Is it ethical to impose a regime on people in the hope that heart disease will be reduced? Surely
prevention is better than cure, you may say. But is it? Such an attitude ignores the real possibility
that such intervention may do more harm than good. 'Preventative' medicine as practised in the
case of heart disease, takes two forms. Firstly we are to change our lifestyles, and seconsecondly we
are screened by our doctors on an opportunity basis.
But this screening is not prevention of the disease, it is merely the early detection of it. For
such procedures to be of use a number of criteria are well established. One important one is that
the disease should be both common and serious, as screening for an uncommon disease will
throw up many false results. These will inevitably incur the cost of further testing, and cause
unnecessary anxiety which itself is harmful.
The first problem with screening in CHD, is deciding what to test for. As a predictor of
coronary risk, total blood cholesterol turns out to be irrelevant, and merely testing for that is
regarded by many experts as misguided. Far more reliable, they claim, is measurement of HDL
(the 'good' cholesterol). However, in a test of the accuracy of checking for HDL at various
laboratories, values differed by as much as 40% in 95% of the samples tested. In another study,
16 instruments manufactured by nine companies were tested in 44 laboratories. In this test,
although the inaccuracies of the machines were lower at 3.6-4.4%, biases attributed to the
methods used ranged from -6.8% to +25%. The accuracy of desktop machines is even more
suspect.
A third study to evaluate the ability of cholesterol screening to detect individuals with blood
cholesterol abnormalities concluded that 41% of those with abnormal levels would not be
detected using present guidelines.
Another criterion is that an effective treatment for the disease is available, as there is little point
in early diagnosis or detection of a disease for which there is no effective remedy.
Some will say that we do know the cause of coronary heart disease; it is high cholesterol, or
too much fat in our diets, or not enough exercise. Or it could be something else. In 1981, two
hundred and forty six 'risk factors' for heart disease were listed. That number is now well over
three hundred. These so called risk factors include having English as a mother tongue, having a
diagonal crease in the left earlobe, not taking siestas, not eating mackerel, snoring and wearing
tight underpants. What a list of this size really tells us is that we have little idea what causes
coronary heart disease. And it is certain that if all the 300 plus do play a part, we have no chance
of defeating the disease.
A director of the Health Education Programme of the American Medical Association
denounced the lifestyle changes with their false promise of benefit as a quasi- religious crusade
when in 1984 he wrote: "Constant lifestyle self-scrutiny in search of risk factors, denial of
pleasure, rejection of the old evil lifestyle and embracing a rigorous new one are followed by
periodical affirmations of faith at revival meetings. . . the self-righteous intolerance of some
wellness zealots borders on health fascism. Historically, humans have been at greatest risk while
being improved in the best image of their possibilities as seen by somebody else."
Telling people who feel fit and well that they are not and, that if they do not make major
changes to their lives, they could drop dead at any moment, not only worries them unnecessarily,
it can have a profound effect on their attitudes to life. The benefits of mass screening are
doubtful and the risk of harm is high. Such intervention, therefore, can only be justified ethically
when either the patient has requested it or symptoms are such as to make it desirable.
If we go to our doctor with a complaint and he treats us with the best medical knowledge, he
should not be held responsible for defects in that knowledge. If, however, the doctor initiates
treatment without being consulted by the patient, then he is in a very different situation.
Cochrane and Holland write that before advocating a course of action in such circumstances,
"He should, in our view, have conclusive evidence that screening can alter the natural history of
disease in a significant proportion of those screened." If he does not, he may be held responsible
for any harm done.
But in the case of heart disease, recognised medical standard tests and ethics have been
thrown out the window. The recommendations were forced on the public even before they had
been tested, and now the perpetrators are afraid to admit that they could have been wrong. But
until they do, whole populations are suffering unnecessarily.
In the United States blood cholesterol level testing for all is routine and that nation is
becoming a nation of 'cholesterophobics'. More concerned with death than with life, many
interviewed said that their lives were ruined as, if they had a treat, it was accompanied by
feelings of guilt. One of COMA's principles is that the measures should "afford a reasonable
prospect of improvement in life expectancy overall, and in the quality of life for the population
as a whole." Experience around the world, and particularly from the United States, makes it
certain that neither of those principles will be met.
In Britain, general practitioners, practice nurses and health visitors are starting to use desk-top
cholesterol testing machines, the majority of which have been loaned by drug companies. A
suggestion in the Lancet is that this is designed merely to enhance the drug companies' profits
by increasing sales of cholesterol-lowering drugs, and questions their ethics. There is also the
question of the psychological harm that could be done to people in view of the United States
experience of the inaccuracy of such machines.
Medical bias towards illness
There is evidence that the medical profession is biassed in favour of diagnosing illness rather
than health. A classic example was a test run in New York on 1,000 11-year-old children and
their tonsils. On first examination 61% were found to have had their tonsils already removed.
The other 39% were re-examined by a group of doctors who recommended tonsillectomy
operations for 46% of them. The rest were again examined by yet another team and, again,
nearly half were recommended for operations to remove their tonsils. After three examinations,
only 65 of the original 1,000 had not been recommended for the operation. The test ended there
as they ran out of physicians to perform the examinations. However, if the physicians had had
their way, it is obvious that a great many unnecessary operations would have been performed.
High error rate in diagnoses
The bias towards illness may also combine with a high diagnostic error rate. Post- mortem
examinations in a British university hospital showed that of the patients who had died of a
diagnosed specific heart disease, over half had actually died of something else. And when the
same sample was tested in different laboratories, different results were given in 25% of cases.
Diagnostic machines, it seems, are no better. In a competition between doctors and computers in
83 cases recommended for pelvic surgery, pathology showed that both the doctors and
computers were right in only 22 cases. In 37 the computers proved the doctors' diagnoses wrong,
in 11 the doctors showed the machines to be in error and in 10 cases they were both wrong.
Variations between countries
There also exists a large variation between diagnostic and prescribing practices between
countries which makes comparisons between them of little use. For example, in Britain, a patient
is 7 times more likely to be prescribed a course of vitamins than in Sweden, and in Sweden, 8
times more likely to get gamma globulin medication than in Britain. United States surgeons
perform operations twice as readily as in Britain and the French will amputate almost anything.
Appendicitis and deaths attributed to it is diagnosed in Germany 3 times more frequently than in
any other country.
And so to the cost
In the late 1980s, intervention alone in the United States was estimated at $14 billion a year.
The cost of cholestyramine for an estimated five million people at 1990's prices was $10 billion
to which up to another $10 billion must be added for laboratory tests and doctors' services. In
Britain, if we also undertook a mass screening and cholesterol reducing programme, it has been
suggested that drug treatment would be recommended for 10% of men aged 40-69 and, as a
result, the NHS drug bill in England and Wales, £2.3 billion in 1992, would be increased by
20%. To put it in terms more familiar to the average person, the cost of the drugs alone would be
between £80 and £120 per person per month. The evidence suggests that for that money we
might be able to delay a fatal heart attack in the average person by between 3 days and 3 months
- but shorten that person's life by a larger amount as he or she died of cancer, osteoporosis or
stroke.
The effect on the NHS
Sir William Beveridge set up the National Health Service on the assumption that "there exists
in any population a strictly limited amount of illness which, if treated under conditions of equity,
will eventually decline." It was calculated that the cost of the service would fall as the rates of
illness went down. No-one considered that the NHS would redefine and broaden its service to
such an extent that only budgetary restrictions would keep it from expanding indefinitely.
The increasing sophistication of treatments available and demanded of the National Health
Service are putting it under a tremendous strain. To spend scarce money and resources on any
unnecessary treatment is waste, but to waste billions of pounds on such unproven and dubious
hypotheses as the present, so-called 'healthy eating' recommendations is quite irresponsible and,
in the long term, can only be harmful.
Dr Halfdan Mahler, Director General, the World Health Organisation recognised such waste
when he said in 1984:
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"The major - and most expensive - part of medical technology as applied today appears to be
far more for the satisfaction of the health professions than for the benefit of the consumers of
health care."
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Side effects
The current 'diet-heart' strictures and media pressure aimed at ever lower blood cholesterol
levels, have driven more people towards unnatural and unhealthy cult diets. Consequently, there
has been a rapid rise in the incidence of infant malnutrition, deficiency diseases and other killer
or debilitating diseases. Without sufficient dietary fat, the body is unable to use the fat soluble
vitamins. Without vitamin D the body cannot utilise calcium. In conjunction with an increase of
bran in the diet, this is another possible factor in the growing incidences of diseases such as
osteoporosis and rickets.
Vegetarian traits are increasing. As animal products are the only natural source of vitamin
B-12, Vegans, who eat no such animal products, run a real risk of pernicious anaemia. Bottles of
pills are not a good substitute as they are generally poorly absorbed. Fermented soy products,
such as tempeh, and spirulinas found in health-food shops, which are supposed to contain
vitamin B-12, for the most part contain only analogues of the vitamin which are not active for
humans and which, in some cases, actually block vitamin B-12 metabolism. Children of Vegans
also usually have a lower body weight and height and suffer other health problems.
Doctors in Britain are reporting cases in 'the muesli belt' of severe nutritional disorders which
include kwashiorkor, marasmus and rickets which are due solely to their parents' food faddism.
Until recently, these diseases were only found among severely malnourished children in Africa.
In Britain it is becoming so serious that they suggest that such cases should be regarded as forms
of child abuse. But are the parents to blame? Could not some of the blame for this deplorable
situation be fairly laid at the doors of the nutritionists?
Doctors in the USA also are reporting ever increasing numbers of children suffering from
nutritional dwarfing and other deficiency problems attributable entirely to pressures to eat
nutrient-poor, low-calorie foods because they are 'healthy'. These children are destined to have
far-reaching problems beyond just being smaller than their peers. It has been shown that adults
whose birth-weights early rates of growth were low have a much higher incidence of CHD. Brain
growth and intelligence are also found to be much lower in such undernourished children.
We really seem incapable of learning from previous experiences. During World War II, when
we are supposed to have been so healthy, protein-calorie deficiency was so pronounced that in
many people pathology showed there was as much as 25% loss of muscle from their hearts -
and similar patterns of protein deficiency are found today.
And it is not just humans who suffer side effects. In the constant quest for ever leaner meat,
food animals are being engineered which could not survive naturally. Belgian Blue cattle, for
example, bred to provide lean meat, have double muscles. This makes the calves too large to
pass along the birth canal and they have to be delivered by Caesarean section. Other cattle and
pigs are fed hormones to make them grow with less fat. As yet it is anyone's guess what the
long-term consequences of this will be on both the animals and humans.
The strictures against red meat also mean that fewer cattle and sheep are being reared and
more fields are used to grow cereals, rape and other vegetable crops. Unlike the animals, which
on the whole produce natural fertiliser for the pastures, the vegetable and cereal crops require
large amounts of manufactured nitrogen fertilisers to be spread. As we know, these leach in
ever-increasing quantities out of the soil to pollute our water supplies. Grass, the food of the
cattle and sheep, on the other hand, locks the nitrates in the soil, thus preventing pollution.
The Mediterranean diet
The 'Mediterranean' diet is healthier than ours, we are told. We should eat what the French,
Italians and Spanish eat. That could be right - but not for the reasons usually given.
The Mediterranean diet is what the health fanatics advocate because, they say, it is low in fat.
This is nonsense! Obviously, they have never been there. They don't seem to know that northern
Italians love butter, that bowls of pork dripping are sold on Spanish markets or that the Spanish
spread it thickly on their toast for breakfast. They don't know that goose fat is used to make
cassoulet in the south of France, or that throughout the Mediterranean the sausages, salamis and
pâtés all contain up to fifty percent fat.
The Mediterranean diet may be healthier than the British but, contrary to popular belief, it is
very far from being a low-fat diet!
However, there are a number of major differences between the Mediterranean countries and
Britain that may play a significant part in their effects on health. Not only is the food eaten by
the average working family in southern Europe very different from that eaten by a typical family
in Britain, more importantly, the way it is bought, presented and eaten is also different. A brief
list of the principal differences is tabled below.
Mediterranean Eating Pattern |
British Eating Pattern |
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The average Mediterranean diet comprises
natural, unprocessed meat, vegetables and fruit
that are usually bought fresh daily. |
The average British diet is composed of
packaged, highly processed foods with
chemical additives. |
|
Meat plays an important part in the diet |
We are told to eat less meat |
|
Fats eaten are butter, olive oil and unprocessed animal fats |
Fats eaten are highly processed margarines, low-fat fat substitutes, and
vegetable oils. |
|
Meals are taken slowly, without hurrying.
Lunch usually takes up to two hours - and is
followed by a siesta. |
Food is rushed. Lunches are eaten on the
run or combined with work. Often, they are
junk-food snacks. |
|
Over sixty percent of energy intake is before
2.00 pm. |
The largest meal is eaten in the evening |
| Wine (believed to be protective against
heart disease), is drunk during meals as part of
that meal. |
Beer, wines and spirits are drunk in the
evening after the evening meal. |
Cholesterol testing
Imagine it is 2.00 a.m., you are lying in bed when you hear a noise downstairs that you know is
caused by a burglar. You know how quickly your heart starts to race. Well, that is how quickly
your cholesterol level can rise - and for the same reason. One of the effects of the 'fight or
flight' reflex is to raise blood cholesterol. Any form of physical or mental stress has this effect.
So if you run to your doctor's, your cholesterol level will be higher than if you walked; if you
have been standing it will be higher than if you sat. If you are anxious, or your doctor looks
worried, it will be higher. If your blood cholesterol were tested hourly throughout a day, or daily
over a month, it would not be unusual to find a wide variation in values.
Blood cholesterol levels also rise naturally as you get older so that while a reading of 9
mmol/l is high at the age of twenty, it is perfectly normal if you are fifty.
Cholesterol measurements are not very accurate - less than eighty percent - even when
conducted in a laboratory. A survey showed that on the same sample, laboratories could differ by
as much as 1.3 mmol/l. When it is tested with a doctor's desktop machine the accuracy will
inevitably be lower.
To put it in perspective, let us assume that you are around thirty years old and your cholesterol
level is a perfectly respectable 6.0 mmol/l. You hurry to the surgery and are anxious about the
result. This could raise it by twenty-five percent to 7.5. If it is sent to a laboratory giving the high
readings it could be raised by a further 1.3. Your perfectly normal 6.0 is now a high 8.8!
In fact, so many variables affect cholesterol levels that a one-off test is a waste of time, and an
unnecessary worry for the patient that can do more harm than good. Bear that in mind if you are
subjected to a cholesterol test.
Part 9: The Dangers of a "Healthy" Diet
Back to index
By Barry Groves
For more articles by Barry Groves exposing dietary and medical misinformation see Second Opinions
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