Scientific American asked ten 'visionary' science experts on its advisory board to tell the world what societal changes they foresaw for the coming decades. You can read the results of their cogitations in SciAm′s August 26, 2010 online edition (1). I myself was mainly interested in what they had to say on the subjects of health and medicine.

George Church's piece "Medicine I can call my own" focuses on the promises of stem cells and affordable genome sequencing. Stem cells hold promise for regenerative medicine. Mapping each patient′s genome should, in the author′s opinion, lead to customized diagnoses, treatments, and diets:

"In the near future, a complex ecosystem of health care and software providers will empower doctors to treat each patient as a unique individual. Your stem cells will be fashioned into ad hoc treatments. Your genome will get sequenced every year or so to check for the emergence of cancer cells, auto-immune cells, inflammation, and so on and will help predict what treatment may work best if a disease appears. Not just knowing but shaping your biology will be part of your life." (1)

The piece reminded me of Thomas Edison′s optimistic prediction:

"The doctor of the future will give no medicine, but will interest her or his patients in the care of the human frame, in a proper diet, and in the cause and prevention of disease." (2)

Edison′s prediction obviously didn′t come true. What happened instead was that Big Pharma took control of the American medical system. Here is how economist Paul Zane Pilzer put it in 2001:

"Sadly, most physicians have become 'technology dispensers' for the products and services of the large multinational medical companies — companies which always seem to tip the scale between profits and patients in favor of profits. In some cases this means manipulating the federal government against the public interest in safety as well as in dollars." (3)

Not only does the pharmacutical industry have no interest in your wellbeing — you are more profitable to them chronically ill than healthy — but neither does the food industry. In fact, both food and drug companies will try to suppress perfectly sound health claims through their influence on regulatory agencies, to protect their profits. Pilzer again:

"While there is obviously no direct conspiracy between the $1 trillion food industry (which causes most of the problems) and the $1.4 trillion medical industry (that treats just enough of the symptoms to get the 'targets' back to work and consumption) the economic effect is the same as if these two industries were conspiring against the American consumer in the most sinister fashion.

On a microeconomic level, each time consumers get real information that could help them take control of their health, the food and medical industries, acting in their own economic self-interest, manipulate this information against them." (3)

Pilzer wrote about the American situation and for an American audience, but these problems aren′t unique to the U.S. Just a couple of days after they gave us a glimpse of the future as they saw it, Scientific American offered us this gem: Researchers at Imperial College London actually proposed that restaurants serving things like cheeseburgers and milkshakes ought to include a statin pill with each order to "offset the health risks of the high fat meal" (4).

Would you take health advice from doctors like these? Yet, the medical establishment has been very successful in equating good health with good medical care in people′s minds. For example, both Thomas Edison and the writer of the SciAm piece took it for granted that health is the purview of medicine. Similarly, the terms 'health care' and 'medical care' are used interchangeably by far too many writers.

Good health is largely the result of a proper diet and exercise, etc. You don′t need your genome sequenced to know whether junk food is right for you or not, and you can find better sources of health information than your family doctor. Most physicians don′t know much more about nutrition than their patients; the subject isn′t even taught in most medical schools!

I do hope that stem cell research and the genome project will lead to medical breakthroughs; we need access to quality medical care even if we make every effort to adopt a healthy life style. But drugs cannot compensate for a lousy diet and a lack of exercise, and bad life style choices will undo any benefits that medical advances might bring.

But they can keep their 'complex ecosystem of health care and software providers' that is supposed to empower doctors to treat each patient as a unique individual. A 'complex ecosystem of lobbyists and drug reps' to control doctors and protect Big Pharma′s interests is far more likely anyway.

Sources

1. Church G. Medicine I can call my own, in What comes next: Experts predict the future. Scientific American online, August 26, 2010.
   http://www.scientificamerican.com/article.cfm?id=what-comes- next&print=true
2. The Quotations Page.
   http://www.quotationspage.com
3. Paul Zane Pilzer. The next trillion. Abridged Version. VideoPlus 2001.
4. Karen Hopkin. Researchers recommend statins with your fries. Scientific American August 26, 2010.
   http://www.scientificamerican.com/podcast/episode.cfm?id=researchers- recommend-statins-with-10-08-26

Back to the battle of the bulge and the series of articles that got me going on that subject. The first part in the series focused on whether exercise would help you lose weight.

Here is how the author introduces the subject (1):

"It′s such a widely accepted idea it′s virtually dieting dogma, a belief pushed with almost religious zeal: You can′t lose weight without exercising more."

and

"We have been taught that exercise is a surefire path to weight loss. But controversy is growing over whether working out to lose weight can be an exercise in futility. At issue is whether the amount of exercise needed to make a meaningful impact is unrealistic and whether gluttony, and not sluggishness, is where we should be focusing our efforts."

So, does exercise help you lose weight? As the introduction implies, the answer seems to be no. This is also the conclusion of a 2009 Time Magazine article (2) that ruffled quite a few feathers. The author of that piece quotes an exercise expert as saying that "In general, for weight loss, exercise is pretty useless … The common belief that physical activity can counteract rising rates of obesity is based on a belief rather than on solid scientific evidence.".

Why doesn′t exercise lead to weight loss? The typical explanation is that people don′t work out long enough or intensely enough (1):

"The amount of exercise needed to cause significant weight loss is more than most free-living individuals are capable of undertaking, and that is particularly true for the obese".

"You need a lot of exercise, and a lot of time, to make a 200, 300, 400 calorie deficit whereas you can easily make a 1,000 calorie deficit by cutting down your intake "

Of course, not everyone agrees that exercising to lose weight is futile, even in the face of evidence to the contrary. Here is my favourite quote &mdash it dmonstrates so beautifully just how misguided expert advice can be (1):

"[It] makes no difference to the human body whether it sheds calories via eating less or exercising more. The end result is the same: weight is lost."

This statement is only partially right. It really doesn′t seem to matter whether we shed calories by eating less or exercising more; the result appears to be the same all right. Unfortunately, the outcome isn′t weight loss, but rather a failure to lose weight.

What is wrong with the idea that all you have to do is create an energy deficit and you′ll lose weight?

Suppose you are overweight or obese. If you′re not losing weight this has to mean that all your energy needs are met by the food you eat. You now start a regular exercise routine hoping to lose weight, i.e. to burn some of your stored fat. Question: Why should your exercise fuel come from your adipose tissue, when all your other metabolic needs are met by food?

For exercise to lead to weight loss it would have to do more than just create an energy deficit. Exercise would have to draw on the fat reserves stored in the body′s adipose tissue, without replenishing those stores afterwards.

Just because exercise doesn′t help you lose weight, this doesn′t mean it is useless. Physical activity has many health benefits, such as increased cardiovascular fitness and insulin sensitivity, lower blood pressure, and improved mental health and cognitive ability. It just doesn′t seem to help you lose weight.

Sources:

1. Sharon Kirkey. Exercise alone doesn′t cut it. Canwest News Service March 6, 2010.
   http://www.timescolonist.com/health/battle+cultural+epidemic/2660423/Exercise+alone+doesn/2649284/story.html
2. John Cloud. Why exercise won′t make you thin. Time Magazine August 9, 2009.
   http://www.time.com/time/printout/0,8816,1914857,00.html

Our local paper just ran a three-part series on the battle of the bulge. Nothing unusual about that; you can hardly open a paper or magazine without coming across something on weight loss. I must say though that I find much of what has been written on this subject simple-minded or outright nonsensical. What good is advice like 'all you have to do is eat fewer calories than you expend'. If it were so simple, why would so many people be fat?

Do I have all the answers? Of course not — nobody does; there is no concensus among experts on what caused this obesity epidemic and how to solve the problem. There are, however, a few observations that would seem obvious, yet are ignored in much of what is written on the subject.

We have hormones that control how much we eat

All animals, including humans, have elaborate hormonal control systems in place to ensure an adequate energy supply — it′s a matter of survival and can′t be left to willpower. Imagine a lioness wondering 'should I eat the rest of this zebra, or is my ass getting too big'.

This hormonal control system works very accurately

Have you ever seen obese wildlife? The only animals that end up obese are those whose food we control — life stock, pets, lab animals.

One third of the population still keeps their weight in a narrow range throughout their adult lives; fifty years ago that was true of the majority.

This hormonal control system works well in obese people too — it just doesn′t work quite well enough

To show that this is so we need some numbers. Suppose you gained just 5 lb every year. In 10 years you would be 50 lb heavier, in 20 years you′d carry around an extra 100 lb, etc. In other words, gaining just 5 lb per year will make you grossly obese. Most of the overweight and obese gain weight more slowly than that.

How many extra calories would you take in if you gained 5 lb? Since 1 lb of fat gives you about 3,500 Kcal, you would take in an extra 5 × 3,500 = 17,500 Kcal/year. Dividing this by 365 gives you roughly 48 additional Kcal/day. At a daily intake of ≈ 2,000 Kcal, an additional 48 Kcal would exceed your daily energy expenditures by just 48 ÷ 2,000 ≈ 2.5%.

In other words, if your hormonal control is out by just 2 or 3 percent you′ll end up grossly obese. Put differently, even the grossly obese still balance energy intakes and expenditures to within 2 or 3 percent; pretty accurate I′d say.

If you are too heavy and aren′t losing weight then all your fuel must come from food

If you are overweight or obese you have two potential fuel sources — your fat reserves and food. If your weight is stable this means that all the fuel you burn comes from the food you eat; a net use of stored fat would result in weight loss.

If you are still gaining weight then there is obviously no net withdrawal of stored fat; your food provides all your energy needs, and then some.

You cannot improve on this hormonal control system — even if it would let you

Say you want to count the calories you eat. You′d have to weigh and measure the amount of food you eat, and you′d need to know its energy content.

First, kitchen scales aren′t accurate enough to weigh food to within a percent or two. Secondly, different foods have different energy contents; 100 g green beans ≠ 100 g dry beans ≠ 100 g chicken breast. You′d have to consult food composition tables, which only give you averages anyway. How many people would do that? Thirdly, we don′t just eat staple foods of known energy content — we cook with them. Do you really think you can determine the energy contents of 100g of your homemade stew to a couple of percent?

Forget portion control and calorie counting! The idea that your head can do better than your hormones at balancing energy input and output is laughable.

You cannot override this hormonal control system — it won′t let you

So you′ve decided to eat fewer calories than your body needs, in the hope of activating your fat reserves. That′s called dieting.

If deliberately cutting back on your calorie intake, aka dieting, worked there would be no weight loss industry, no obesity research, no medical specialty called bariatrics, and no endless stream of advice on 'how to lose weight and keep it off'; the very term 'dieting' would have no meaning.

So where does all this leave us?

As I see it, this leaves us with two obvious questions:

1. why is there a slight imbalance between energy intake and expenditure in the overweight and obese, and
2. why do the overweight and obese not mobilize their fat reserves

We need to understand why energy intake and expenditure aren′t always completely balanced to stop obesity. And we need to understand why the body doesn′t use its fat reserves to reverse it.

In my last post I talked about micronutrient triage. When micronutrients — vitamins and minerals — are in short supply they are preferentially allocated to physiological functions crucial for survival; maintenance and repair are temporarily put on hold (1). If our diets are chronically deficient in micronutrients, the prolonged neglect of vital repair functions is bound to take its toll.

That vitamins and minerals play a crucial role in health and disease should come as no surprise. Vitamins are defined as substances that the body needs but cannot make; and we obviously cannot make minerals. Vitamins and minerals act as antioxidants, stabilize protein structures and are enzyme cofactors. They are involved in all aspects of physiology, starting with such fundamental processes as DNA maintenance and gene expression.

Inefficient or incorrect DNA repair due to micronutrient shortages leads to genome instability, a known contributor to increased cancer risk, accelerated aging and neurodegenerative diseases (2). Genome damage caused by micronutrient deficiencies is believed to be at least as extensive as genome damage from environmental genotoxins like chemical carcinogens, UV and ionizing radiation. Genome instability caused by micronutrient deficiencies in turn increases DNA sensitivity to environmental genotoxic stressors.

Since degenerative diseases, the main health problems in the developed world, are partly caused by DNA damage, it makes sense to diagnose and nutritionally prevent the underlying cause, genome instability. This requires a knowledge of optimal intakes for vitamins and minerals that are needed to prevent DNA damage (2):

• "Excessive genome instability, a fundamental cause of disease, is often an indication of micronutrient deficiency and is therefore preventable
• accurate diagnosis of genome instability using DNA damage biomarkers that are sensitive to micronutrient deficiency is technically feasible
• it should be possible to optimise nutritional status and verify efficacy by diagnosis of a reduction in genome damage rate after intervention"

Vitamins C, E, B₂, B₆, B₁₂, folate and niacin, and the minerals zinc, iron, magnesium and manganese are some of the micronutrients known to be critical to genome stability (2). Optimal intakes of most of these micronutrients have not yet been determined, but for those that have been studied — e.g. folate and vitamin B₁₂ — intakes in excess of current RDA values are required to prevent genome damage. Optimal micronutrient intakes will also vary with people′s genetic make-up.

Optimizing micronutrient intakes seems like a promising way to reduce the degenerative disease burdens threatening to bankrupt medical care systems:

"… instead of diagnosing and treating diseases caused by genome damage, health and medical practitioners will be trained to diagnose and nutritionally prevent the initiating cause, i.e. genome instability itself." (2).

We′ll see.

Sources:

1. Ames BN. Low micronutrient intake may accelerate the degenerative diseases of aging through allocation of scarce resources by triage. Proc Natl Acad Sci USA 2006;103(47):17589-17594.
   http://www.pnas.org/content/103/47/17589.full.pdf
2. Fenech M. Nutritional treatment of genome instability: a paradigm shift in disease prevention and in the setting of recommended dietary allowances. Nutr Res Rev 2003;16:109-122.
   http://dx.doi.org/10.1016/S0278-6915(02)00028-5

When our bodies are starved of oxygen, blood flow is redirected from non-vital organs to those crucial for survival - the heart, brain and adrenal glands (1). This is an example of physiological triage — a survival mechanism.

Could micronutrients also be allocated by triage in times of shortages? According to Prof. Bruce Ames the answer is yes (1). When micronutrients — vitamins and minerals, as well as other biochemicals like omega-3 polyunsaturated fatty acids — are in short supply, available micronutrients are first used for life-preserving physiological functions.

Problem solved? In the short run, yes. But in the long run we pay a heavy price for chronic deficiencies in micronutrients; the forced neglect of vital maintenance functions like DNA repair, immune function and other systems not needed for immediate survival eventually leads to health problems. Micronutrient shortages have been linked to mitochondrial damage resulting in increased free radical production, cell damage and late onset diseases like cancer (1).

Because vital bodily functions remain unimpaired in times of micronutrient deficiencies, the problem may unfortunately not be noticed for some time; neglect of DNA repair doesn′t manifest itself immediately in clinical symptoms. We can go on for quite some time falsely believing that we are getting all the nutrients we need from our "balanced diet". Once clinical symptoms appear the damage is done.

Is micronutrient deficiency really such a problem? Unfortunately, the answer is yes. For example, the 2001-2002 National Health and Nutrition Examination Survey (NHANES) found that micronutrient shortages are widespread in the U.S. population (1). Many of the participants in that study had vitamin and mineral intakes below the Estimated Average Requirement (EAR). EAR values are even lower than recommended Dietary Allowance (RDA) values, which in turn are widely believed to be inadequate (2). The situation in other industrialized countries isn′t any better.

Micronutrient deficiency is definitely a problem. Since our eating habits don′t change over time, any nutritional deficiencies are likely chronic. Supplementation is therefore a must for most of us. Taking a daily multivitamin-mineral (MVM) complex is an inexpensive and effective solution with big payoffs down the road:

“Micronutrient inadequacies are widespread in the population, and a MVM supplement is inexpensive. A solution is to encourage MVM supplementation, particularly in those groups with widespread deficiencies such as the poor, teenagers, the obese, African Americans, and the elderly, in addition to urging people to eat a more balanced diet.” (1)

Sources

1. Ames BN. Low micronutrient intake may accelerate the degenerative diseases of aging through allocation of scarce resources by triage. Proc Natl Acad Sci USA 2006;103(47):17589-17594.
   http://www.pnas.org/content/103/47/17589.full.pdf
2. Doctors say, raise the RDAs now. Orthomolecular Medicine News Service, October 30, 2007.
   http://orthomolecular.org/resources/omns/v03n10.shtml

"UK professor says supplements are a waste of time". That was one of the headlines in a recent edition of NutraIngredients.com (1). The article quotes a Scottish professor of nutrition and dietetics saying that "People who take multivitamin supplements are probably just wasting their money and boosting the profits of vitamin companies".

He isn′t the first to speak out against the use of dietary supplements. Earlier this year NutraIngredients.com commented on a study of supplement use among American children and adolescents participating in the 1999 to 2004 National Health and Nutrition Examination Survey (NHANES) (2). About one third of children and youths between 2 and 17 in that survey took dietary supplements. The investigators suggested that "health care providers in the country should discourage the use of supplements by children with healthy diets" (2).

Last year NutraIngredients.com quoted a member of the Harvard School of Public Health saying that dietary supplements will not provide the nutritional boost a poor diet requires (3). His exact quote, "A supplement is called a supplement because it′s supposed to be supplementing a healthy lifestyle", is actually quite amusing and presumably not what he meant. He is saying in effect that you need supplements even if you follow a healthy lifestyle, which surely includes the proverbial "balanced diet". Proponents of dietary supplementation couldn′t have put it any better!

How widespread is this anti-supplement attitude among doctors? The Council for Responsible Nutrition (CRN), a trade association representing the dietary supplement industry, conducted a couple of surveys among health care professionals to find out. What they discovered was that dietary supplement use was just as common among health care professionals as among the general public.

The first CRN survey, conducted in 2007, questioned 900 physicians and 277 nurses about their thoughts on dietary supplements (4). The survey revealed that 51% of the doctors and 59% of the nurses took dietary supplements regularly, comparable to supplement use in the general population. 79% of the physicians and 82% of the nurses also recommended dietary supplements to their patients, whether they themselved took supplements or not. The list of supplements taken and recommended included things like fish oils, in addition to vitamins and minerals.

The second CRN survey, released in 2008, questioned around 1200 orthopedic specialists, cardiologists and dermatologists (5). Among the orthopedic specialists 73% took supplements themselves; 94% of those who took supplements also recommended them to their patients. For the cardiologists surveyed those figures were 57% and 86%, and for the dermatologists 75% and 79%. Even many of the doctors who did not take dietary supplements still recommended them to their patients.

Are these health care professionals "just as naive and gullible as the general public"? I doubt it. The doctors and nurses surveyed may not be nutrition experts, but they see the extent and consequences of poor eating habits and sedentary lifestyles in their medical practices; they just have to look at their patients′ expanding waistlines. How do you get obese on a "balanced diet"? Given the shear number of the overweight and the obese, how could most people possibly get all the micronutrients they need from the food they eat?

In 2007 investigators from the U.S. Centers for Disease Control and Prevention (CDC) examined the dietary habits of about 100,000 high school students to find out how many ate the recommended two servings of fruits and three servings of vegetables per day. The results of the survey, released just recently (6,7), were sobering. Only 32% got two daily servings of fruit and only 13% the recommended three servings of vegetable. Less than one in ten high school students surveyed ate enough of both. The adults questioned in the same survey didn′t do much better. So much for the balanced diet.

I let the Independent Vitamin Safety Review Panel, a group of physicians, academics and researchers, have the last word on this subject:

"In the past, over-conservative government-sponsored standards have encouraged dietary complacency. People have been led to believe that they can get all the nutrients they need from a 'balanced diet' of processed foods. That is not true. For adequate vitamin and mineral intake, a diet of unprocessed, whole foods, along with the intelligent use of nutritional supplements, is more than just a good idea: it is essential." (8)

Sources:

1. Shane Starling. UK professor says supplements are a waste of time. NutraIngredients.com Sept. 10, 2009.
   http://www.nutraingredients.com/content/view/print/259495
2. Lorraine Heller. Most children don′t need supplements, says study. NutraIngredients.com Feb. 4, 2009.
   http://www.nutraingredients-usa.com/content/view/print/235056
3. Shane Starling. Harvard professor slams supplements. NutraIngredients.com Jul. 7, 2008.
   http://www.nutraingredients-usa.com/content/view/print/173318
4. Dickinson A, Boyon N, Shao A. Physicians and nurses use and recommend dietary supplements: report of a survey. Nutr J 2009;8:29
   http://www.nutritionj.com/content/8/1/29
5. Lorraine Heller. Doctors reveal supplement recommendations. NutraIngredients.com Dec. 11, 2008.
   http://www.nutraingredients-usa.com/content/view/print/229798
6. 9 in 10 teens fall short on fruits and veggies. Associated Press Sep. 29, 2009.
   http://www.msnbc.msn.com/id/33071814/ns/health-diet_and_nutrition/
7. State indicator report on fruits and vegetables. Department of Health and Human Services, Centers for Disease Control and Prevention.
   http://www.fruitsandveggiesmatter.gov/downloads/StateIndicatorReport2009.pdf
8. Doctors say, raise the RDAs now. Orthomolecular Medicine News Service Oct. 30, 2007.
   http://orthomolecular.org/resources/omns/v03n10.shtml

"If you are an editor, author, reviewer, or reader of medical journals, or if you depend on your doctor or health care provider getting unbiased information from medical journals, then the 1,500 documents now hosted on the PLoS Medicine Web site [1] should make you very concerned and angry. Because, quite simply, the story told in these documents amounts to one of the most compelling expositions ever seen of the systematic manipulation and abuse of scholarly publishing by the pharmaceutical industry and its commercial partners in their attempt to influence the health care decisions of physicians and the general public."

So starts an editorial, "Ghostwriting: The dirty little secret of medical publishing that just got bigger", in the September 2009 issue of PLoS Medicine (1). This is not the first time that PLoS editors and contributors have spoken out against this practice. What is different this time around is that a clear paper trail detailing these shenanigans surfaced in the course of litigation involving Wyeth and its HRT drug Prempro. Lawyers for PLoS Medicine and the New York Times were instrumental in getting these documents made public (2), and the New York Times ran a piece about this in their Aug 4, 2009 edition (3).

What is medical ghostwriting? The term refers to the Pharma practice of having writing firms produce manuscripts to the company′s specifications, paying "respected" academics to pose as authors, and getting these articles published in medical journals — without acknowledging the company′s involvement of course. As the PLoS Medicine editors put it:

"…articles highlighting specific marketing messages written by unattributed writers, but "authored" by academics, are strategically placed in the medical literature …" (2).

These ghostwritten articles are typically reviews favourable to drugs sold by the company commissioning the manuscript; benefits are exaggerated and side effects are minimized. However, even research papers and clinical trial results may be "authored" by ghostwriters. As cruder methods of persuasion lost their effectiveness, pharmaceutical companies turned to "educating" and influencing medical doctors by faking scholarly articles and submitting them to respectable academic publications.

"What, a cynical reader might ask, can I truly trust as being unbiased? The answer is that, sadly, for some or even many journal articles, we just don't know." (1)

The term "ghostwriting" is actually a bit misleading. It isn′t the writing firms that are the problem; it′s the academics posing as authors. Their names and reputations give credence to articles that are little more than ads masquerading as scholarly publications; the unsuspecting reader can′t tell the difference. Clearly, these "authors"and the pharmaceutical companies recruiting them are guilty of fraud.

"How did an industry whose products have contributed to astounding advances in global health over the past several decades come to accept such practices as the norm?" (1)

Well, judging by the recent scandals in the banking and financial sectors, corruption seems to be endemic in American business. Power tends to corrupt, Lord Acton said. Big Business is certainly powerful, and they are proving him right.

Sources:

1. The PLoS Medicine Editors. Ghostwriting: The dirty little secret of medical publishing that just got bigger. PLoS Medicine 2009;6(9):e1000156.
   http://dx.doi.org/10.1371/journal.pmed.1000156
2. Wyeth ghostwriting archive. PLoS Medicine.
   http://www.plosmedicine.org/static/ghostwriting.action
3. Natasha Singer. Medical papers by ghostwriters pushed therapy. NY Times Aug 4, 2009.
   http://www.nytimes.com/2009/08/05/health/research/05ghost.html

You say you never heard of orthorexia nervosa? Well, neither had I until I read Jenny Thompson′s article "April [Fool′s Day] in August" in the September 8, 2009 edition of the HSI e-Alert (1). Here is how she introduced the subject:

"Do you read nutrition labels to avoid hidden trans fats, harmful additives, and sugar-substitutes? Do you choose organic foods to keep your intake of pesticides and herbides to a minimum? Do you even go out of your way to purchase free-range meat so you′ll get a maximum of omega-3 fatty acids and a minimum of trace antibiotics and growth hormones? If you answered yes to any of these questions, don′t be surprised if your doctor breaks the bad news: You have an eating disorder."

That supposed eating disorder — orthorexia nervosa — is an obsession with healthy eating, an obsessive compulsive disorder centered around food.

Here is what an article in the Observer (2) had to say about this grave new "disease":

"Eating disorder charities are reporting a rise in the number of people suffering from a serious psychological condition characterised by an obsession with healthy eating. The condition, orthorexia nervosa, affects equal numbers of men and women, but sufferers tend to be aged over 30, middle-class and well-educated."

A serious psychological condition characterized by an obsession with healthy eating? Hm.

"I am definitely seeing significantly more orthorexics than just a few years ago", the chairwoman of the mental health group of the British Dietetic Association was quoted as saying. "[Orthorexics] are solely concerned with the quality of food they put in their bodies, refining and restricting their diets according to their personal understanding of which foods are truly ′pure′."

What kinds of foods do these seriously disturbed orthorexics refuse to touch? Sugar, salt, caffeine, alcohol, wheat, gluten, yeast, soya, corn, and dairy foods are mentioned, as well as anything likely to contain pesticides, herbicides, and artificial additives. A bit strict maybe, but hardly a sign of a serious psychological problem. Even mainstream nutritionists warn against excess sugar, salt, and alcohol consumption. Gluten (wheat) as well as dairy products cause problems for many, and when did unfermented soy beans become food? I also try to avoid pesticides and herbicides; I should think you do too.

Who came up with this new-fangled disease called "orthorexia nervosa"? The term was introduced in 1997 by one Steven Bratman, M.D., who describes the affliction this way:

"Many of the most unbalanced people I have ever met are those who have devoted themselves to healthy eating. In fact, I believe some of them have actually contracted a novel eating disorder for which I have coined the name ′orthorexia nervosa.′ The term uses ′ortho,′ meaning straight, correct, and true, to modify ′anorexia nervosa.′ Orthorexia nervosa refers to a pathological fixation on eating proper food." (3)

"[people concerned with healthy eating] are sometimes affectionately called ′healthfood junkies.′ However, in some cases, orthorexia goes beyond a mere lifestyle choice. Obsession with healthy food can progress to the point where it crowds out other activities and interests, impairs relationships, and even becomes physically dangerous. When this happens, orthorexia takes on the dimensions of a true eating disorder, like anorexia nervosa or bulimia." (4)

To better understand Bratman and his "disease", one has to read his (short) original essay on orthorexia (3). It describes his experience with the lunatic fringe of the health food movement at a commune of health fanatics. He himself was part of that commune, before he was brought back to his senses; he is a "recovering orthorexic" himself. On reading this article (3) it becomes clear that he doesn′t apply the term orthorexia nervosa to people who simply focus on healthy eating. It is meant to describe someone with cockamamie ideas about food and a tendency toward obsessive compulsive behaviour.

Bratman is apparently quite sincere in his belief that orthorexia nervosa is an affliction to be taken seriously, a genuine disease requiring treatment. I suppose such misguided eating can actually lead to health problems. But does your typical "orthorexic" believe he needs treatment? And would he take nutritional advice from the medical establishment? Mainstream nutritional advice may be less extreme, but can be just as wrong-headed (dangers of cholesterol and saturated fat, etc).

I have to admit though that the term orthorexia nervosa appeals to my sense of humour. The lunatic fringe of the health food movement deserves a good ribbing, and orthorexia nervosa describes them wonderfully well. Still, there is something very sad about the extent to which we have lost our way in such a simple everyday matter as food.

Sources:

1. Jenny Thompson. April in August. HSI eAlert Sep 8, 2009.
   http://mail.live.com/default.aspx?wa=wsignin1.0
2. Amelia Hill. Healthy food obsession sparks rise in new eating disorder. The Observer Aug 16, 2009.
   http://www.guardian.co.uk/society/2009/aug/16/orthorexia-mental-health-eating-disorder
3. Steven Bratman, M.D.. Original essay on orthorexia.
   http://orthorexia.com/index.php?page=essay
4. Steven Bratman, M.D.. What is orthorexia?
   http://orthorexia.com/Index.php?page=katef

If we were asked to name the leading causes of death, most of us would name cardivascular disease and cancer. These are indeed the primary pathophysiological conditions identified at the time of death, but they are not the root causes. Diseases are the result of a combination of (unmodifiable) genetic and (modifiable) lifestyle factors. The real question therefore is what factors make the most significant contributions to these and other diseases.

A 1993 paper (1) attempted to answer that question. The authors searched the scientific literature from 1977 to 1993 for articles that quantitatively related lifestyle factors with disease. Coupled with actual U.S. death rates for 1990, they arrived at the following table of top risk factors and associated death tolls:

1. tobacco 400,000
2. diet/activity patterns 300,000
3. alcohol 100,000
4. microbial agents 90,000
5. toxic agents 60,000
6. firearms 35,000
7. sexual behavior 30,000
8. motor vehicules 25,000
9. illicit drug use 20,000

These ten factors (poor diet and sedentary lifestyle were lumped together) were estimated to account for about 50% of all U.S. deaths in 1990. Smoking, bad diets and lack of exercise are seen to be by far the major problems, accounting for 19% and 14% of all deaths, respectively.

The authors of a 2004 paper (2) put the U.S. death toll from smoking and poor diet/physical inactivity, the leading causes of death in the 1993 article, at 430,000 and 400,000, respectively. Their estimates are based on a survey of the relevant literature from 1980 to 2002 and actual numbers of U.S. deaths in 2000. As these authors point out, poor diet and lack of physical activity may soon overtake smoking as the leading cause of death in the United States.

The authors of a 2009 paper (3) analyzed data from the Potsdam, Germany, segment of the multi-center European Prospective Investigation Into Cancer (EPIC-Potsdam) study to estimate the risks associated with smoking, poor diet, lack of physical activity and high body mass index (a rather strange choice, given its dependence on diet and activity level). People who had none of these risk factors turned out to be 78% less likely to develop any chronic disease compared to those who smoked, ate poorly, were inactive and too heavy. Specific risk reductions were estimated to be 93% for diabetes, 81% for heart attacks, 50% for stroke, and 36% for cancer.

The authors of these papers emphasize that their numbers are only rough estimates of the death toll from perfectly avoidable risks. But these figures show very convincingly just how many of our chronic health problems are self-inflicted.

Sources

1. McGinnis JM, Foege WH. Actual causes of death in the United States. JAMA 1993;270(18):2207-2212.
   http://jama.ama-assn.org/cgi/reprint/270/18/2207
2. Mokdad AH, Marks JS, Stroup DF, Gerberding JL. Actual causes of death in the United States, 2000. JAMA 2004;291:1238-1245.
   http://jama.ama-assn.org/cgi/content/abstract/291/10/1238 [Free Abstract]
3. Ford ES, Bergmann MM, Kröger J, Schienkiewitz A, Weikert C, Boeing H. Healthy living is the best revenge. Findings from the European Prospective Investigation Into Cancer and Nutrition - Potsdam Study. Arch Intern Med 2009;169:1355-1362.
   http://archinte.ama-assn.org/cgi/reprint/169/15/1355

In the Aug 27, 2009 edition of The Scientist a UCLA infectious disease specialist makes an impassioned plea to help push for funding for the development of new antibiotics (1). Brad Spellberg, the author of a new book on the antibiotic resistance crisis, Rising plague (2), entreats scientific and lay communities for help in the quest for new weapons against antibiotic-resistant bacteria:

"This crisis will not be averted without your support, without a grassroots movement to put pressure on all sides — political, medical, pharmaceutical, and consumer — to band together to act. I will tell you what can be done, but we need your help to do it." (1)

Why does he need our help? Don′t we have the pharmaceutical industry to save us and keep us healthy? Apparently not:

"The problem here is not scientific. New antibiotics are dying before they have a chance to enter the marketplace due to a murky regulatory landscape and also due to unfavorable economics (i.e., the relatively low rate of return on investment afforded by sales of short-course antibiotics compared to sales of drugs for chronic conditions, such as hypertension, dementia, cancer, arthritis, and high cholesterol). Big Pharma has largely exited the scene. (1) [emphasis added]

Does he really mean to say that the wealthiest of all the multinational companies are unwilling to fund the necessary work, just because there is more money to be made elsewhere — even if our very survival is at stake? And I thought "capitalism" and "free markets" would solve all our problems!

Sources:

1. Spellberg B. Rising Plague. The Scientist Aug 27, 2009.
   http://www.the-scientist.com/news/display/55951/
2. Brad Spellberg. Rising plague: The global threat from deadly bacteria and our dwindling arsenal to fight them. Prometheus Books, Amherst, New York, 2009.