Pep, zing, oomph, ker-ching. CoQ10.

March 15th, 2008 by Ben Goldacre in adverts, bad science, medicalisation, nutritionists, times | 35 Comments »

Ben Goldacre
The Guardian,
Saturday March 15 2008

Doctors love pills: so do the public, and the media, and of course so do pill companies. When one pill dies, another must take its place. Are you feeling tired? Demotivated? I bet you are. But there is a solution – a pill – pushed by no less than Dr Thomas Stuttaford of the Times. Just two days ago in an article about “office tiredness” he cheerfully rehashed a press release on Boots’ exciting new pep pills. He opines at length on how tired we all feel in the office. So tired.

Why not try Coenzyme Q10, at just £4.99 for seven tablets (with a money back guarantee)? There is much talk of “energy”. “Biochemists were interested in the possible role that Coenzyme Q10, also known as CoQ10 (ubidecarenone or ubiquinone) might have in providing energy to cope with modern life.” Big words. “Most doctors will remember learning about the role of CoQ10 as a factor in the oxidative pathway adenosine triphosphate (ATP), upon which all cellular metabolism depends.”

I do remember. CoQ10 is one of many molecules involved in shunting chemical potential energy about cells. That’s chemical energy, from the breaking of bonds, which is used to make other chemical reactions happen.

This is not the same thing as emotional energy, get up and go, zip, welly, or “energy” energy. Stuttaford obediently recycles Boots’ fanciful and lucrative elision of these two distinct meanings. But Boots did have a sciencey-looking reference on their press release: “Energy levels can suffer as the body struggles to convert food into energy*.” The optimistic asterisk is to the authoritative looking reference: “Ernster L, Dallner G., Biochem.Biophys.Acta. 1995 May 24;1271(1):195-204”.

I have it here. It’s an old review paper on the biochemistry of CoQ10, its role in the cell. It has nothing to add on the pills making you feel more zippy. In fact no evidence is presented to support the claim that CoQ10 will make you feel perkier. I don’t think you’ll find any, except for anecdotes that are vulnerable to the placebo effect.

This is called “disease mongering“, and is a well known strategy. Big pharma is running out of new molecular entities (they registered 50 a year in the 1990s, now it’s 20 a year, a lot of them copies).

Because they cannot find new treatments for diseases we already have, they invent new diseases for treatments they already have. Favourites include social anxiety disorder (SSRIs) and female sexual dysfunction (Viagra): problems, in a very real sense, but not necessarily the stuff of pills. In fact, reframing loss of libido, shyness and tiredness as medical pill problems could well be considered crass, exploitative, expensive, and disempowering.

Big pharma is worth £150bn, it pushes products to doctors, who are trained to spot drug company nonsense. The food supplement industry is worth £30bn, and is marketed at you, with sciencey-sounding rhetoric, through the media, where no regulator will touch their claims. Sleep and exercise (not much work, but better than CoQ10 , much of it in the field of cancer eg here) have a much better evidence base for tiredness. They don’t come in pills, and you don’t see them much in the media, because you can’t sell them for 71p a day.

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Boots’ killer reference is here:

Ernster L, Dallner G., Biochem.Biophys.Acta. 1995 May 24;1271(1):195-204″

There’s a lot of stuff around on exercise and tiredness in the cancer literature, covered for example in this rather good review.

Assessment and management of cancer-related fatigue in adults
The Lancet Volume 362, Issue 9384, 23 August 2003, Pages 640-650

The commonest cause of tiredness is going to bed too late. I left my nice scan of that page from the don sleep textbook at work, will grab it next week.

More on disease mongering here and a lecture on it here.

CoQ10 also blogged at tremendous length by the excellent David Colquhoun, and from a business and historical perspective by Holfordwatch. I must say I find it fascinating how all these companies from the $60bn food supplement industry really do approach all this exactly the same as big pharma. You might call it cynical.

If you like what I do, and you want me to do more, you can: buy my books Bad Science and Bad Pharma, give them to your friends, put them on your reading list, employ me to do a talk, or tweet this article to your friends. Thanks! ++++++++++++++++++++++++++++++++++++++++++

35 Responses

  1. davimack said,

    March 15, 2008 at 4:10 am

    Some of the other claims about CoQ10 are that it can help lower blood pressure. So, what if you have normal blood pressure and are taking it to feel ‘peppy’? You’ll feel peppy, but have extra-low blood pressure? Bah.

  2. mjrobbins said,

    March 15, 2008 at 4:51 am

    Well, the logical conclusion surely is that we end up with companies marketing pills as general panaceas. Policosanol from the less reputable side of Cuba’s pharmaceutical scene is an amazing example of this, and companies like GSK are already “building links” there – see

  3. jodyaberdein said,

    March 15, 2008 at 8:23 am

    Perhaps Boots should market concentrated solutions of H+ considering their importance in the respiratory chain. Certainly would give more pep.

  4. Dr* T said,

    March 15, 2008 at 8:48 am

    Pep, Zing, Oomph, Kerching…

    Is this the till bit at the start of Pink Floyd’s “Money”?

  5. ControlFreak said,

    March 15, 2008 at 9:15 am

    Surprised nobody has tried marketing a suicide prevention pill, with money back guarantee of course. Or is that too sick even for the drug companies.

  6. Andrew Clegg said,

    March 15, 2008 at 9:22 am

    Doesn’t elision mean removal? Conflation maybe?


  7. abcde said,

    March 15, 2008 at 11:13 am

    Reframing shyness as a medical problem may well be crass, but social anxiety is an anxiety disorder. Google the forums if you are sceptical. It always shocks me a little when people elide the two. It’s rather like saying depression is the medicalisation of sadness. Perhaps this wasn’t exactly what you meant, but it is how it reads. Not helpful, Ben.

  8. Dr Aust said,

    March 15, 2008 at 11:38 am

    “It’s rather like saying depression is the medicalisation of sadness.”

    But that is surely the point, abcde. It may not be in the textbooks, but out in the real world it is hard to escape the conclusion that a highly significant subgroup of the people diagnosed “mildly to moderately depressed” and given SSRIs each year are indeed sad, rather than depressed. Once a disorder is defined, and enshrined in the DSM IV and similar, then the potential for “disease creep” is obvious. And it is even more blatant in the direct-to-consumer advertising for drugs in the US. I recall seeing TV adverts for SSRIs for social anxiety disorder, featuring a famous American footballer, which it would have taken six pairs of rose-tinted spectacles to see as being targetted on people with real anxiety disorders rather than “wish I wasn’t so shy”.

    To sum up – no-one disputes that some people have a real problem and need the help – but selling to them alone doesn’t make the Pharmas the cash that making the tent bigger and bigger does.

  9. RS said,

    March 15, 2008 at 1:40 pm

    Social phobia (defined in the ICD-10 as well as DSM-IV) is far from a new condition made up by drug companies, it is well attested to with serious repurcussions for the sufferer – and it is a rather obvious subclassification of phobic disorders in general. Social phobics have strong anxiety symptoms and panic attacks, with an elevated rate of suicide, and high rates of comorbid alcoholism and depression. It is not ‘just shyness’, just as major depression isn’t just ‘feeling a bit low’. And, most importantly, the best attested to treatment is CBT (with exposure and avoidance of safety behaviours), not SSRIs.

    Much like the ‘antidepressants don’t work’ story I worry that people are just lazily letting their prejudices be confirmed.

    Sure, some people feeling mildly low may be innapropriately medicated, but we could do with some hard data rather than just repeating our anecdotal prejudices – I particularly deplore the one where people report the number of antidepressant prescriptions and try and imply that gives us an idea of the number of people being given antidepressants for depression – which is blatant bollocks since the number of prescriptions is different to the number of people, and because antidepressants as a class of drugs are given for a very wide range of conditions including neuropathic pain, anxiety, and sleeping problems.

    Oh yeah, and why can’t females have sexual dysfunction? What is it about having a penis that makes sexual dysfunction the preserve of men?

  10. BSM said,

    March 15, 2008 at 2:21 pm

    “Perhaps it would be a marvelous idea if we all went out to Boots and bought a few packets and then invoked their money back guarantee”

    I would do, but I haven’t got the “energy”. Can someone do it for me, please?

  11. bhaji said,

    March 15, 2008 at 3:09 pm

    Isn’t Q10 supposed to “defy the signs of ageing”? i.e. get rid of wrinkles, hope that doesn’t happen in the gut, would surely reduce the surface area available to absorb the products of digestion, leading to malnutrition and even more tiredness?

  12. Ben Goldacre said,

    March 15, 2008 at 3:36 pm

    RS: this is always a fascinating issue. the problems eg shyness can be v v serious and extreme, they may even be helped by a pill, nothing i say is to doubt that, the more interesting issue to me is how these marketing campaigns reframe our understanding of the phenomena, as seen particularly with the serotonin hypothesis in depression

    they are selling the pill and the model. the latter to my mind is almost more venal and disempowering than the former. i’m not saying we should get all psychodynamic on this, simply that if you’re tired at work, you should get more sleep and exercise, or work on the practical issues around the fact that your life is shit. placebo pills are an exploitative non-answer.

  13. mjrobbins said,

    March 15, 2008 at 4:23 pm

    ControlFreak said: “Surprised nobody has tried marketing a suicide prevention pill, with money back guarantee of course. Or is that too sick even for the drug companies.”


    Is that actually such a bad idea?! I mean, given how big a part psychology plays in suicide, and given the influence of placebos on psychology, I wouldn’t be surprised if it worked to some statistically significant extent!

  14. Daibhid C said,

    March 15, 2008 at 6:42 pm

    I take it Dr Stuttaford is the inspiration for Private Eye’s “A Doctor Writes” column, featuring Dr Thomas Utterfraud?

  15. Daibhid C said,

    March 15, 2008 at 6:43 pm

    Whoops, imediately after posting, I noticed mrhunnybun had already referenced this…

  16. Ben Goldacre said,

    March 15, 2008 at 7:04 pm

    you misunderstand.

    this is not about whether SSRIs “work” or not – they do in many circumstances – you completely misunderstand.

    it’s about the entirely separate question of whether the well-marketed serotonin hypothesis (“not enough and you’re down”) as featured so prominently in popular culture, is a valid explanatory model or not. it is not. moreover, it is a marketing spiel which has been very successful, and which has arguable toxic cultural side effects in reframing our view of mood, agency and personhood.

  17. Dr Aust said,

    March 15, 2008 at 7:41 pm

    Re comments #15, #19:

    Advance apologies for the shameless self-plug:

    In one of my alternative personae of “Dr Otherfraud”, I have been inspired to pen a hopefully suitable Utterfraud-alike testimonial for CoQ10 over at David Colquhoun’s Improbable Science.

  18. Ben Goldacre said,

    March 15, 2008 at 8:25 pm

    oh yeah maybe fair enough, apols, was only typing out of the corner of my eye.

    but i think confusion arose as you are taking issue with something i have never said. where did i ever say that SSRIs do not affect the serotonin system?

  19. RS said,

    March 15, 2008 at 11:57 pm

    The problems with ‘shyness’ can indeed be very serious, what worries me is your implication above that social phobia is simply ‘bad’ shyness. Presumably schizophrenia is just ‘hearing voices’ (Romme stylee) now and then. Female sexual dysfunction is a particularly amusing one because people will often cast aspersions upon the existence of such a condition (evil drug companies making up conditions to sell PDE inhibitors) when they happily accept the existence of a condition for men – something about tumescent members being more ‘real’ perhaps?

    I agree that drug company advertising can have a pernicious effect altering the public perception of nature, causality, and treatment of various psychiatric phenomena, particularly in the US where it is frankly bizarre (although most US avertising is bizarre) – but we must remember that the monoamine hypothesis did not originate in the drug companies but the psychiatrists – it is the medical profession that spreads these myths about causality – the drug companies simply jumped on the bandwagon.

    I’m not sure about your reference to getting some sleep and exercise, or about having a shit life. Sure, if you have subclinical depressive symptoms then maybe some lifestyle issue could do with addressing – if you have a major depressive episode then telling people their life is shit and should be sorted out (e.g.’stop being someone who was abused!’) is hardly going to help.

    I think my concern is that a lot of what people say in regards to this issue is over generalising the issues of the essentially worried well to the seriously ill – and in particular ignoring the pre-existing criteria we have to distinguish between the two. Sure, musculoskeletal chest pain is an annoying waste of the time of an SHO, but that doesn’t mean we ignore the 50 year old with central crushing chest pain!

  20. Ben Goldacre said,

    March 16, 2008 at 12:43 am

    RS you’re arguing with something i havent said. i dont know how you got depression into this. you might be getting confused over what i said about tiredness:

    “i’m not saying we should get all psychodynamic on this, simply that if you’re tired at work, you should get more sleep and exercise, or work on the practical issues around the fact that your life is shit. placebo pills are an exploitative non-answer.”

    or maybe you think tiredness = depression?

    everybody agrees that serious problems of any variety deserve our serious attention. the question is whether a pill is a good solution, and whether a biomedical explanation is the most appropriate.

    this already dubious process reaches its nadir in the peddling of placebo CoQ10 pills for tiredness at the office.

  21. peningda said,

    March 16, 2008 at 1:26 am

    “Sleep and exercise have a much better evidence base for tiredness.”

    Exercise helps you sleep, and cycling to work is a great way of getting exercise without investing much time [except during UK winters]. Cycling with kids to school has helped my wife gain fitness and lose weight with minimal time investment.

  22. RS said,

    March 16, 2008 at 12:21 pm

    I’m talking to Dr Aust as well – but yeah, I didn’t notice that you’d switched back to talking about CoQ10. But my main problem is that I don’t think you, and others, when you refer to disease mongering by name checking things like social anxiety, are careful enough to state that they don’t think the whole thing is disease mongering, just that pharmaceutical companies (and society in general) try to get people who are the ‘worried well’ to believe that they have a particular condition and need medicating. I think failing to make that distinction leads to some of the views that have become current in a lotof media commentary that a lot of pyschiatric conditions aren’t ‘real’. Note that Dr Aust says:

    “it is hard to escape the conclusion that a highly significant subgroup of the people diagnosed “mildly to moderately depressed” and given SSRIs each year are indeed sad, rather than depressed.”

  23. thescientist said,

    March 16, 2008 at 2:53 pm

    Sorry, since when did energy come from the breaking of chemical bonds?

    To make a bond releases energy and to break one requires energy input.

    It is only the overall reaction of respiration that releases energy ie the energy released in making new bonds is greater than that used by breaking existing ones.

  24. Dr Aust said,

    March 16, 2008 at 9:58 pm

    PS Oops – sorry, 2nd hotlink got screwed up. The right one is here, if anyone is interested. And there is an amusing rapid response here.

  25. RS said,

    March 17, 2008 at 9:03 am

    Dr Aust – I’ve learned to be very careful about knee-jerk ‘bullshit’ responses to prevalence data. You have to remember that we don’t mix with all that many people with social phobia in our everyday lives for rather obvious reasons. Also there are generalised and specific forms of social phobia – for instance I know a few people with specific forms of social phobia for public speaking – you might think that is ‘normal’ but it causes considerable distress and dysfunctional self-medication with alcohol.

    Part of the problem with psychiatry is the assumption that everything should be divided into ‘normal’ and ‘abnormal’ and the ‘normal’ people told to fuck off. It is obviously rather more of a continuum and telling people that their distress is part of the ‘normal spectrum’ is not helpful.

    That doesn’t mean we should be dishing SSRIs out to every person that comes into a GP’s surgery feeling a bit low for a few days, but nor does it mean turning away people with serious distress because we think it is ‘normal’.

    Personally I think a major depressive disorder is probably a totally ‘normal’ response to childhood abuse, but that doesn’t mean we don’t try and find ways to alleviate or ameliorate the suffering involved.

  26. emilypk said,

    March 17, 2008 at 2:12 pm

    “Finding ways” is a pull economy approach where people have a problem and you try different ways to solve it until one works.

    This is more a “push economy” issue where they have a solution and want the largest possible group of people to use it regardless of whether it plausibly addresses their underlying issue.

    Negative affect and fatigue are both gross categories with many different underlying causes and effective treatments, so I think push strategies can be perilous for vulnerable consumers.

  27. keeftalent said,

    March 18, 2008 at 1:40 pm

    There are quite a few studies showing the inefficacy of CoQ10 supplements. Here’s a summary of a few.

    My favourite is the one where the Placebo group beat the CoQ10 supplemented group.

  28. Dave Gould said,

    March 19, 2008 at 10:02 am

    I suspect that social phobias are the most common of psychological problems. As a (non-prescribing) psychotherapist, such problems account for about 1/3rd of my clients, even though I do not market for them.

    There is also the question of scale. I believe that the number of people completely at ease in all social situations is zero. The market for an effective treatment for ‘social anxiety’ is probably bigger than that for weight loss. Alcohol is just one example of self-medicating here.

    There are also hundreds of variations of social phobia. One person might be afraid of eye contact whilst another might dislike speaking out in front of groups, another afraid of confronting people etc.

    The chances of a drug being able to target solely these individual variations is zero. It’s no coincidence that Prozac has been promoted for social anxiety as well as other anxieties, depression and numerous other DSV IV classifications.

    DSM IV classifications are quite arbitrary then.

  29. Ben Goldacre said,

    March 19, 2008 at 12:25 pm

    interesting email from someone with a vague preference for not having their name on the internet:

    Dear Ben Goldacre,

    As a regular reader of “Bad science”, I was particularly interested in
    your piece on ubiquinone (often sold as a health supplement as
    Coenzyme Q10), having worked in Lars Ernster”s laboratory in
    Stockholm in the early 1960s. There, I had carried out many
    measurements of ubiquinone levels in the mitochondria of several
    tissues, as one of the several components of the chain determining the
    regulation of oxidative phosphorylation leading to the production (or
    not) of ATP.

    After reading your piece, I re-read the review by L. Ernster and G.
    Dallner on the biochemistry of ubiquinone, cited by Boots in promoting
    the sale of Coenzyme Q10. It is especially ironical that the company
    refers to this review, which deals mainly with the biochemistry of
    ubiquinone, since at the end of their article they mention briefly
    anything about this substance as a supplement for human consumption.
    Despite many claims over several decades about its magical properties,
    the two authors conclude that exogenous ubiquinone accumulates in the
    blood and in the lysosomes in the liver lysosomes, the latter being
    the route for disposal or degradation of harmful substances!

    I look forward to further “Bad science” articles from you, which I
    find, simultaneously entertaining and alarming.

    Best wishes

  30. Dr Aust said,

    March 19, 2008 at 10:27 pm

    Yet another shameless self-plug: I have collected my various grumblings about CoQ10 over at my blog here. I freely admit it doesn’t add anything much to what Ben and DC have said already far more succinctly, except that it was already apparent a decade ago that the promotion of CoQ10 was complete flim-flam. It does have lots of snide innuendo and invective, though.

    Re. what the anonymous biochemist said (last post): One of the big semi-respectable sales pitches for CoQ10 is that people who take statins should chomp CoQ10 to “combat the CoQ10-lowering effects of taking statins” (statins inhibit a key biosynthetic pathway that leads to both CoQ10 and cholesterol). However, as I read the reviews in the actual scientific lit, CoQ10 supplementation, while raising plasma CoQ10, doesn’t seem to raise CoQ10 levels in target tissues like muscle. Which sounds entirely consistent with what Ben’s friendly biochemist just said.

    Coracle has a nice post about statins and Q10 here.

  31. Dr Aust said,

    March 20, 2008 at 10:46 am

    I think that is a brilliant “substitution”, Mottainai… but I don’t suppose there is much chance of getting Boots to adopt it.

    However, I will certainly henceforth be substituting “energy” (in its man-in-the-street sense”) with “pep”, “zip”, “get up and go” or “bushy-tailed-ness”.

    Personally, whenever I hear the Alt-oids talking vaguely about “energy” I am always reminded of Star Trek, where Mr Spock was forever telling Capt. Kirk things like “It appears to be some form of energy field, Captain”.

    Perhaps my distant youth watching such things explains why I tend to view mysterious “energies” as the stuff of fiction…

  32. ForeverAutumn said,

    March 20, 2008 at 11:45 am

    @Dave Gould
    “There is also the question of scale. I believe that the number of people completely at ease in all social situations is zero. The market for an effective treatment for ’social anxiety’ is probably bigger than that for weight loss.”

    I wonder also how much the perception “shyness” is influenced by culture. A person considered shy in America may be considered normal in Britain and annoyingly pushy in Japan. Some surveys (mostly in America) have found that the percentage of people self-describing as “shy” has increased in recent decades; I doubt that this is due to an increase in actual timidity but rather to less tolerance of shyness even in limited form.

    While extreme social phobia is no doubt life-limiting, a low level of “shyness” or social reticence may have its advantages. Holding back until you have sussed out a situation can prevent you from “rushing in where angels fear to tread”. I once saw a documentary about some kind of small penguin. There were two siblings: the brother took lots of risks, the sister held back and watched. He became seal food; she survived to adulthood and had chicks of her own.

    I have a mild phobia about public presentations, which means I prepare *really* well if I know I’ll have to speak in public. And shy people are often perceived by others as “nicer” than the outspoken (whether they are or not).

  33. Martinus said,

    March 20, 2008 at 6:57 pm

    I’ve just received a promoitional email from Boots plugging this offer. I’ve sent an angry response asking them to remove me from their list if they propose sending any similarly unscientific promotions. I’ll let you know if I get a reply.

  34. Robert Carnegie said,

    March 24, 2008 at 2:00 am

    Promotional energy drink? Accept it and pour it on the floor. Hand them back the empty can and go about your business. See which of you doesn’t get asked back to the shop.

    You could also do a Heather Mills job but I am worried about the sexism of reporting of that incident, although also curious to see the lawyer whose personal charm apparently was tremendously accentuated by having her wool wig wetted. Does moral qualm oblige me to deny myself seeking out the image? After all, it seems that the woman was assaulted.

  35. MrIncognito said,

    April 3, 2008 at 4:51 pm

    One of the main problems with Q-10 is that the bioavailability is so poor. A relative of mine has Huntington’s Disease, and there are several decent enough studies which show that Q-10 can slow the progression of the disease. The problem is that the study patients have to take hundreds of mg on a TID or QID schedule. There are efforts here in the states to improve the ADME and bring a related drug to market, but I am not aware of any successful attempts as of yet. At this point, even if Q-10 potentially had some benefit, it’s clearly a waste of money.