Part 4 (1/2)

Looking at these enormous, overwhelming interlocking webs, it's hard not to be struck by the versatility of the human body, and how it can perform acts of near alchemy from so many different starting points. It would be very easy to pick one of the elements of these vast interlocking systems and become fixated on the idea that it is uniquely important. Perhaps it appears a lot on the diagram; or perhaps rarely, and seems to serve a uniquely important function in one key place. It would be easy to a.s.sume that if there was more of it around, then that function would be performed with greater efficiency.

But, as with all enormous interlocking systems-like societies, for example, or businesses-an intervention in one place can have quite unexpected consequences: there are feedback mechanisms, compensatory mechanisms. Rates of change in one localised area can be limited by quite unexpected factors that are entirely remote from what you are altering, and excesses of one thing in one place can distort the usual pathways and flows, to give counterintuitive results.

The theory underlying the view that antioxidants are good for you is the 'free radical theory of ageing'. Free radicals are highly chemically reactive, as are many things in the body. Often this reactivity is put to very good use. For example, if you have an infection, and there are some harmful bacteria in your body, then a phagocytic cell from your immune system might come along, identify the bacteria as unwelcome, build a strong wall around as many of them as it can find, and blast them with destructive free radicals. Free radicals are basically like bleach, and this process is a lot like pouring bleach down the toilet. Once again, the human body is cleverer than anybody you know.

But free radicals in the wrong places can damage the desirable components of cells. They can damage the lining of your arteries, and they can damage DNA; and damaged DNA leads to ageing or cancer, and so on. For this reason, it has been suggested that free radicals are responsible for ageing and various diseases. This is a theory, and it may or may not be correct.

Antioxidants are compounds which can-and do-'mop up' these free radicals, by reacting with them. If you look at the vast, interlocking flow chart diagrams of how all the molecules in your body are metabolised from one form to the next, you can see that this is happening all over the shop.

The theory that antioxidants are protective is separate to-but builds upon-the free radical theory of disease. If free radicals are dangerous, the argument goes, and antioxidants on the big diagrams are involved in neutralising them, then eating more antioxidants should be good for you, and reverse or slow ageing, and prevent disease.

There are a number of problems with this as a theory. Firsdy, who says free radicals are always bad? If you're going to reason just from theory, and from the diagrams, then you can hook all kinds of things together and make it seem as if you're talking sense. As I said, free radicals are vital for your body to kill off bacteria in phagocytic immune cells: so should you set yourself up in business and market an antioxidant-free diet for people with bacterial infections?

Secondly, just because antioxidants are involved in doing something good, why should eating more of them necessarily make that process more efficient? I know it makes sense superficially, but so do a lot of things, and that's what's really interesting about science (and this story in particular): sometimes the results aren't quite what you might expect. Perhaps an excess of antioxidants is simply excreted, or turned into something else. Perhaps it just sits there doing nothing, because it's not needed. After all, half a tank of petrol will get you across town just as easily as a full tank. Or perhaps, if you have an unusually enormous amount of antioxidant lying around in your body doing nothing, it doesn't just do nothing. Perhaps it does something actively harmful. That would be a turn-up for the books, wouldn't it?

There were a couple of other reasons why the antioxidant theory seemed like a good idea twenty years ago. Firsdy, when you take a static picture of society, people who eat lots of fresh fruit and vegetables tend to live longer, and have less cancer and heart disease; and there are lots of antioxidants in fruit and vegetables (although there are lots of other things in them too, and, you might rightly a.s.sume, lots of other healthy things about the lives of people who eat lots healthy fresh fruit and vegetables, like their posh jobs, moderate alcohol intake, etc.).

Similarly, when you take a snapshot picture of the people who take antioxidant supplement pills, you will often find that they are healthier, or live longer: but again (although nutritionists are keen to ignore this fact), these are simply surveys of people who have already chosen to take vitamin pills. These are people who are more likely to care about their health, and are different from the everyday population-and perhaps from you-in lots of other ways, far beyond their vitamin pill consumption: they may take more exercise, have more social supports, smoke less, drink less, and so on.

But the early evidence in favour of antioxidants was genuinely promising, and went beyond mere observational data on nutrition and health: there were also some very seductive blood results. In 1981 Richard Peto, one of the most famous epidemiologists in the world, who shares the credit for discovering that smoking causes 95 per cent of lung cancer, published a major paper in Nature Nature. He reviewed a number of studies which apparently showed a positive relations.h.i.+p between having a lot of -carotene onboard (this is an antioxidant available in the diet) and a reduced risk of cancer.

This evidence included 'case-control studies', where people with with various cancers were compared against people various cancers were compared against people without without cancer (but matched for age, social cla.s.s, gender and so on), and it was found that the cancer-free subjects had higher plasma carotene. There were also 'prospective cohort studies', in which people were cla.s.sified by their plasma carotene level at the beginning of the study, before any of them had cancer, and then followed up for many years. These studies showed twice as much lung cancer in the group with the lowest plasma carotene, compared with those with the highest level. It looked as if having more of these antioxidants might be a very good thing. cancer (but matched for age, social cla.s.s, gender and so on), and it was found that the cancer-free subjects had higher plasma carotene. There were also 'prospective cohort studies', in which people were cla.s.sified by their plasma carotene level at the beginning of the study, before any of them had cancer, and then followed up for many years. These studies showed twice as much lung cancer in the group with the lowest plasma carotene, compared with those with the highest level. It looked as if having more of these antioxidants might be a very good thing.

Similar studies showed that higher plasma levels of antioxidant vitamin E were related to lower levels of heart disease. It was suggested that vitamin E status explained much of the variations in levels of ischaemic heart disease between different countries in Europe, which could not be explained by differences in plasma cholesterol or blood pressure.

But the editor of Nature Nature was cautious. A footnote was put onto the Peto paper which read as follows: was cautious. A footnote was put onto the Peto paper which read as follows: Unwary readers (if such there are) should not take the accompanying article as a sign that the consumption of large quant.i.ties of carrots (or other dietary sources of (3-carotene) is necessarily protective against cancer. Unwary readers (if such there are) should not take the accompanying article as a sign that the consumption of large quant.i.ties of carrots (or other dietary sources of (3-carotene) is necessarily protective against cancer.

It was a very prescient footnote indeed.

The antioxidant dream unravels Whatever the shrill alternative therapists may say, doctors and academics have an interest in chasing hints that could bear fruit, and compelling hypotheses like these-which could save millions of lives-are not taken lightly. These studies were acted upon, with many huge trials of vitamins set up and run around the world. There's also an important cultural context for this rush of activity which cannot be ignored: it was the tail end of the golden age of medicine. Before 1935 there weren't too many effective treatments around: we had insulin, liver for iron deficiency anaemia, and morphine-a drug with superficial charm at least-but in many respects, doctors were fairly useless. Then suddenly, between about 1935 and 1975, science poured out a constant stream of miracles.

Almost everything we a.s.sociate with modern medicine happened in that time: treatments like antibiotics, dialysis, transplants, intensive care, heart surgery, almost every drug you've ever heard of, and more. As well as the miracle treatments, we really were finding those simple, direct, hidden killers that the media still pine for so desperately in their headlines. Smoking, to everybody's genuine surprise-one single risk factor-turned out to cause almost all lung cancer. And asbestos, through some genuinely brave and subversive investigative work, was shown to cause mesothelioma.

The epidemiologists of the 1980s were On a roll, and they believed that they were going to find lifestyle causes for all the major diseases of humankind. A discipline that had got cracking when John Snow took the handle off the Broad Street pump in 1854, terminating that pocket of the Soho cholera epidemic by cutting off the supply of contaminated water (it was a bit more complicated than that, but we don't have the time here) was going to come into its own. They were going to identify more and more of these one-to-one correlations between exposures and disease, and, in their fervent imaginations, with simple interventions and cautionary advice they were going to save whole nations of people. This dream was very much not realised, as it turned out to be a bit more complicated than that. were On a roll, and they believed that they were going to find lifestyle causes for all the major diseases of humankind. A discipline that had got cracking when John Snow took the handle off the Broad Street pump in 1854, terminating that pocket of the Soho cholera epidemic by cutting off the supply of contaminated water (it was a bit more complicated than that, but we don't have the time here) was going to come into its own. They were going to identify more and more of these one-to-one correlations between exposures and disease, and, in their fervent imaginations, with simple interventions and cautionary advice they were going to save whole nations of people. This dream was very much not realised, as it turned out to be a bit more complicated than that.

Two large trials of antioxidants were set up after Peto's paper (which rather gives the lie to nutritionists' claims that vitamins are never studied because they cannot be patented: in fact there have been a great many such trials, although the food supplement industry, estimated by one report to be worth over $50 billion globally, rarely deigns to fund them). One was in Finland, where 30,000 partic.i.p.ants at high risk of lung cancer were recruited, and randomised to receive either -carotene, vitamin E, or both, or neither. Not only were there more lung cancers among the people receiving the supposedly protective -carotene supplements, compared with placebo, but this vitamin group also had more deaths overall, from both lung cancer and heart disease.

The results of the other trial were almost worse. It was called the 'Carotene and Retinol Efficacy Trial', or 'CARET', in honour of the high p-carotene content of carrots. It's interesting to note, while we're here, that carrots were the source of one of the great disinformation coups of World War II, when the Germans couldn't understand how our pilots could see their planes coming from huge distances, even in the dark. To stop them trying to work out if we'd invented anything clever like radar (which we had), the British instead started an elaborate and entirely made-up nutritionist rumour. Carotenes in carrots, they explained, are transported to the eye and converted to retinal, which is the molecule that detects light in the eye (this is basically true, and is a plausible mechanism, like those we've already dealt with): so, went the story, doubtless with much chortling behind their excellent RAF moustaches, we have been feeding our chaps huge plates of carrots, to jolly good effect.

Anyway. Two groups of people at high risk of lung cancer were studied: smokers, and people who had been exposed to asbestos at work. Half were given 3-carotene and vitamin A, while the other half got placebo. Eighteen thousand partic.i.p.ants were due to be recruited throughout its course, and the intention was that they would be followed up for an average of six years; but in fact the trial was terminated early, because it was considered unethical to continue it. Why? The people having the antioxidant tablets were 46 per cent more likely to die from lung cancer, and 17 per cent more likely to die of any cause,* than the people taking placebo pills. This is not news, hot off the presses: it happened well over a decade ago.

- I have deliberately expressed this risk in terms of the 'relative risk increase', as part of a dubious in-joke with myself. You will learn about this on page 240. - I have deliberately expressed this risk in terms of the 'relative risk increase', as part of a dubious in-joke with myself. You will learn about this on page 240.

Since then the placebo-controlled trial data on antioxidant vitamin supplements has continued to give negative results. The most up-to-date Cochrane reviews of the literature pool together all the trials on the subject, after sourcing the widest possible range of data using the systematic search strategies described above (rather than 'cherry-picking' studies to an agenda): they a.s.sess the quality of the studies, and then put them all into one giant spreadsheet to give the most accurate possible estimate of the risks of benefits, and they show that antioxidant supplements are either ineffective, or perhaps even actively harmful.

The Cochrane review on preventing lung cancer pooled data from four trials, describing the experiences of over 100,000 partic.i.p.ants, and found no benefit from antioxidants, and indeed an increase in risk of lung cancer in partic.i.p.ants taking -carotene and retinol together. The most up-to-date systematic review and meta-a.n.a.lysis on the use of antioxidants to reduce heart attacks and stroke looked at vitamin E, and separately 0-carotene, in fifteen trials, and found no benefit for either. For -carotene, there was a small but significant increase in death.

Most recently, a Cochrane review looked at the number of deaths, from any cause, in all the placebo-controlled randomised trials on antioxidants which have ever been performed (many of which looked at quite high doses, but perfectly in line with what you can buy in health-food stores), describing the experiences of 230,000 people in total. This showed that overall, antioxidant vitamin pills do not reduce deaths, and in fact they may increase your chance of dying.

Where does all this leave us? There was an observed correlation between low blood levels of these antioxidant nutrients and a higher incidence of cancer and heart disease, and a plausible mechanism for how they could have been preventive: but when you gave them as supplements, it turned out that people were no better off, or were possibly more more likely to die. That is, in some respects, a shame, as nice quick fixes are always useful, but there you go. It means that something funny is going on, and it will be interesting to get to the bottom of it and find out what. likely to die. That is, in some respects, a shame, as nice quick fixes are always useful, but there you go. It means that something funny is going on, and it will be interesting to get to the bottom of it and find out what.

More interesting is how uncommon it is for people even to be aware of these findings about antioxidants. There are various reasons why this has happened. Firstly, it's an unexpected finding, although in that regard antioxidants are hardly an isolated case. Things that work in theory often do not work in practice, and in such cases we need to revise our theories, even if it is painful. Hormone replacement therapy seemed like a good idea for many decades, until the follow-up studies revealed the problems with it, so we changed our views. And calcium supplements once looked like a good idea for osteoporosis, but now it turns out that they probably increase the risk of heart attacks in older women, so we change our view.

It's a chilling thought that when we think we are doing good, we may actually be doing harm, but it is one we must always be alive to, even in the most innocuous situations. The paediatrician Dr Benjamin Spock wrote a record-breaking best-seller called Baby and Child Care Baby and Child Care, first published in 1946, which was hugely influential and largely sensible. In it, he confidently recommended that babies should sleep on their tummies. Dr Spock had little to go on, but we now know that this advice is wrong, and the apparently trivial suggestion contained in his book, which was so widely read and followed, has led to thousands, and perhaps even tens of thousands, of avoidable cot deaths. The more people are listening to you, the greater the effects of a small error can be. I find this simple anecdote deeply disturbing.

But of course, there is a more mundane reason why people may not be aware of these findings on antioxidants, or at least may not take them seriously, and that is the phenomenal lobbying power of a large, sometimes rather dirty industry, which sells a lifestyle product that many people feel pa.s.sionately about. The food supplement industry has engineered itself a beneficent public image, but this is not borne out by the facts. Firstly, there is essentially no difference between the vitamin industry and the pharmaceutical and biotech industries (that is one message of this book, after all: the tricks of the trade are the same the world over). Key players include companies like Roche and Aventis; BioCare, the vitamin pill company that media nutritionist Patrick Holford works for, is part-owned by Elder Pharmaceuticals, and so on. The vitamin industry is also-amusingly-legendary in the world of economics as the setting of the most outrageous price-fixing cartel ever doc.u.mented. During the 1990s the main offenders were forced to pay the main offenders were forced to pay the largest criminal fines ever levied in legal history the largest criminal fines ever levied in legal history-$1.5 billion in total-after entering guilty pleas with the US Department of Justice and regulators in Canada, Australia and the European Union. That's quite some cosy cottage industry.

Whenever a piece of evidence is published suggesting that the $50-billion food supplement pill industry's products are ineffective, or even harmful, an enormous marketing machine lumbers into life, producing spurious and groundless methodological criticisms of the published data in order to muddy the waters-not enough to be noteworthy in a meaningful academic discussion, but that is not their purpose. This is a well-worn risk-management tactic from many industries, including those producing tobacco, asbestos, lead, vinyl chloride, chromium and more. It is called 'manufacturing doubt', and in 1969 one tobacco executive was stupid enough to commit it to paper in a memo: 'Doubt is our product,' he wrote, 'since it is the best means of competing with the 'body of fact' that exists in the minds of the general public. It is also the means of establis.h.i.+ng a controversy.'

n.o.body in the media dares to challenge these tactics, where lobbyists raise sciencey-sounding defences of their products, because they feel intimidated, and lack the skills to do so. Even if they did, there would simply be a confusing and technical discussion on the radio, which everyone would switch off, and at most the consumer would hear only 'controversy': job done.

I don't think that food supplement pills are as dangerous as tobacco-few things are-but it's hard to think of any other kind of pill where research could be published showing a possible increase in death, and industry figures would be wheeled out and given as easy a ride as the vitamin companies' employees are given when papers are published on their risks. But then, of course, many of them have their own slots in the media to sell their wares and their world view.

The antioxidant story is an excellent example of how wary we should be of blindly following hunches based on laboratory-level and theoretical data, and naively a.s.suming, in a reductionist manner, that this must automatically map onto dietary and supplement advice, as the media nutritionists would have us do. It is an object lesson in what an unreliable source of research information these characters can be, and we would all do well to remember this story the next time someone tries to persuade us with blood test data, or talk about molecules, or theories based on vast, interlocking metabolism diagrams, that we should buy their book, their wacky diet, or their bottle of pills.

More than anything it ill.u.s.trates how this atomised, overcomplicated view of diet can be used to mislead and oversell. I don't think it's melodramatic to speak of people disempowered and paralysed by confusion, with all the unnecessarily complex and conflicting messages about food. If you're really worried, you can buy Fruitella Plus with added vitamins A, C, E and calcium, and during Christmas 2007 two new antioxidant products came on the market, the ultimate expression of how nutritionism has perverted and distorted our common sense about food. Choxi+ is milk chocolate with 'extra antioxidants'. The Daily Mirror Daily Mirror says it's 'too good to be true'. It's 'chocolate that is good for you, as well as seductive', according to the says it's 'too good to be true'. It's 'chocolate that is good for you, as well as seductive', according to the Daily Telegraph Daily Telegraph. 'Guilt free', says the Daily Mail Daily Mail: it's 'the chocolate bar that's 'healthier' than 5lb of apples'. The company even 'recommends' two pieces of its chocolate a day. Meanwhile, Sainsbury's is promoting Red Heart wine-with extra antioxidants-as if drinking the stuff was a duty to your grandchildren.

If I was writing a lifestyle book it would have the same advice on every page, and you'd know it all already. Eat lots of fruit and vegetables, and live your whole life in every way as well as you can: exercise regularly as part of your daily routine, avoid obesity, don't drink too much, don't smoke, and don't get distracted from the real, basic, simple causes of ill health. But as we will see, even these things are hard to do on your own, and in reality require wholesale social and political changes.

7 Dr Gillian McKeith PhD

I'm going to push the boat out here, and suggest that since you've bought this book you may already be harbouring some suspicions about multi-millionaire pill entrepreneur and clinical nutritionist Gillian McKeith (or, to give her full medical t.i.tle: Gillian McKeith).

She is an empire, a prime-time TV' celebrity, a best-selling author. She has her own range of foods and mysterious powders, she has pills to give you an erection, and her face is in every health food store in the country. Scottish Conservative politicians want her to advise the government. The Soil a.s.sociation gave her a prize for educating the public. But to anyone who knows even the slightest bit about science, she is a joke.

The most important thing to recognise is that there is nothing new here. Although the contemporary nutritionism movement likes to present itself as a thoroughly modern and evidence-based enterprise, the food-guru industry, with its outlandish promises, moralising and s.e.xual obsessions, goes back at least two centuries.

Like our modern food gurus, the historical figures of nutritionism were mostly enthusiastic lay people, and they all claimed to understand nutritional science, evidence and medicine better than the scientists and doctors of their era. The advice and the products may have s.h.i.+fted with prevailing religious and moral notions, but they have always played to the market, be it puritan or liberal, New Age or Christian.

Graham crackers are a digestive biscuit invented in the nineteenth century by Sylvester Graham, the first great advocate of vegetarianism and nutritionism as we would know it, and proprietor of the world's first health food shop. Like his descendants today, Graham mixed up sensible notions-such as cutting down on cigarettes and alcohol-with some other, rather more esoteric, ideas which he concocted for himself. He warned that ketchup and mustard, for example, can cause 'insanity'.

I've got no great beef with the organic food movement (even if its claims are a little unrealistic), but it's still interesting to note that Graham's health food store-in 1837-heavily promoted its food as being grown according to 'physiological principles' on 'virgin unvitiated soil'. By the retro-fetis.h.i.+sm of the time, this was soil which had not been 'subjected' to 'overstimulation'...by manure.

Soon these food marketing techniques were picked up by more overtly puritanical religious zealots like John Harvey Kellogg, the man behind the cornflake. Kellogg was a natural healer, anti-masturbation campaigner, and health food advocate, promoting his granola bars as the route to abstinence, temperance and solid morals. He ran a sanatorium for private clients, using 'holistic' techniques, including Gillian McKeith's favourite, colonic irrigation.

Kellogg was also a keen anti-masturbation campaigner. He advocated exposing the tissue on the end of the p.e.n.i.s, so that it smarted with friction during acts of self-pollution (and you do have to wonder about the motives of anyone who thinks the problem through in that much detail). Here is a particularly enjoyable pa.s.sage from his Treatment for Self-Abuse and its Effects Treatment for Self-Abuse and its Effects (1888), in which Kellogg outlines his views on circ.u.mcision: (1888), in which Kellogg outlines his views on circ.u.mcision: The operation should be performed by a surgeon without administering an anesthetic, as the brief pain attending the operation will have a salutary effect upon the mind, especially if it be connected with the idea of punishment. In females, the author has found the application of pure carbolic acid to the c.l.i.toris an excellent means of allaying the abnormal excitement. The operation should be performed by a surgeon without administering an anesthetic, as the brief pain attending the operation will have a salutary effect upon the mind, especially if it be connected with the idea of punishment. In females, the author has found the application of pure carbolic acid to the c.l.i.toris an excellent means of allaying the abnormal excitement.

By the early twentieth century a man called Bernard Macfadden had updated the nutritionism model for contemporary moral values, and so became the most commercially successful health guru of his time. He changed his Christian name from Bernard to Bernarr, because it sounded more like the roar of a lion (this is completely true), and ran a successful magazine called Physical Culture Physical Culture, featuring beautiful bodies doing healthy things. The pseudoscience and the posturing were the same, but he used liberal s.e.xuality to his advantage, selling his granola bars as a food that would promote a muscular, thrusting, l.u.s.tful lifestyle in that decadent rush that flooded the populations of the West between the wars.*

- Interestingly, Macfadden's food product range was complemented by a more unusual invention of his own. The 'p.e.n.i.scope was a popular suction device designed to enlarge the male organ which is still used by many today, in a modestly updated form. Since this may be your only opportunity to learn about the data on p.e.n.i.s enlargement, it's worih mentioning that there is, in fact, some evidence that stretching devices can increase p.e.n.i.s size. Gillian McKeith's 'Wild Pink' and 'h.o.r.n.y Goat Weed' s.e.x supplement pills, however, sold for 'maintaining erections, o.r.g.a.s.mic pleasure, e.j.a.c.u.l.a.t.i.o.n...lubrication, satisfaction, and arousal', could claim no such evidence for efficacy (and in 2007, after much complaining, these seedy and rather oldfas.h.i.+oned products were declared illegal by the Medicines and Healthcare Products Regulatory Agency, or MHRA). I mention this only because, rather charmingly, it means that Macfadden's p.e.n.i.scope may have a better evidence base for its claims than either his own food products or McKeith's h.o.r.n.y Goat p.e.n.i.s pills. - Interestingly, Macfadden's food product range was complemented by a more unusual invention of his own. The 'p.e.n.i.scope was a popular suction device designed to enlarge the male organ which is still used by many today, in a modestly updated form. Since this may be your only opportunity to learn about the data on p.e.n.i.s enlargement, it's worih mentioning that there is, in fact, some evidence that stretching devices can increase p.e.n.i.s size. Gillian McKeith's 'Wild Pink' and 'h.o.r.n.y Goat Weed' s.e.x supplement pills, however, sold for 'maintaining erections, o.r.g.a.s.mic pleasure, e.j.a.c.u.l.a.t.i.o.n...lubrication, satisfaction, and arousal', could claim no such evidence for efficacy (and in 2007, after much complaining, these seedy and rather oldfas.h.i.+oned products were declared illegal by the Medicines and Healthcare Products Regulatory Agency, or MHRA). I mention this only because, rather charmingly, it means that Macfadden's p.e.n.i.scope may have a better evidence base for its claims than either his own food products or McKeith's h.o.r.n.y Goat p.e.n.i.s pills.

More recently there was Dudley J. LeBlanc, a Louisiana Senator and the man behind Hadacol ('I had'da call it something'). It cured everything, cost $100 a year for the recommended dose, and to Dudley's open amazement, it sold in millions. 'They came in to buy Hadacol,' said one pharmacist, 'when they didn't have money to buy food. They had holes in their shoes and they paid $3.50 for a bottle of Hadacol.'

LeBlanc made no medicinal claims, but pushed customer testimonials to an eager media. He appointed a medical director who had been convicted in California of practising medicine with no licence and no medical degree. A diabetic patient almost died when she gave up insulin to treat herself with Hadacol, but n.o.body cared. 'It's a craze. It's a culture. It's a political movement,' said Newsweek Newsweek.