fewer confounding variables).

    Another team looked at 47 pre-existing reviews, and concluded:

    ❝The review found that citicoline has been proven to be a useful compound in preventing dementia progression.

    Citicoline has a wide range of effects and could be an essential substance in the treatment of many neurological diseases.

    Its positive impact on learning and cognitive functions among the healthy population is also worth noting.❞

    Source: Application of Citicoline in Neurological Disorders: A Systematic Review

    The dopamine bonus

    Remember how we said that citicoline has a knock-on effect on other systems, including the dopaminergic system? This means that it’s been studied (and found meritorious) for alleviating symptoms of Parkinson’s disease:

    ❝Patients with Parkinson’s disease who were taking citicoline had significant improvement in rigidity, akinesia, tremor, handwriting, and speech.

    Citicoline allowed effective reduction of levodopa by up to 50%.

    Significant improvement in cognitive status evaluation was also noted with citicoline adjunctive therapy.❞

    Source: Citicoline as Adjuvant Therapy in Parkinson’s Disease: A Systematic Review

    Where to get it?

    We don’t sell it, but here’s an example product on Amazon, for your convenience

    Enjoy!

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  • Peaceful Kitchen – by Catherine Perez

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    The author, a keen cook and Registered Dietician with a Master’s in same, covers the basics of the science of nutrition as relevant to her recipes, but first and foremost this is not a science textbook—it’s a cookbook, and its pages contain more love for the art than citations for the (perfectly respectable) science.

    Mexican and Dominican cuisine are the main influences in this book, but there are dishes from around the world too.

    The recipes themselves are… Comparable in difficulty to the things we often feature in our recipes section here at 10almonds. They’re probably not winning any restaurants Michelin stars, but they’re not exactly student survival recipes either. They’re made from mostly non-obscure whole foods, nutritionally-dense ingredients at that, with minimal processed foods involved.

    That said, she does take a “add, don’t subtract” approach to nutrition, i.e. focussing more on adding in diversity of plants than on “don’t eat this; don’t eat that” mandates.

    If there’s any criticism to be levelled at the book, it’s that in most cases we’d multiply the spices severalfold, but that’s not a big problem as readers can always judge that individually; she’s given the basic information of which spices in which proportions, which is the key knowledge.

    Bottom line: if you’re looking to expand your plant-based cooking repertoire, this one is a fine choice.

    Click here to check out Peaceful Kitchen, and try some new things!

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