Healthy eating in a diseased society
After reading the government's latest report on healthy eating, Dr Michael
Fitzpatrick offers an alternative prescription: stop worrying about dying
and start living
It's official! According to a recent government report, if you eat less
fat, salt and sugar, and more fibre and starchy carbohydrates, you might
succeed in living a bit longer. But why should anybody want to prolong the
agony of old age in a society that treats old people so badly?
Working as a general practitioner, I am struck by the contrast between two
types of patient. I see many young people, usually in professional occupations,
who worry about their health, watch their diet and take regular exercise.
They also seek regular check-ups and screening tests for various diseases.
I also see many old people, often former manual workers, who have never
been much concerned about their health and have rarely modified their lifestyles
or consulted their doctors with a view to preserving it. If you congratulate
them on their longevity, they often say that they only wish they had not
lived so long. Sometimes they even request my help in assisting their escape
from the misery of loneliness, infirmity and poverty.
The current preoccupation with the link between diet and health reveals
the grip of irrationality on modern medicine and the pervasive anxiety of
According to Nutritional Aspects ofCardiovascular Disease, the report
of the government's Cardiovascular Review Group Committee on Medical Aspects
of Food Policy (Coma), changes in the national diet could produce a substantial
reduction in levels of illness and death resulting from such diseases. At
present coronary heart disease (CHD) accounts for 27 per cent of all deaths
in the UK and stroke for a further 12 per cent.
The key link identified in the report is that between dietary fat, the level
of cholesterol circulating in the blood and the incidence of angina, heart
attack and stroke. Citing the results of a meta-analysis of numerous surveys
and clinical trials published in the British Medical Journal on 5
February 1994, the Coma report asserts that 'these data are strong, consistent
and show the characteristics of a causal relationship between plasma cholesterol
and CHD mortality' (p31).
'The cholesterol papers', as they are dubbed in an accompanying editorial,
indeed make an impressive case for the link between cholesterol and CHD
(BMJ, 5 February 1994, pp363-72). The authors conclude that a 10
per cent reduction in serum cholesterol in Britain would result in a 27
per cent fall in mortality from CHD. This reduction could be produced by
a 10 per cent fall in the proportion of energy derived in the national diet
from saturated fatty acids (the sort of fats found in meat and dairy products).
They demand 'appropriate action', including 'wider health education, labelling
of foods, and policies on food subsidies that are linked to health priorities'
(p371). The Coma report has taken up these demands and produced detailed
recommendations on proposed changes to the national diet.
All of this sounds eminently reasonable. Indeed the notion that fatty foods
lead to clogged coronaries is already firmly established, as in the popular
description of the traditional British fried breakfast as a 'heart attack
on a plate'. Yet while health educators wonder if this awareness leads to
any change in eating habits, it is worth asking whether the link between
diet and heart disease is so straightforward and the potential benefits
of change so great as to make major dietary adjustments advisable. Many
important criticisms of the policy conclusions drawn from the 'cholesterol
papers' appeared in subsequent issues of the BMJ.
The association between cholesterol and coronary heart disease may be strong,
but it is clearly not the only factor involved (BMJ, 16 April 1994,
p1038). The incidence of CHD has been declining over many years in different
Western populations, despite steady or even increasing levels of cholesterol.
A major British study has shown that, though cholesterol levels tend to
be lower in lower social classes, the incidence of CHD is around four times
higher. Genetic, cultural and environmental factors, as well as chance,
also appear to affect any particular individual's likelihood of acquiring
CHD. This means that the scope for personal initiative in improving one's
survival prospects is relatively small.
Other critics drew attention to the distinction between the apparently impressive
improvement in the relative risk of CHD resulting from dietary change and
the marginal improvement in absolute risk:
'Most doctors answer in the affirmative when asked whether they would take
a daily pill to reduce their chances of dying from a heart attack by 50
per cent. When asked if they would do so for 10 to 20 years if the risk
was reduced from 2/1000 to 1/1000, a reduction of 50 per cent, there is
much less enthusiasm.' (BMJ, 16 April 1994, p1040)
The chances of a 40-year old man with a relatively high serum cholesterol
dying from a heart attack are very small indeed. Reducing his serum cholesterol
level by 10 per cent would make his chances of such a death very very small
indeed. The authors comment that such improvements 'may represent substantial
epidemiological benefit', but are of 'trivial clinical importance'.
A man advised of his chances in these terms might well decide to live dangerously
(but happily) on bacon and eggs, rather than marginally more safely on muesli
and skimmed milk, with the added risk of dying miserable and flatulent.
In all the computerised number-crunching involved in the cholesterol-CHD
debate, one statistic stands out. Two contributors to the discussion from
the Netherlands note that the postulated 27 per cent decline in CHD mortality
resulting from the proposed dietary changes 'seems high', but, they continue,
'expressed in terms of individual life expectancy gained, this represents
only 2.5 to 5.0 months' (BMJ, 16 April, p1038).
In other words, if you forgo the pleasures of meat and cheese for the rest
of your life, and eat plenty of pulses and potatoes, you might prolong your
melancholy existence by a mere few months. Once again, offered the choice
in these terms, many would opt to eat now and forfeit the 2.5 to 5.0 months.
Another set of problems arises from the presumption that the recommended
reduction in serum cholesterol is easily achieved by dietary changes. According
to one group of experts who have studied this matter, simple fat-reducing
diets are ineffective, while effective diets are unpalatable and cannot
be sustained (BMJ, 16 April 1994, p1038-39). They conclude that the
authors of the cholesterol papers 'should apply the same rigour to assessing
the effectiveness of intervention as they have to their analyses of the
epidemiological and clinical trial data'.
The dietary approach to heart disease reflects the peculiar predicament
of modern medicine. Ever since the causes of the infectious diseases that
were the major killers of the past were identified and effective treatments
were developed, attention has shifted to the 'modern epidemics' of heart
disease and cancer. The problem here is that, though diverse 'associations'
and 'risk factors' have been identified, the causes of these conditions
remain obscure and treatment remains largely unsatisfactory. Furthermore,
because these are diseases of ageing--83 per cent of people who die of CHD
are over 65--the scope for any intervention is likely to be limited. Old
people will still die.
Where clinical medicine falters, epidemiology steps in. Doctors who cannot
help individuals turn to treating populations. The Coma report raises this
strategy to a new level of absurdity:
'The main recommendations are given as targets for populations. These are
proposed averages for population groups rather than for individual eating.
They should not be interpreted as recommended maximum (or minimum) intakes
for individuals. The distinction is crucial. To meet a given population
dietary target approximately half the population will be expected to consume
less than that target, and half more.' (p5)
But unless every Jack Spratt who follows the Coma guidelines randomly acquires
a mate who complements his dietary idiosyncrasies and so maintains the national
average, the targets will not be met.
One alternative would be for the population to be assigned in roughly equal
numbers to one side or other of the dietary average, perhaps after consultation
and appropriate counselling. In the Coma report the health foods shops of
the seventies meet the Stalinist five-year plans of the thirties.
According to the late Petr Skrabanek, a trenchant critic of the excesses
of modern epidemiology, the prevailing obsession about health is 'not orchestrated
by some worldwide conspiracy, but is rather the result of a positive feedback
between the masses stricken by fear of death and the health promotionists
seeking enrichment and power' (The Death of Humane Medicine and the Rise
of Coercive Healthism, 1994, p38). In fact, a fear of death and a pervasive
anxiety about health are strongest among the middle classes, who have experienced
a growing sense of insecurity in recent years as a result of the economic
slump and the collapse of the old political systems.
In an age of diminishing expectations, there is a widespread loss of faith
in the future. As a result, the meaning of life for everybody shrinks to
the number of years of its duration. For every individual, his or her lifespan
is all they have. Staying alive becomes an end in itself. Hence they become
preoccupied with clinging on to it, with holding off death, with playing
safe, with avoiding risks. As Skrabanek puts it, 'a dying century and a
dying culture makes war against death its main preoccupation' (p39). Paradoxically,
when there appears to be nothing to live for, people are reduced to trying
to prolong life itself. Yet, as Skrabanek also observes, to live in fear
of death is to fear living.
Such a climate of fear is receptive to any agency that offers greater security,
or any source of rules to enhance the individual's prospects of survival
in a world experienced as hostile and threatening. Anxiety invites moralism
and self-regulation; it thrives on the sort of guidelines to behaviour now
offered in the Coma report and in numerous other such codes of conduct covering
everything from language to sex.
Numerous commentators have noted that the evils targeted by modern health
promotion are strikingly similar to the sins defined by traditional religion - from
promiscuity to drunkenness and gluttony. In fact, today's health moralism
is even worse: at least religion accepts the reality of suffering and offers
consolation in an afterlife. 'Healthism' offers only fear and guilt.
A climate of fear is also receptive to measures of external regulation,
and the government is not slow to respond with the facile rhetoric of health
promotion. Like Virginia Bottomley's 1992 white paper, 'The health of the
nation', the Coma report expresses the government's concern with issues
of public health, in an attempt to bolster its flagging popularity. Such
reports cost little and, through their emphasis on individual responsibility
in matters of health, imply the expenditure of less rather than more money
on the National Health Service. By promoting measures of public self-regulation,
these measures also intensify the pressures of individuation and help to
enhance the power of the state over an increasingly atomised society.
'Hope I die before I get old': this was the spirit of the 1960s as proclaimed
by The Who. In the 1990s we live in a society in which young people want
to get old and old people wish they were dead. Once we stop worrying about
dying, we can start living (and eating) and concentrate on improving the
quality rather than extending the duration of our existence.
Reproduced from Living Marxism issue 75, January 1995