Ben Goldacre responds to nutritionist Paul Clayton further down below…

The last prescription

The future of healthcare lies not at your local chemist, argues Paul Clayton, but at the supermarket checkout.

Tuesday June 10, 2003
The Guardian

We are spending more money on healthcare than ever before. We are living longer, yet never have we been less healthy. Our medicines have reached the highest level of sophistication, yet the incidence of degenerative diseases continues to increase, with many, such as diabetes, appearing in progressively younger people.

Five out of six people in their 60s have symptoms of one or more of the chronic degenerative diseases, such as coronary artery disease, osteoporosis and Alzheimer’s. Drugs alleviate their symptoms, but do little to alter the underlying illness, which generally continues to deteriorate. Drugs are designed to block a single step in the process leading to the symptoms of illness: a strategy unlikely to cure, and with a high risk of side effects. Iatrogenic illnesses – ill health caused by side effects of drugs – are listed as the fourth most common cause of death.

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Modern medicine is practised as crisis management: wait until diagnosis, then start treatment. But by the time the symptoms of disease appear, damage has been done that drugs cannot address. Most apparently healthy people are “pre-ill”; arteries are furring, bone is thinning, leading eventually to a heart attack or fracture. Drugs can do little to prevent this.

But are these conditions inevitably degenerative? A new science, known as pharmaco-nutrition, is emerging which focuses on the pre-ill, and analyses the metabolic errors that lead to clinical illness, in order to correct them before the first twinge of angina or fracture. Forget drugs: the next wave of healthcare will be food and diet supplements. The old adage that we are what we eat is being re-examined – and it promises longer, healthier lives.

There is a commonly held belief that adequate nutrition is obtained from a well-balanced diet. However, studies such as the US department of agriculture survey of micro-nutrient intake have revealed that malnutrition is common in the west. This is not the calorie and micronutrient deficiency associated with developing nations (type A malnutrition), but multiple micronutrient depletion, usually combined with calorific balance or excess (type B). According to the 1997 survey, 68% of Americans are not getting adequate levels of vitamin E, 55% are deficient in vitamin A, 54% in B6, and 37% in vitamin C. There is also evidence that the American diet is dangerously lacking the newer micronutrient groups such as essential fatty acids, xanthophylls, various fibre types and flavonoids. This is due to a combination of factors:

1. We were designed to live active lives, and to consume 3,000-4,000 calories per day. No longer hunter-gatherers, we live sedentary lives, and typically burn fewer than 2,000 calories daily. When we eat less, we’re consuming fewer micronutrients.

2. Many (not all) processed foods are depleted in micronutrients, and more processed foods are being consumed than ever before. British consumption of fresh green vegetables declined by 7% in 2001-2.

3. Many soils are low in key minerals, and crops or animals raised in these areas are depleted in these minerals also.

4. Smoking, pollution and excessive alcohol all deplete the body of micronutrients.

5. Type B malnutrition worsens with age. Activity levels fall, and reduced finances may mean a restricted diet.

The progressive worsening of our health in most cases has less to do with ageing than with worsening type B malnutrition. Lacking the micronutrients needed for repair and those that normally keep the process of decay in check, we slide prematurely into degenerative disease. If this is the case, then it is logical to treat such diseases not with drugs, but with multiple micronutrient repletion, or “pharmaco-nutrition”.

This approach has largely been neglected hitherto because it is relatively unprofitable for drug companies – the products are hard to patent – and is a strategy that does not sit easily with modern medical interventionism. The pharmaceutical industry has invested heavily in developing drugs to treat the diseases we are subject to.

However, although we have drugs that suppress the symptoms of degenerative disease, we have hardly any cures – suggesting that when the pharmaceutical industry was founded on the “magic bullets” of Robert Koch and Paul Ehrlich, it started at the wrong place. We should have followed Pasteur, who realised that “le terrain” (our internal physiology) was all important. And “le terrain” is in bad shape because of the increasing prevalence and severity of type B malnutrition.

One problem for supporters of this approach is lack of the right evidence. We have data linking dietary factors to disease risks, and plenty of information on mechanism, ie how food factors interact with our biochemistry. However, most intervention studies with micronutrients have produced negative results. Our “science” appears to have no predictive value. Does this invalidate the science? Or were we asking the wrong questions?

Most studies have attempted to measure the impact of a single micronutrient on disease. But in the field of nutrition, this is nonsense. It is like the mechanic who, confronted with a chronically undermaintained car, insists on a test drive after changing the oil filter, another after replacing one of the spark plugs, and so on. Each intervention on its own will hardly make enough difference to be measured. To make the car run noticeably better and last longer requires a comprehensive service. Similarly, to enable humans to live healthier and longer lives, comprehensive nutritional support is needed.

For example, the etiology of coronary artery disease reveals that there is no single weak link. The logical response is to combine micronutrients which, working together, normalise the “terrain”, leaving its owner effectively immune to the disease which currently kills one in two UK citizens. The prospective changes in mortality, which may represent as many as 25 additional years of healthy middle and old age, are staggering.

In Finland, one simple dietary change – the reduction of salt in manufactured foods and the introduction of a substitute called pansuola – halved heart attacks and strokes during the 80s and 90s, significantly reducing drug sales. British GPs who attended a pioneering course in nutritional therapy at the University of Surrey have reported up to 30% savings in prescription costs. Such trends, if duplicated in larger markets, would be disastrous for drug companies.

Recent media scare stories about certain vitamins and herbs have helped to push consumer groups into the anti-supplement camp. There are certainly problems with the existing supplements business, which is worth almost £400m a year. Most over-the-counter supplements are not well designed and most consumers do not take them regularly enough or for long enough to see any effect. None of this, however, justifies the attack on the supplements and vitamins industry by the government’s food standards agency last month.

None the less, there are forces on the side of pharmaco-nutrition. These include the manufacturers of so-called functional foods, which are already making major contri- butions to Japanese and Finnish public health. Functional foods contain supplements specifically designed to improve health or reduce the risk of disease. In this country, we’ve seen the introduction of pro- biotic yoghurts, which improve gastro-intestinal conditions, and chewing gums that contain xylitol and prevent decay.

But what pharmaco-nutrition needs is the support of a few far-sighted politicians who grasp that the next wave of healthcare will be food, not more drugs, and that the point of delivery will shift from the pharmacy to the supermarket, providing a kinder and more cost-effective way of preserving the nation’s health.

· Paul Clayton is a fellow of the Royal Society of Medicine and author of Health Defence, published by Accelerated Learning Systems. This is an edited version of an article that appears in the June issue of Prospect magazine.

I beg to differ: A doctor replies
Ben Goldacre

It’s all about laziness: intellectual and physical. People have bad diets because they can’t be bothered to eat properly. Then along comes someone to tell us that we needn’t worry, because we can cure all ills by taking a few pills with our chips. Unfortunately, diet fads have all the hallmarks of classic pseudoscience. Firstly, there is always a sinister conspiracy to suppress their truth. Well, I’m a doctor who tells his patients about eating properly, and I read a lot more about funny diets, pills and fads than I do about eating a proper, sensible, balanced diet, which is after all the only thing that has been proven – convincingly – to make us healthier.

Perhaps I could wake you up by pointing out a few of the more worrying suggestions of the diet-fad movement. “We have never been less healthy”? Lowest ever infant and perinatal mortality, longest ever life expectancy, shortest hospital admissions. Of course people are getting more diseases in old age, if they are living to be older.

And are we really getting fewer calories since we stopped hunter-gathering? That seems unlikely, with the figures taken here from the US, the most overfed nation on earth.

In the real world, poverty is the main determinant of ill-health. People with no car who live in “food deserts”, created by supermarkets closing down local shops, who are literally unable to get regular fresh produce, who eat processed long-life rubbish: are they going to be buying micro-nutrients? I don’t think so.

What I find most worrying is the way these theories are always coupled with an attack on conventional medicine. That old chestnut about medicine addressing “symptoms not cures” is so poorly evidenced, prevalent and long-winded that I am writing a long, boring book on the subject. Medicine isn’t all about painkillers. What about surgery? What about replacing genetically absent clotting factors, or insulin in type I diabetes?

And lastly, doctors deal only with crises because you all decided to elect governments that systematically underfunded the health service. Your bad luck, I’m afraid.

· Ben Goldacre is a doctor who writes Bad Science for the Guardian’s Life section.