The Zen of Science

I once read the following advice in an article by a so-called alternative healer. “If you really crave a food, you ought not to eat it because craving is a sign of allergy.” This sentiment looks to me like a modern restatement of the old Puritanical distrust of the physical body, wrapped up in pseudo-scientific gobbledygook. If something appeals to your senses, that author reasons, it must be bad for you. Only now it seems that it’s not just bad for your soul. It’s bad for your body too.
Much of what passes in the standard medical literature for solid nutritional advice is also cast in such a negative tone. It’s all about what you shouldn’t put in your mouth: saturated fat, alcohol, simple carbohydrates, etc. Though inundated by messages about what not to consume, the American public eats less healthily and supersizes itself more with every passing year. Epidemiologists are even speculating that some of the gains in longevity made in recent decades are being wiped out by the obesity epidemic. After a half-century of harping, you’d think both the straight and the alternative medical communities would get the message that self-denial doesn’t work, at least not as a public health strategy.
In 2003, a couple of professors from the University of London published an article in The British Medical Journal entitled, “A strategy to reduce cardiovascular disease by more than 80 percent.” Their work broke new conceptual ground in the field of health promotion and disease prevention. The authors recommended universal administration of a “Polypill” to people over 55. This pill would contain a small dose of a cholesterol-lowering drug, aspirin, folic acid, and sub-therapeutic doses of three antihypertensive drugs.

The cholesterol drug reduces levels of LDL (“bad”) cholesterol, and so retards growth of the plaque on coronary and cerebral arteries that can initiate the clots that cause heart attack or stroke. Aspirin inhibits blood clotting. Folic acid raises homocysteine levels. (Though we don’t know the exact mechanism or even if there’s a real cause and effect relationship between homocysteine and arterial plaque, we do know that lower levels of this amino acid are associated with higher levels of vascular disease.) And there is a near-linear relationship between blood pressure and arterial disease risk. The lower the pressure, the lower the risk.

So, the doctors reasoned, why not reduce everybody’s risk factors for the deadliest diseases in the developed world by giving small, safe doses of drugs that heretofore have been prescribed in larger therapeutic doses only for people who have bona fide elevated risk of arterial disease? And they threw in aspirin and a vitamin too.

The scientists calculated that if this regimen were adopted by every British adult 55 and over, it would reduce the incidence of coronary artery disease by 88 percent and of stroke by 80 percent, tacking an average of 11 years onto the life of the Queen’s subjects. They estimated that with a formulation containing lower-cost anti-hypertensive medications, about 15 percent of recipients would suffer significant side effects. That number could be whittled down to eight percent by using more expensive drugs with fewer side effects, a regimen that might be reserved for those who don’t tolerate the lower-cost combination.

The majority of complications would be caused by the small dose of aspirin, 75 mg., about one fifth the quantity in a regular-strength adult aspirin. Those side effects are bleeding from the stomach and bleeding into the cranium. Still, the excess deaths resulting from stomach hemorrhages would be far less than the lives saved by preventing heart attacks and strokes. Furthermore, the strokes avoided by retarding blood clots from forming in or traveling to the brain would significantly outweigh the increased incidence of hemorrhagic strokes, producing an overall net reduction of cerebral events by 16 percent.

This sounds like a good deal, doesn’t it? It certainly would make my job easier, requiring a lot less medical testing and tedious individualizing of drug choices and doses. A universally applied, one-size-fits-all approach to vascular disease prevention might help a wide swath of my patients who were otherwise destined to die from or to be incapacitated by heart attack or stroke.

These ideas have generated a lot of discussion. There is plenty to quibble about in terms of estimating and balancing positive effects of each of the medications and of the overall intervention with negative effects and costs. As far as I know, no government nor pharmaceutical company has begun developing a Polypill since the article came out in 2003.
About a year and half after publication of the original Polypill piece a most interesting response appeared, also in The British Medical Journal, written by researchers from Holland, Belgium and Australia. Their work, a takeoff on the Polypill concept, is entitled, “The Polymeal: A more natural, safer, and probably tastier (than the Polypill) strategy to reduce cardiovascular disease by more than 75 percent.” These scientists took the best epidemiologic evidence about foods that reduce the risk of cardiovascular disease and came up with an eating plan which they called the “Polymeal.” They calculated the Polymeal would decrease the incidence of heart attack and stroke by almost as much as the Polypill.
Like their Polypill colleagues before them, the Polymeal folks did not preach avoidance of a whole list of pleasurable foods. Their positive attitude ought to give the intervention a much better chance of working than the usual abstinence-based lifestyle recommendations so piously intoned by just about every healthcare professional and organization. The “Just Say No” approach appears to be doomed to irrelevance when it comes up against the biological fact of human appetites.

By contrast, the Polymeal actually sounds pleasurable. It is a prescription for daily consumption of five ounces of wine, three ounces of dark chocolate, 14 ounces of fruits and vegetables, two ounces of almonds, and the equivalent of about one clove of garlic, plus four ounces of fish four times a week. Imagine, a diet that requires wine, dark chocolate and almonds!

Unlike with the Polypill, there are no side-effects of the Polymeal lifestyle, except, of course, for those who may be allergic to one or more of the prescribed comestibles. There are well-founded concerns about people who cannot keep their alcohol consumption to a reasonable level or who cannot stay off the road after drinking. And some scientists worry that increased intake of large ocean fish, which concentrate mercury pollutants in their flesh, could raise the quantity of that toxic substance to unacceptably high levels in the human body.

There is a problem with garlic too. Even when delivered in capsules as a powder, garlic causes indigestion in some and a garlicky body odor in many. Referring to this spice, the authors “...do not recommend taking the Polymeal before a romantic rendezvous unless the partner also complies with the Polymeal.”

Without enhancements, the researchers estimate that the Polymeal would add 6.6 years to the lives of British men and 4.8 years to women. Other healthful dietary practices, not so well studied and quantified as those recommended by the authors, such as consuming monounsaturated oils like olive and canola, tomatoes, oat bran and other foods, could further increase the benefits to a population that adopts them. Walking and other forms of exercise would certainly contribute to longevity too.

The Polypill regimen could even be added to the Polymeal (or vice versa). The authors of the Polymeal article go so far as to suggest that if enough of these dietary and pharmacologic practices are adopted by a large segment of the population, “Redundant cardiologists could be retrained as Polymeal chefs and wine advisers.”
Judging by the appeal of their recommendations, not to mention the wit with which they write, the Polymeal folks have significantly more fun than the Polypill people do. You’d probably be better off and certainly happier if you were to break bread with the authors of either of the articles than you would with that guy who believes that any food you crave must not be good for you.

Marc Ringel, MD, is a family practitioner and writer based in Greeley, Colorado.