“Sub-laboratory” Hypothyroidism and the Empirical Use of Armour® Thyroid use

A very useful article by Dr Alan Gaby.


Evidence is presented that many people have hypothyroidism undetected by conventional laboratory thyroid-function tests, and cases are reported to support the empirical use of Armour® thyroid. Clinical evaluation can identify individuals with “sub-laboratory” hypothyroidism who are likely to benefit from thyroid-replacement therapy. In a significant proportion of cases, treatment with thyroid hormone has resulted in marked improvement in chronic symptoms that had failed to respond to a wide array of conventional and “alternative” treatments. In some cases, treatment with desiccated thyroid has produced better clinical results than levothyroxine. Research supporting the existence of sub-laboratory hypothyroidism is reviewed, and the author’s clinical approach to the diagnosis and treatment of this condition is described.

Alternative Medicine Review, Volume 9, Number 2, 2004


Mary Shoman Interviews Dr Kenneth Wolinger – New Hypothyroidism Guidelines Ignore Patient Concerns

Kenneth Woliner, MD is an integrative physician in private practice in Boca Raton, Florida, who uses conventional medicine as well as evidence-based complementary and alternative therapies to treat a variety of conditions, including hypothyroidism. Dr. Woliner has concerns about the American Thyroid Association (ATA) new “Guidelines for the Treatment of Hypothyroidism,” and has shared them in this Q&A interview.

Dr Wollinger: I think they are misnamed. Instead of being called “Guidelines for the Treatment of Hypothyroidism,” this white paper should have been called “Levothyroxine: How to Protect its Market Share.” Simply put, the entire paper, starting with its “Background Statement” is a defense of levothyroxine monotherapy, despite the general dissatisfaction that many patients have when faced with no choices, and told there is only one possible drug to treat their medical conditions.

See the whole interview at:


Public Support and New Research Promote Changes in Thyroid Treatment Guidelines

Gary Pepper M.D.    Metabolism.com    October 21, 2014

Clearly this is not an endorsement for the use of desiccated thyroid but it does open the door for its use when the clinical situation is appropriate. Until now, a prescriber could face the accusation of recommending toxic treatment, if held to the AACE standard.

In overturning the prior ban on Armour the new AACE recommendations refer to a study done at the NIH by Hoang and colleagues published in May 2013 in  Clinical Endocrinology and Metababolism  which showed that desiccated thyroid could be used safely and effectively in treatment of hypothyroidism.  In this study, about 50% of the individuals treated at different times with levothyroxine and Armour preferred Armour, while 19% preferred levothyroxine. Since the time of publication of the NIH study, Paul Cassanova-Romero  and myself, published our study showing that almost 80% of people who had inadequate relief of hypothyroid symptoms on levothyroxine, preferred Armour Thyroid treatment.

In explaining the new stance of the AACE on use of desiccated thyroid, the committee also referenced a growing understanding of the diverse genetic factors controlling how the body utilizes and responds to thyroid hormone. Due to genetically programmed differences it is plausible that a portion of the hypothyroid population would require treatment with supplemental T3 (as opposed to  Synthroid or levothyroxine made of the hormone T4) supplied by Armour. In addition, desiccated thyroid contains other hormones which could be important to achieving full clinical benefits of thyroid replacement therapy. Genetic testing is not yet at a point where this could be used to determine who needs the addition of T3.

As far as the AACE’s stated concern about safety of Armour Thyroid, it seems strange that desiccated thyroid which has been in use for 100 years is questioned while the synthetic thyroid preparations available for merely half that time, are not being held to the same safety standards.

I have made a request to the organizers of the yearly national meeting of endocrinologist, to allow presentation of our study on patient preference for Armour Thyroid.  Several weeks have gone by without response to our request, however.  A public campaign will help assure the new information reaches the nation’s endocrinologists. For this purpose please email Sheila Spitola, administrator for the national meeting,  (sspatola@aace.com)   , with the statement,   “ I support an open discussion of use of desiccated thyroid in the treatment of hypothyroidism.  The authors of Conversion to Armour Thyroid from Levothyroxine Improved Patient Satisfaction in the Treatment of Hypothyroidism,  should be given the opportunity to present their data at the 2015 national AACE meeting. “




Conversion to Armour Thyroid from Levothyroxine Improved Patient Satisfaction

An interesting article by Gary M. Pepper & Paul Y.  Casanova-Romero in the Journal of Endocrinology, Diabetes & Obesity,  2(3): 1055, (2014), which contains this telling sentence:

. . . treatment of hypothyroidism with levothyroxine (L-T4) monotherapy has been the standard of care in the United States for over 3 decades. This is despite the reported failure of this form of therapy to result in satisfactory resolution of symptoms in a portion of treated individuals.


The use of Armour Thyroid (natural desiccated thyroid) in the treatment of hypothyroidism has generated debate among endocrinologists although there is evidence that a significant percentage of patients prefer this medication to T4-only replacement strategies. In this retrospective analysis we investigate the preference for replacement therapy of patients with persistent subjective symptoms of  hypothyroidism on T4-only treatment who subsequently switched to Armour Thyroid (AT).

Methods: 450 consecutive patients being treated for hypothyroidism were screened. Of these, 154 had been switched from either generic or brand T4 replacement to AT for treatment of persistent symptoms of hypothyroidism. Patients undergoing treatment for thyroid cancer or on suppression therapy for nodular thyroid disease were excluded. Patients were instructed to have their blood sampled for thyroid function testing in the morning after taking their medication. After a minimum of 4 weeks on medication patients were asked to compare AT treatment versus T4-only treatment using a 5 point satisfaction rating scale. Results are reported as mean ± SD.

Results: On a 5 point Satisfaction Rating Scale with “5” indicative of the highest level of satisfaction, 117 (78.0%) patients gave a score of greater than “3” in preference for AT. Three patients treated with AT and one treated with LT4 reported adverse events, all minor. TSH was 1.30 ± 1.9 mIU/L and T3 1.81 ± 0.78 pmol/L on L-T4 monotherapy while TSH was 1.27 ± 2.2 mIU/L and T3 2.31 ± 1.33 pmol/L on AT (NS for TSH and p<0.003 for T3 ). T4 to T3 ratio on L-T4 monotherapy was 8.45 ± 3.7 while it was 4.70 ± 2.0 (p<0.001) on AT. There was no significant change in weight after switching to AT.

Conclusion: AT treatment produced high satisfaction scores in a group of hypothyroid patients with persistent symptoms on L-T4 therapy. Our findings suggest that AT preference is not due to placebo effect, induction of hyperthyroidism or weight loss. No significant untoward effects of this therapy were noted inclusive of 30 subjects 65 yrs of age and older. As suggested by Hershman [20], AT seems no more dangerous than adding T3 to L-T4 therapy and can be offered to patients who “don’t feel normal” on L-T4 monotherapy. Larger prospective studies would help clarify what role AT plays in replacement therapy of   patients dissatisfied with L-T4 monotherapy for hypothyroidism. Our results are encouraging to clinicians that this drug does provide a viable treatment alternative.


TSH: Thyroid Stimulating Hormone; L-T4: Levothyroxine; T4: Thyroxine; T3: Triiodothyronine; AT: Armour Thyroid; L-T4 levothyroxine; NT: No Thyroid Disease; SRS: Satisfaction Rating Scale

See the full article at:


Management of perimenopause and male andropause with bioidentical hormone replacement therapy – Dr Bill Reeder

Another very interesting letter written by Dr Bill Reeder in New Zealand to General Practitioners regarding the use of bioidentical hormone replacement therapy.

The summary, reproduced here, bolding by HCS, is succinct:


The overarching factor is that with diminished quality of life, and it can vary from nuisance level to serious, hormone replacement can be very effective.

The answer to these questions, which to me is logical, then is to replace using safe, physiological dosing, transdermal where possible, bio-Identical hormones. 

And maintain healthy patient surveillance using meaningful lab methodology. 

I always recommend patients be their own advocates and read as widely on the subject as they can. We doctors guide, council and at best we do no harm.

(See below for full letter.)___________________________________________________________________________

                                                     Dr Bill Reeder                                                                       

Integrative and Biomedical Medicine

458 Airport Rd Hamilton 3282 New Zealand

Tel 64 7 856 8568 Fax 07 859 1212 wjr@medcom.co.nz

 Dear Doctor,

Management of perimenopause and male andropause with  Bio-identical Hormone Replacement (BHRT) 

Firstly, bio-identical means exactly the same molecular structure steroid as human – so not a derivative or equine sourced.

There is some confusion about the ‘natural’ word. Bio-identical hormones have a plant derived source and then synthesised into human hormones. So are most pharmaceutical hormones but they are analogues or altered. Pharmaceutically compounded hormones (BHRT) are not natural’ i.e. from humans, they’re still synthesised but remain bio-identical. Most, but not all are used as a transdermal form – for good reason.

One of my several special interests is bio-identical hormone management. It is controversial for a number of reasons for some critics of the treatment: 

  • “Its not an ‘approved’ or ‘guideline’ medicine”. 

* Most drugs by their synthetic nature and non-human occurrence    require extensive RCT testing and approval processes. ‘Bioidentical Replacement Hormones’ (BHRT) have already been ‘proven’ biologically. That’s common sense. Moreover, these natural hormones have been used by many doctors world-wide for at least 2 decades now. There is no evidence of any higher risk than in the non-treated population when prescribed correctly.

* What is up for discussion is long term exposure to even natural hormones. Are we designed to have minimal hormones at mid-life for some safety reason or is it just that we are living beyond fertility use by date. Its unlikely that continuation of low dose replacement would be harmful when used according to natural cycles and in appropriate dosage.

  • Unfamiliarity with the method.

 *There are no drug reps or promotional materials. Information is via doctor personal education, international conferences, workshops etc.

  • There are no large RCTs.

*No pharmaceutical company or other agency is willing to fund  the high expense for no return. No RCT’s – means just that – the large trials haven’t been done – it does not mean the treatment may not be effective.

*There are good data nevertheless.

  • BHRT hasn’t been proven to be of benefit? 

*Actually there is good data and clinical experience showing effective benefits.

*In my own experience using BHRT over 18 years, I have no doubt at all of the efficacy and safety. I listen to the patients, they know.

  • Studies show the risks of past HRT – particularly the 2002 WHI data.

*Bio-identical hormones are NOT the same as the hormones used in the WHI studies. Here the estrogens were equine (horse) species derived and the ‘progesterone’ was synthetic MPA progestin – neither has been in the human before. Progesterone (the only form in the human) is NOT a ‘progestin’. Whilst the biochemical steroid composition may appear similar, the effects can be very different just as estrogen and testosterone – with their subtle substitutions, have totally different physiological responses.

*Cohort WHI studies actually showed that using natural progesterone instead of MPA (progestin) was not associated with the risks in the WHI data (CEE and Progestin).

*Its very salient to examine even the WHI data itself – in fact the risks even with oral HRT were extremely low considering the benefits. Its just that the reporting method as % risk rather than absolute was emotive and caused panic. 25% increase in breast cancer is far more compelling than expressing as about 7 chances in 10,000 risk.

For example, ask a woman whose life has turned upside down from menopause the question of risk acceptance using standard pharmaceutical HRT in two ways – consider the reaction to the question put different ways:

  • You have a 25% increased risk of breast cancer – is that OK?
  • Or, you have about 7 more chances in 10,000 of breast cancer risk – is that OK?

Same thing, different perspective.

Women I pose this question to, usually respond quite differently to the use of HRT. Using bio-identical products the risk is almost certainly minimised further the gains in QOL very significant.


Advantages in using BHRT.

This communication is meant to be brief so the discussion is limited for that reason. There are many publications on the subject of ‘natural’ hormone supplementation for women and men.

  • It replaces deficient levels with the exact same human substance.
  • The dosing is low, never reaching physiological levels of younger fertile women – those levels are not necessary to resolve menopause or andropause symptoms. This is in line with WHI later recommendations.
  • Most BHRT hormones are in transdermal cream applications. Hence avoiding liver first-pass. The evidence for the benefits over oral routes, especially estrogens, is well documented in mainstream literature. It appears not so well established a need for progesterone or DHEA, which seem to be safe orally. It’s the first pass through liver that’s important for E2 and E3 – conversion to 16-OH metabolytes is variable as is reduced safe methylation and likely the source for unwanted risk.

Is there a place for single unopposed hormone replacement?

  •  With intact uterus, micronized oral progesterone is used to reduce risk of endometrial neoplasia as with traditional estrogen treatments.
  • Post hysterectomy – we still advocate the addition of progesterone as the philosophy is to mimic nature as close as possible. Also we may add testosterone and DHEA where these are sub-optimal. There is ample evidence of improved QOL in so doing. Hard data on prevention of disease is less robust as there is little gain in this research.
  • Some women have hormone ‘imbalance’ for example estrogen dominance as evidenced by symptoms and lab workup. She may do very well on transdermal progesterone only.
  • Some women may have very low testosterone and clinical symptoms supporting this – she may respond to gentle T supplementation for libido, muscle strength, vitality and so on.

So are there risks?

Nothing is guaranteed in medicine. It is good practice to screen for risk factors, to ensure ‘healthy woman’ ongoing screening. I ask patients on BHRT to ensure they work with their GP for regular checks. There is still some belief that long term exposure to estrogen may enhance risk of BCa. The data on this when considering protection with concomitant progesterone, healthy diet, exercise etc. is still being worked on. It is still a very small risk. As always, consider the risks to benefits.

Testosterone replacement for men.

Another large discussion point, which I will not cover other than to say, similar principles apply. The major criticisms are again not supported by the literature:

  • Testosterone supplementation especially bio-identical does NOT cause prostate cancer. Sure, if PCa occurs, and statistically it does as we age, then T replacement is contra-indicated.
  • T does not cause or aggravate heart disease – in fact it is PROTECTIVE.
  • Recent literature has pointed to higher risk of cardiac events for older men on T replacement. It appears to contradict other studies. This year there have been criticisms of the study with major flaws in design. We await further analysis. To date T appears protective when used in sufficient dose to place T in the upper protective centiles.
  • So for men the data on testosterone replacement efficacy is well established.
  • What formulation is less clear. As a general rule in integrative medicine, we prefer to use exact biological equivalents where possible. So T is available as actual testosterone, applied transdermally. Six months use will determine efficacy. Some men will prefer the injectables when T creams are not effective.

Ongoing surveillance

  • As mentioned above, serum levels are useless when using transdermals. Urine is better. In fact I have access to a US lab that can determine what we do with our testosterone metabolically – DHT, aromatising to E2 etc.
  • Must watch for excess aromatisation to estrogens and treat.
  • Regular prostate checking especially in first 12 months.
  • CBC for Hb.

When we look at the long list of potential loss of vitality symptoms for men as we age and lose testosterone production, as evidenced by the loss of vitality, depression, increased abdominal size, metabolic syndrome, libido etc – it seems to me astounding that go to lengths to avoid this area of management. Women have long understood the huge benefits of HRT for them.  

I’m sure if a drug was produced to make men feel younger and vital again, as testosterone does, it would be a block-buster – even if it had side-effects and some risk.


What a strange profession we are in sometimes… 


The overarching factor is that with diminished quality of life, and it can vary from nuisance level to serious, hormone replacement can be very effective.

The answer to these questions, which to me is logical, then is to replace using safe, physiological dosing, transdermal where possible, bio-Identical hormones.

And maintain healthy patient surveillance using meaningful lab methodology.

I always recommend patients be their own advocates and read as widely on the subject as they can. We doctors guide, council and at best we do no harm.

Dr Bill Reeder

Biomedical Clinic


See original document at:



Singapore’s Medical Tourism Fatally Threatened

This article from the November 2014 edition of Singapore Business Review explains how Singapore’s medical tourism is under threat from competition from neighbouring countries. Many people come to Singapore from neighbouring countries to obtain their bioidentical hormone treatment under the care of well-qualified western medicine doctors here. If these hormones are no longer available in Singapore, these medical tourists too will go elsewhere.

[See also   http://www.straitstimes.com/premium/forum-letters/story/why-disallow-hormone-treatment-20140425]

Medical Tourism

Bioidentical Hormones – What you need to know

This very informative article is on the website of Dr Christiane Northrup, M.D. It deals with issues regarding the various “labels” used in the field of hormone replacement.

There seems to be a lot of confusion around the definition of “natural” versus “bioidentical” versus “synthetic” hormones. One thing to remember when making this distinction is that “bioidentical” refers to the shape of the molecule itself rather than the source of the hormone. By this, I mean that hormones can be marketed as “natural” or “plant-based,” yet not come near to being “bioidentical” to native human female hormones or performing as such in the body. Examples of this are the numerous proprietary HRT options being marketed as “plant-based” and “natural,” as well as purely yam-based creams.



Cold hands? Always tired? It could be the hidden thyroid problem many doctors refuse to treat

From  The Daily Mail – by Jerome Burne, 26 August 2012, Updated 29 August 2014

1 in 20 – The proportion of people in the UK affected by thyroid disorders

A decade ago, Lilian Swallow got very ill, with a long list of complaints. ‘At my worst, I had an irritable bowel, my hair was falling out and I was so tired that just making a cup of tea exhausted me.’

Her GP sent her for various tests but they all came back negative.

‘Eventually, he decided I must be depressed and that it was all in my head,’ says Lilian, now 75. ‘But that didn’t seem right. I was so weak, I couldn’t even pick up my baby granddaughter. Friends never called after 9pm, as they knew I’d be asleep.’

Lilian, a retired legal secretary, sought the advice of another doctor, who checked her thyroid and found one crucial form of thyroid hormone was present in very low levels. She was prescribed a hormone replacement and ‘the effect was astounding. Within a few weeks all my symptoms started to clear up’.

However, the thyroid hormone Lilian was lacking is not normally screened for by the NHS, and the treatment she received is contrary to official guidelines – although a growing number of doctors disagree.

Every year, one in four people in Britain has a standard blood test to see if their thyroid hormone levels are normal. Three million are told they are thyroid deficient (or hypothyroid), and the majority are successfully treated with a synthetic version of the thyroid hormone, known as T4.

But patient groups and some experts claim the test is unreliable because it measures only one thyroid hormone. In fact there are two. The thyroid gland produces T4, which is checked in the blood test. This is then converted into T3 – the active hormone that can be used by the body’s tissues and cells.

People such as Lilian can be fine for T4 but low in T3. However, the T3 tests are complex and rarely offered by the NHS.

So, if your blood test doesn’t show you to be low in T4, you won’t be prescribed thyroid hormones that could alleviate your symptoms, including fatigue, weight gain, cold extremities, muscle aches and weakness. Instead, these symptoms are often dismissed as being ‘all in the mind’.

It is estimated that 300,000 people, mostly women, are in this position.

Official policy advises they shouldn’t get thyroid hormone replacement because they aren’t deficient – despite not knowing what their T3 levels are – and that giving them the drug could cause an overdose or damaging side-effects such as raised blood pressure.

If your blood test doesn’t show you to be low in T4, you won’t be prescribed thyroid hormones that could alleviate your symptoms, including fatigue, weight gain, cold extremities and muscle aches

This leaves doctors in a difficult position. Only around 100 are prepared to treat these people. One is Professor Stafford Lightman, a senior endocrinologist at Bristol University, who believes that there is a case for giving these patients either form of thyroid hormone.

‘Many of my patients are angry,’ he says. ‘They’re convinced doctors aren’t going to take them seriously.

‘But we don’t have a reliable blood test to tell us if enough T3 is getting into tissues. If it is, then an excess can cause harm, but if it isn’t, that’s when patients should be treated.’

T3 is given as a treatment to some patients, but mainly those who have had thyroid cancer.

Sheila Turner, chairwoman of the charity Thyroid Patient Advocacy, is fundraising for a legal challenge to the guidelines. ‘My blood tests show my thyroid levels are normal, but I can only campaign as hard as I do because I get a hormone supplement from a supportive doctor. Without it I’d be on the floor, almost paralysed with fatigue,’ she says.

She wants endocrinologists to accept there are two sorts of hypo-thyroidism – the ‘official’ sort that affects 85 per cent of patients, and those with ‘Low T3 Syndrome’. She explains: ‘We produce enough T4 but don’t turn it into T3 at all well.’

However, she and other patients may have their supply of T3 withdrawn because of the pressure put on doctors not to prescribe it. In a letter recently sent to the charity, an endocrinologist admitted to feeling ‘vulnerable and fearful’ over reports of medics being struck off or suspended for prescribing an unofficial thyroid remedy.

‘I am withdrawing my name from your list until I have been able to clarify the situation,’ she wrote.

Sheila and her supporters are taking on the Royal College of Physicians and five other bodies, including the Society for Endocrinology and British Thyroid Association. Their combined policy statement says that if a blood test shows you are not deficient in T4, you don’t need a replacement. But Sheila says: ‘It assumes that the only reason people have low thyroid hormones is that their thyroid gland isn’t making enough. It doesn’t allow for the fact that even though you’ve got enough in your blood, not enough is getting into your cells.’

Some experts agree. One is American endocrinologist Dr Kent Holtorf, medical director of the Holtorf Medical Group and the National Academy of Hypothyroidism. He says that as well as people who can’t convert T4 into T3 effectively, other patients don’t benefit from standard thyroid tests either.

‘If you’ve got a chronic disease, you’re going to have less energy for getting thyroid hormone into the cells where it is needed,’ he explains. ‘This could mean you show up as having a normal level in your blood when you actually have a damagingly low level in your cells.’ Depression, obesity, diabetes and auto-immune disease are examples.

The Royal College of Physicians is opposed to treating patients with normal blood levels of T4 because symptoms such as fatigue and weight gain are common in people in their 50s and 60s due to other factors. ‘That’s why the blood test is so useful,’ says a spokesman. ‘If patients get treated for an illness they don’t have, genuine and more serious illnesses such as cancer or liver disease could be missed.’

But one result of withdrawing treatment is that patients are driven to get supplies elsewhere, such as unregulated online pharmacies.

Lilian resorted to buying supplies from the internet when, two years after her health improved, her doctor said her blood levels of thyroid hormones were too high and she was in danger of overdosing. Her dose was cut, and within a few weeks her symptoms returned.

‘Every part of my body had a pain. I was in bed for 20 hours a day. I felt suicidal,’ she recalls. A local hospital was eventually persuaded to do tests for T3, which found her levels to be low again. Lilian was then prescribed a dose she describes as ‘inadequate’, so she tops it up with a hormone bought from a website. ‘I’ve now got more energy than I had at 60,’ she says.

But such reports don’t convince endocrinologists who support the current policy. ‘There’s a strong placebo effect with these patients,’ says Professor Colin Dayan, director of the Institute of Molecular and Experimental Medicine at Cardiff University.

‘I’ve done double-blind studies that have found patients can respond much more strongly to getting thyroid hormone in a trial, even when they have been getting it as a regular treatment. ‘They assume it’s a new and different treatment.’

But Dr Holtorf claims that official bodies haven’t been keeping up with the latest research.

‘I’ve just done a review in The Journal of Restorative Medicine showing why it is not scientific just to rely on the blood test to rule out hypothyroidism in patients who have chronic conditions,’ he says. Now researchers are looking at the possibility that certain patients do better on T3.

Dr Birte Nygaard, of Denmark’s Herlev Hospital, recently produced proposals for treating patients who have symptoms of low thyroid but normal blood levels of T4. She suggests an ‘experimental approach’, giving them added T3 at specialist centres.

Professor Lightman would like to see a similar approach in the UK.

The Royal College of Physicians has always claimed that not being able to convert one hormone into the other isn’t a serious problem – trials showed that when T3 was given to patients already getting T4, it didn’t make any difference.

But Sheila Turner has compiled a register of nearly 3,000 patients who say they remained ill when they got only the T4 hormone, but their symptoms went away when they got T3.

Meanwhile, Lilian is thankful that she got the help she needed.

‘When I was being treated according to the official guidelines I was taking 17 drugs a day and still felt dreadful,’ she says. ‘Now I’m taking one and I feel great.

‘If a doctor hadn’t gone against the guidelines I’d be dead by now. That can’t be right.’


Inside Health – Conflicted Medicine – BBC Radio 4

BBC Radio 4 recently ran a series of three broadcasts entitled Inside Health, each 28 minutes long, which may be of relevance in Singapore.

  • Programme One, first broadcast 12 August 2014 – Conflicted Medicine: Pharmaceuticals 

Are conflicts of interest in medicine out of control and undermining public trust, or an over-hyped concern? Dr Mark Porter investigates the hidden influences affecting your health.


  • Programme Two, first broadcast 19 August 2014 – Conflicted Medicine: Specialists & GPs

Dr Mark Porter examines the hidden conflicts of interest that may affect how your GP or specialist treats you. He discovers that the advice patient groups give you is also not immune to the influences of organisations such as pharmaceutical companies.


  • Programme Three, first broadcast  26 August 2014 – Conflicted Medicine: Public Health Campaigns

Dr Mark Porter examines how powerful lobbying groups like the food and alcohol industries steer public health policy in the direction that suits them most.