Fourteen Do’s and Don’ts for Medical Bloggers

acmedsci snake shhhh

Fellow freelance journalist James Butcher alerted me to the existence of a clutch of rather verbose guidelines for journalists and others pertaining to the reporting of medical research results.

The guidelines were published in November by the UK’s Academy of Medical Sciences, an organisation that apparently promotes advances in medical science and campaigns to ensure these are translated as quickly as possible into healthcare benefits for society. The report primarily highlights the role of observational research in identifying environmental and lifestyle causes of disease, such as obesity and diabetes, cancer, cardiovascular disease etc, but warns researchers against overstating the importance of their findings.

The guidelines themselves actually formed part of a much wider document entitled not very snappily: Identifying the environmental causes of disease: how should we decide what to believe and when to take action?. The report’s title alone should have warned readers by now that the guidelines themselves are likely to raise a few issues.

Of course, most medical and science journalists will already have their own internal list of guidelines to follow, probably in much clearer and simple English, and directed firmly in the direction of writing the best piece they can rather than aimed at satisfying some higher bureaucratic order. Depending on the writer’s background these internal guidelines will overlap in essence with the fourteen do’s and don’ts listed below and in other areas there will be little common ground.

Some might say that the list of guidelines is a little patronising to journalists and written in an ostentatious and overblown manner. Others might point out that they assume far too much prior knowledge. Do political, legal, financial, and arts correspondents get such lists of guidelines I wonder? Would those correspondents, as opposed to a science or medical writer understand the technicalities of item 1a “What is the sample?” Well, if you know how to answer that question, you probably don’t need the guidelines, and if you don’t know how to answer it then you should maybe stick to covering art gallery openings and ministerial indiscretions. Either that or head back to school for a quick stats course.

This is not the first time an organisation like this has attempted to lay down guidelines for journalists and others. The Royal Society made an attempt at it a few years ago and recently revised them. Ironically, they did not consult the Association of British Science Writers in producing their guidelines and so they went down like the proverbial plumbum inflatable. More to the point, rulez is for breakin’ and if you’re a (tabloid) hack intent on writing a health scare story, then you’re going to write it regardless of any list of guidelines from an organisation of which you have probably never even heard. And, if you’re not a scaremonger, then, as I said before, you will already have your own endogenous list of guidelines.

Perhaps what is needed is some kind of guidance for the public rather than the journalists that allows them to make more sense of the dozens and dozens of health stories on cancer, obesity, estrogen, bird flu, HIV, MMR vaccination. Such advice might help them to see the facts when those internal guidelines have been overridden in the name of great headlines.

It would be an interesting exercise to analyse each of the news articles and others that I cited in a recent post entitled Obesity News Epidemic, to see just how well each of those mesh with the ACMedSci guidelines. Anyone care to take on the research project?

Anyway, with ACMedSci permission I’ve cribbed the guidelines below for your delectation and to save you wading through the 150 pages of the less-than snappy document. They were originally aimed at journalists and others in the media, presumably to help prevent sensationalisation and healthscares. They could be equally useful/useless (del. as applic.) to bloggers and others too.

  1. Pay detailed attention to the methodology of all studies being reported. Important questions to consider include: a. What was the sample? b. What were the measures? c. How strong were the effects in both relative and absolute terms? d. Has there been adequate attention to alternative explanations, and to good control of possible confounding variables? e. Has the finding been replicated? f. Is there supporting experimental or quasi-experimental evidence? g. Are the findings in keeping with what is known about disease mechanisms?
  2. Whilst it may not be appropriate to offer extensive discussion of all these details when writing or speaking to the general public, key aspects can be communicated successfully using clear, jargon free, language.
  3. The science or medical correspondent needs to have an appropriate grasp of the scientific issues in order to know how best to convey what was novel, interesting and important in the research.
  4. Exercise appropriate judgment in identifying and drawing attention to those points of design that are particularly relevant to the study in question – especially when ignoring them might lead to misunderstanding.
  5. Bear in mind the research track record of the researchers and of their employing institutions.
  6. Consider whether there are any conflicts of interest that might lead to possible bias.
  7. Seek to determine the theory or set of biological findings that constitute the basis for the research – noting how this fits in with, or forces changes in, what we already know or believe.
  8. Whilst paying appropriate attention to competing views, be wary of creating spurious and misleading ‘balance’ by giving equal weight to solid research evidence and weakly supported idiosyncratic views.
  9. Be very wary of drawing conclusions on the basis of any single study, whatever its quality.
  10. When considering public policy implications, draw a careful distinction between relative risk (i.e. the increased probability of some outcome given the disease causing factor) and absolute risk (i.e. the probability of that disease outcome in those with the disease risk).
  11. Use simple counts to describe risk whenever possible, rather than probabilities.
  12. Be careful, insofar as the evidence allows, to clarify whether the causal effect applies to everyone or only to a small special sub-segment of the population.
  13. Set the causal factor you are describing in the context of all known causal factors, whilst explaining that there may be others, as yet unknown or unsuspected.
  14. In writing about research, seek to educate and engage readers with the science and to encourage them to think critically.

Obesity News Epidemic

obese-overweightWe all know we’re all getting fatter, don’t we? Obesity has become the latest plague of the developed world. And, body mass index has become the vital statistic your GP is most interested.

Well, I’ve actually lost a few pounds from my Adonis-like physique* over the last few months, it must be the daily dog walking. Nevertheless, my BMI is high, but then so is that of at least half of the England rugby team – it’s big bones and muscular hypertrophy that do it. You cannot visit a health-related website or pick up a medical newsfeed these days without seeing some bizarre news related to obesity and overweight. [*Yeah, right!]

The research results are often contradictory, one day we’re told it is high saturated fat content that we must worry about. The next we hear that Gary Taubes has resurrected almost forgotten research that suggests carbohydrates are to blame for boosting insulin production and it is high insulin levels that make us fat. It sounds like a 1950s notion, too many potatoes will make you fat, but he could have a point. The link between insulin and obesity is very strong, but does one cause the other or do they operate synergistically to the detriment of our health. Who knows? Certainly not the headline writers were see, as I say apparently contradictory and at best confusing statements day in, day out.

  • Study firmly links obesity, cancer
  • Diabetes up amid rising obesity
  • Obesity ‘fuels cancer in women’
  • Obesity ‘epidemic’ turns global
  • Obesity May Be Protective in Progressive Prostate Cancer
  • Obesity and overweight linked to higher prostate cancer mortality
  • Little bit of fat not so bad: new study
  • Diabetes up amid rising obesity
  • Obesity ‘not individuals’ fault’
  • Gyms ‘little help’ in obesity
  • Inflammation, Not Obesity, Cause Of Insulin Resistance
  • Study finds some overweight people live longer
  • Little extra weight may not be bad

That’s just an almost random sample from this week’s news. But, the message is clear – we don’t really know what’s going on. The conventional wisdom has it that the more calories you take in and the fewer you use, the more overweight you will become. But, the type of calories do matter, as Taubes points out, we don’t tend to talk about middle-aged guys with burger guts, the more usual description of choice is a beer belly. The calorific content of beer, of course, arising from carbohydrates as opposed to fat.

There are also issues with the public health statements that tell us to reduce our saturated fat intake and to keep our (bad) cholesterol levels low. But, did you know there isn’t just one form of low-density lipoprotein, there are two – a dense form and a diffuse form. New evidence points to the dense form of LDL as being the bad form and not the nice fluffy type, but related research also hints that the presence of cholesterol is not actually a relevant risk factor for cardiovascular disease. It’s the dense LDL itself. So, is there any point your GP measuring your blood cholesterol and putting you on statins? Possibly not.

And, what of the possibilities that obesity is down to genetics, viral infection, bacterial infection, (fungal infection?), hormonal imbalances, pancreatic problems, missing out on breastfeeding as an infant, getting too much breast milk as an infant, a throwback to our grandparents’ diet, an evolutionary aberration, too much TV, not enough sleep, too much carbohydrate, too much protein, too much fat, too little exercise, too much walking and not enough running…

Taubes comes to 11 critical conclusions in Good Calories, Bad Calories, based on substantial literature research and interviews, summarised below:

  1. Dietary fat does not cause heart disease
  2. Carbohydrates do, because of their effect on insulin
  3. Sugars are particularly harmful
  4. Refined carbohydrates, starches, and sugars are the most likely dietary causes of cancer, Alzheimer’s Disease, and the other common chronic diseases
  5. Obesity is a disorder of excess fat accumulation, not overeating and not sedentary behaviour
  6. Consuming excess calories does not make us fatter any more than it makes a child grow taller
  7. Exercise does not make us lose excess fat; it makes us hungry
  8. We get fat because of an imbalance between hormonal regulation of fat tissue and fat metabolism.
  9. Insulin is the primary regulator of fat storage
  10. Carbohydrates make us fat by stimulating insulin secretion
  11. The fewer carbohydrates we eat, the leaner we will be

Confused? It’s enough to make you head for the donut bar. Or, maybe not. Next week, “Cardiovascular Disease News Epidemic”. Incidentally, I was going to call this post Bingo Wings and Muffin Tops, but thought better of it. You can look up definitions in the Urban Dictionary.

Asthma sufferers, don’t hold your breath

TL:DR – If you have asthma, do not fall for quackery, seek professional medical advice and adhere to the qualified recommendations for prescribed medication. By quackery I mean various therapies, crystal healing, homeopathy, chiropractic, osteopathy, acupuncture etc. None of it has any medical validity whatsoever.


As someone who developed exercise-induced bronchospasm (mild asthma) only after coming up to Cambridge in the late 1980s and having never suffered in childhood, I was rather disappointed to find myself on first one inhaler (a reliever) and then a second (preventer). UPDATE: 2020 – The GINA guidelines recommend nobody use Salbutamol these days, much better to be on a preventer with a combined reliever.

Anyway, asthma sufferers everywhere could benefit from breathing exercises that allow them to regain control of their breath, reduce wheezing and breathlessness, and in time cut down on their reliance on inhaled medication. When I mentioned these techniques to my GP during a general checkup, he confessed that before inhalers were available, breathing exercises were all that he and his fellow practitioners could prescribe for mild attacks. What goes around, comes around it seems.

Breathing exercises could be something of a breath of fresh air. Although saying that cold, fresh air is one of the triggers for an asthma episode as fellow sufferers will know.

Across the UK more than 5 million people suffer the potentially debilitating effects of asthma and many millions more around the world. Diagnosis is usually straightforward and most sufferers are prescribed one or both of two kinds of inhaler – an inhaler to reduce symptoms (Salbutamol, for instance, known as a reliever) and another to reduce the underlying inflammation in the lungs (a corticosteroid such as beclomethasone).

Learning to control one’s breath and to breathe through the nose is important for asthma sufferers and something many fail to do, especially when asleep.

Five golden rules for reducing your asthma symptoms:

  1. Breathe through your nose when you can, but never tape up your mouth
  2. Take control of your breathing
  3. Try to avoid nervous or unnecessary coughing
  4. Look after yourself in general
  5. Most importantly, use your prescribed medication properly

You are best advised to talk to your GP about the potential of breathing techniques for you and at the very least to adhere strictly to Rule 5. Whatever you do, do not abandon your medication. Recently, there has been a lot of talk about the Buteyko Method. This is based on a false premise about carbon dioxide levels in the blood being the problem. Don’t follow that route. Breathing exercises may well help you cope, but they will not cure your asthma.

Flu Clinic Widget

Flu shot

Is flu vaccination a shot in the dark? Regular readers will recall the recent debate on multiple vaccines, statistics, and risk we had here in September. I also have rather close personal experience of one of the risks associated with having the annual flu vaccine – Guillain-Barré Syndrome (GBS). This autoimmune disorder is purportedly associated with a respiratory or gastrointestinal tract infection although there is a statistical risk that connects it to the flu vaccine. A close relative of mine developed GBS symptoms about six weeks after having the flu jab last December and has not yet fully recovered. GBS support groups recommend she not have the vaccine again.

So, it is with mixed feelings that I read an email from Charles Forsyth (a public relations professional at www.btstrategies.com apparently working for the American Lung Association). Charles is helping the ALA raise awareness of the importance of getting an influenza vaccination at this time of year. He explains that part of the campaign involves persuading bloggers and other website owners to add a widget to their site. The widget helps readers find a local flu clinic quickly and easily where they can be vaccinated.

You can try the widget here http://www.flucliniclocator.org and download it to add to your site. Just enter your zip code to find clinics in your area and make an appointment. You could use it to find a clinic for elderly or infirm friends or relatives too or others in high-risk categories, such as asthma sufferers, and those on immunosuppressant drugs.

Tragically, influenza kills about 36,000 people each year in the US, Charles tells me, and requires another 200,000 to be hospitalized. Most of these deaths are preventable by getting a simple flu shot each fall.

The following groups are considered at higher risk than the general population

  • People who are 50 years of age and older
  • Women who will be pregnant during influenza season
  • Young children 6 to 59 months of age [Not sure what changes at 59 months, presumably they just mean under fives]
  • People with chronic medical conditions such as asthma, emphysema, chronic bronchitis, TB, CF, heart disease, kidney problems, diabetes, and severe anaemia
  • People who have diseases or having treatments that depress immunity
  • Caregivers of those at risk

Charles suggested I add the widget to the Sciencebase bird flu symptoms page, but I think that would be a little irresponsible, given that a vaccine against human influenza will most likely provide absolutely no protection against an impending bird flu epidemic. Instead, I’ve added it to my seasonal page on how to avoid colds and flu in the first place. This page rears its ugly head at this time of year on an annual basis, so it’s as good a place to slot the widget as any. I should emphasize though, that if you have any concerns about the protective efficacy of vaccination or the risks associated with the flu jab you should discuss them with your GP.

Oh, and if you think you have flu or a bad cold, don’t spread it around, stay at home.

Nobel Prize for Medicine 2007

Nobel Prize

The Nobel Prize website was offline at the time of writing presumably unable to take the strain of hacks and bloggers every scrabbling to learn of the winners. Anyway, Mario R. Capecchi (US) and Oliver Smithies (US) and Martin J. Evans (UK) have won the 2007 Nobel Prize in medicine or physiology for their work on gene targeting in mice.

Their research is being used to help scientists understand at the cellular level why certain diseases, such as cystic fibrosis, occur and why otherwise healthy people can succumb to cardiovascular and neurodegenerative diseases, diabetes, and cancer.

The same threesome the Lasker prize in 2001, so in the absence of a Nobel website you can read more about the award-winning work here. Thanks to blogger Luboš Motl for bringing that link to my attention.

You can see a complete list of past winners of the Nobel Prize for Medicine here.

No More Chocolate Headaches

chocolate-chunksDoes eating chocolate give you a headache? What about red wine? Cheese, perhaps? Yes, well read on to find out how a space-age detector developed to look for signs of life on Mars could soon become the kitchen gadget of choice for anyone who suffers a painful reaction to their food.

According to a paper to be published in the November 1 issue of Analytical Chemistry, researchers at the University of California Berkeley have developed a fast and inexpensive test suitable for domestic use that can spot the toxins in certain foods, particularly “aged” or fermented products, including chocolate, cheese and wine. The device could be engineered into a PDA or other handheld device for greater portability and instant access to information on any toxins found in a particular food or drink.

The test detects biogenic amines, natural toxins known to trigger headaches, cause facial flushing, lead to nausea, and raise high-blood pressure. Current tests for biogenic amines usually take hours in a specialist laboratory with bulky and expensive test equipment. With the aim of packing the test into a package small and efficient enough for a Mars landing, Richard Mathies and colleagues, have simplified the whole system down to a lab-on-a-chip device (portable microchip capillary electrophoresis) that produces results in just five minutes.

These toxins can be a serious health problem and are more common than people think,” says study Mathies, “They are hidden in a wide variety of foods, so having a quick and convenient way to identify them will help consumers avoid them or at least limit their intake.”

The toxins, which include tyramine, histamine, and phenylethylamine, are particularly hazardous to people with reduced levels of the enzyme monoamine oxidase and to people on older antidepressant drugs which act as MAO inhibitors. For these individuals the risk of a seriously dangerous rise in blood pressure is very possible.

Biogenic amine tyramine“Some foods have more biogenic amines than others,” explains Mathies, “but you cannot tell in advance because they aren’t listed on the food labels.” Even a single glass of wine has been known to trigger elevated blood pressure, heart rate and headaches in some people, he adds. He suggests that food manufactures and wine producers should be obliged to list biogenic amine content in their products by law. Although if they did, then this would preclude the need for the test kit, I assume, so the research team could concentrate on sending it to Mars instead.

Healthy PubMed Searching

This post is more in the bio camp than the chemo field, but may be of interest both to chemists with a life sciences investment and/or hypochondriacs in your lab.

The Healia health portal has added a specially designed PubMed/Medline search to their site that helps consumers retrieve abstracts of scientific articles published in biomedical journals in a more user-friendly way than the standard PubMed search. The system still searches the National Library of Medicine’s (NLM) PubMed/Medline dataset, which includes more than 17 million abstracts and citations from approximately 5000 biomedical journals published since the 1950s. One of the unique capabilities of the additional Healia Clinical Trials Search is that you can restrict searches geographically and map locations of study sites.

It is possible to filter a search to Professionals, Females, Males, Kids, Teens, Seniors, African Heritage, Asian Heritage, Hispanic Heritage, Native Peoples and a few other categories.

Male-Female Crabs Split their Difference

Male-Female Crab

David Johnson and Robert Watson thought they had seen all there was to see in the Chesapeake Bay in almost three decades until they pulled out a crab from the way that had a male left half and a female right half. Now, that crab, acquired by Romuald Lipcius of the Virginia Institute of Marine Science at the College of William & Mary, has moved sideways into the world of natural metabolites where its gynandromorphic peculiarities have helped scientists, for the first time, discover that some molecules can be made only by one sex and not the other.

The male-female crab is a unique example of the blue crabs. It turns out that the males of this species produce a natural metabolite that is absent in females. This suggests that some complex biochemistry is underway that is activated only in males. Robert Kleps of the University of Illinois at Chicago and colleagues have isolated this small molecule and identified it as 2-aminoethylphosphonic acid (AEP), an uncommon but well-documented natural metabolite.

We used low-field NMR using phosphorus-31, to observe the small molecule, explains Kleps. He points out that science tends to get lost in the rush for higher field NMR running hydrogen-1 and carbon-13 on 100 kilodalton proteins. However, he adds that, “Even low-field NMR spectroscopists can make interesting discoveries. I’m very happy to have stumbled over this metabolite, while doing basic research on invertebrate metabolism.”

So, why might the existence of a metabolite in the males of this blue crab species and not the females have any bearing on our everyday lives? Well, there are well known differences between the sexes in people, such as disease susceptibility, anatomy and drug metabolism. Kleps points out that these differences might in fact be due to the presence or absence of a crucial metabolite.

Now that the existence of a sex-specific metabolite has been found for one animal the search is on for others, including ones that might exist in people.

For more details on the NMR study check out my column on SpectroscopyNOW.com, the research paper itself is available in Plos One.

You can hear a description of the crab from Lipcius here and listen to Kleps’ podcast

MMR and Statistical Manipulation

Measles virus

When I was still at high school, way back in the late 1970s, there was a health scare that got a lot of media attention. Apparently, there was a perceived risk that the whooping cough vaccine could cause brain damage. The fall off in vaccination for this disease is claimed to have led to the widespread outbreaks of whooping cough in 1979 and 1982, there having previously been almost zero annual cases. At the peak there were some 60,000 cases.

Fast forward to the near present and you will recall similar scare stories about the combined measles-mumps-rubella vaccine, the MMR, and claims by researcher Andrew Wakefield (Lancet, 1998) that MMR could cause autism in some children. It’s a topic guest blogger Michael Marshall covered on Sciencebase in November 2004. It seemed that, at the time, the debate was pretty much over. However, despite repeated demonstrations of the apparent inadequacies of the original research into a link between MMR and autism, the issue is resurrected on a regular basis. Most recently in a cover story in The Observer, which drew much flack, but also left the chattering classes once more in a flap.

Right now, I’m looking at an article from the print edition of The Times offering an answer to the Question of the Week – “Measles or vaccine?” – the article talks of how measles has reappeared and it is apparently all down to many parents’ reluctance to have their children vaccinated with the MMR jab. The article talks of “herd immunity” and how enough children have had a double dose of MMR which should stave off an epidemic. The emergence of herd immunity, of course, will be little comfort for a parent whose child experience any of the potentially severe side-effects of vaccination.

In the article, pictured alongside a blow-up of the measles virus and an image of a nasty-looking hypodermic needle, are two charts, one showing the number of cases of measles in the UK from 1940 to the present day and the other showing the number of deaths over the same period. Incidence of the disease ebbed and flowed during the period up to the early 1970s whereupon cases began to fall rapidly from a peak of 800,000 a year in the early 1960s to just one or two hundred a year by the mid-1970s.

The MMR vaccine was introduced in the US in 1971 and later in the UK, thereafter incidence of measles has pretty much fallen to levels close to zero. It seems that the pre-vaccine drop had another cause, presumably reduced overcrowding, improved nutrition, better hygiene and healthcare. No one knows at what point this fall would have reached a plateau.

In contrast, the second chart of death rates shows an exponential decline in measles deaths since the 1940s, by about 1970 measles deaths were also close to zero. The risk of getting measles is about one in three, assuming no vaccination coverage at all. The risk of serious consequences to this disease, which personally I had in 1972 or thereabouts, is somewhere between 1 in 5000 and 1 in 15,000. Compare that to the risk of death in a road accident. According to Transport2000 , the UK’s national environmental transport body, each of us has a 1 in 17 chance of being killed or seriously injured in a road crash during our lives. Such figures damn the disease statistics somewhat. Of course, vaccination does come with some risks, but adverse reactions, such as seizures with an associated risk of brain damage, exist at the 1 in 10,000 level.

There has been one UK death from measles since 1992 (as opposed to the several hundred each year during the 1940s). The unfortunate victim was apparently suffering an underlying lung disease for which he required long-term immunosuppressant drugs. He was very unfortunate to be exposed to the measles virus, and when he contracted the disease he was very unlikely to have recovered. This is one fatal case. Even with near 100% vaccination, there would still be a finite risk of any random member of the population contracting the disease. Unfortunate, but true. The statistics would not lie surely?

Cacao caffeine myth – Chocolate Myths

TL:DR – Cocoa beans, and so chocolate, can contain a small amount of caffeine despite claims to the contrary.


Caffeine theobromine

A front page item on a social bookmarking site claimed that chocolate does not contain caffeine. The link was tied to an introductory paragraph that said: “There is a persistent urban legend that chocolate contains caffeine. It would seem that this rumor is based primarily on a confusion between two similar alkaloids: caffeine and theobromine. Theobromine is the active ingredient in chocolate and it occurs only in [the plant Theobroma cacao. The two stimulants are related and have similar structures.”

Yes, they most certainly do, theobromine (not in any way related to the element bromine by the way) and caffeine are almost the same chemical structure but in the caffeine molecule the hydrogen atom on a nitrogen atom in theobromine has been swapped for a methyl (CH3) group. Why is this important? Well, the difference in chemical and biological activity of two molecules that can differ by a couple of hydrogens and a carbon is astounding. More on that later. What about the site’s claims that chocolate does not contain caffeine?

A quick search on PubMed plucked out several papers all of which have carried out analyses of chocolate to demonstrate that it does indeed contain caffeine. As just one example, in 2006, German researchers Stark, Bareuther, and Hofmann of the German Research Institute for Food Chemistry, in Garching, provided a molecular definition of the taste of roasted cocoa nibs (Theobroma cacao) by means of quantitative studies and sensory experiments. In their paper they state: “theobromine and caffeine…were among the key compounds contributing to the bitter taste of roasted cocoa.” Their tests were carried out using solvent extraction, gel permeation chromatography, and reversed-phase high-performance liquid chromatography (RP-HPLC) and corroborated earlier findings. The actual quantity of caffeine in chocolate is very small, especially compared with the amount of theobromine.

To quote the UK’s Institute of Food Research on the subject of caffeine in chocolate:

“Chocolate contains bio-active compounds, e.g. caffeine and theobromine. Caffeine is only present in small amounts in chocolate – in fact, one would have to eat about eight 100-gram bars of milk chocolate to consume the amount of caffeine present in a cup of coffee. Theobromine is related to caffeine, and is present in chocolate in much higher amounts, although it has relatively weak stimulant effects. It is possible that in combination, these and other potentially bio-active constituents do influence our liking for chocolate. At present, however, there is no direct evidence to support this.”

Caffeine is a bitter-tasting alkaloid, a natural product, a xanthine, found in several plant species, coffee, tea, and cacao. It is a stimulant, like its close chemical cousin, theobromine. There have been dozens of media articles, purportedly based on solid research, that send out mixed messages regarding the health effects of caffeine on people and whether or not we should expose our bodies to this stimulant.

A quick search of the web for cacao theobromine and caffeine reveals several sites warning of the toxicity of stimulants in chocolate, coffee and other products. But, an NIH page also appears that says something along the line of caffeine content need only be reported if levels are above a certain threshold.