Georg Ivanovas From Autism to Humanism - systems theory in medicine

2.8 Complexity

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a) the nontrivial nature of nutrition

Bircher-Benner (1867-1939) observed at the beginning of the 20th century that a healthy diet was helpful in many diseases. For rheumatism he introduced a diet without animal products. This should last one month, at least. Until recently this was regarded as pure mysticism.

Lately it could be proved that the archidonic acid plays a major role as a mediator of inflammation in RA. It is mainly present in animal fats, and, as Bircher-Benner had already observed, the depots of archidonic acid are depleted after about four weeks leading to a decline of the inflammatory process (Sandmann/Ollenschläger 1996). Bircher-Benner’s only mistake was to attribute the effect to animal protein and not to animal fat. But this is of no importance under natural conditions, that is, if the treatment is a healthy diet.

But the physiological model did not change the therapeutic attitude. If any drug would have had the same anti-inflammatory potency as the abstinence of animal fats the result would have been published in all major medical journals. It would be seen as a medical breakthrough and would be promoted, especially by the producing pharmaceutic company. But as the therapy is not drug based it is rather neglected.

This is one aspect. Another aspect is that a diet rich in animal fats does not only rise archidonic acid, but other parameters as well, such as cholesterol (McDougall et al 1995) and it even increases the probability to develop type 2 diabetes (Song et al 2004). Under the current paradigm any of these problems is treated with a different drug.

Complexity arises here on two levels. One is that a diet low in animal fat and protein is helpful in ‘unrelated’ diseases (Fung et al 2008). The other is that value decisions influence the evidence and knowledge of physicians who might use different therapeutic strategies. A first order question would be to decide whether Atorvastation is effective in the treatment of hypercholesterinaemia. It is a second order question (chap 4.3) to decide what kind of therapy should be chosen (drug vs. diet).

There are, of course, also studies showing the value of meat. In an – obviously extremely biased study – 544 children, who had an average age of seven years, were given two spoonfuls (about 60 grams) of minced beef each day to supplement their ordinary diet. Other groups were given a cup of milk, an equivalent amount of energy as vegetable oil, or no supplement at all. In the group without meat, children grow up smaller, less strong and less intelligent. The authors concluded that the benefits were so clear that denying children meat would be unethical (Allen 2003).

With nutrition and ‘nutritionism’ (the treatment with defined substances or the supplementation of water, flour or other products) we enter a rather dark chapter of medicine. It has a lot to do with financial interests, lobbyism and the dependency of governments on pressure groups (Pollan 2007). But nutritionism is also an expression of reductionism. Food research found and still finds numerous ‘important’ factors. To administer all of them in a natural way, that is, through food, would necessarily lead to obesity. What can be done? According to the current paradigm the ingredients are given purified as a defined drug, from fibres, over vitamins to essential elements. But this is a flawed process. First of all, we have no idea what the human really needs. Continuously new substances seemingly important for a healthy diet are detected. Second, there is little evidence what happens, if all the substances are given together, or if certain substances are not included. As a result, everything is promoted as healthy and given plenty oft it. This makes logically no sense, in the first place, and newer findings suggest that this strategy is not really beneficial. Vitamins and supplements seem to have the tendency to do more harm than good (Palmer et al 2003; US Preventive Services Task Force 2003). Here are two deliberate examples:

That does not mean that a nutrition rich in these substances is ineffective or harmful. These studies only prove that the linear concept of nutritionism is not appropriate in dealing with the complexity of nutrition.

Another example is the current fashions of folic acid. Its effect has been established in many trials. Folic acid became a widespread supplement. In the US and Canada the flour is enriched. This is associated with a decline in spina bifida of 78%, from 4,36 to 0,96 in thousand births (Liu et al 2004b). This is, in fact, impressing even in absolute numbers. However, the result was established in a region in Canada with a high incidence of spina bifida and with a growing incidence since the seventies. In Canada as a whole the reduction was less, from 1,16 per 1000 births to 0,75 per 1000 births. We do not know why in one special region of Canada spina bifida became so high. If it was not a lack of folic acid, the ‘cause’ might lead to other harmful effects in the humans concerned and fortification would lead to a phenomenon called suppression (chap. 6.8). The question is also why in other regions (in a different context) folic acid should be supplemented.

Nobody knows the long term effects of a consequent folic acid substitution, especially as the substituted form pteroylmonoglutamate (PGA) does not occur in nature (Lucock 2004).

As folate is “involved in so many of life's fundamental processes nobody knows the long term effects of exposing whole populations to the unnatural folate. There is thus great potential for good, some possibility of harm, and much uncertainty. The question of fortifying foods inevitably becomes highly political, and the politics of nutrition are just as complex as the science” (Smith 2004a).

The amount of PGA administered with folic acid fortification exceeds the ability of the liver to metabolise it. Unmetabolised folic acid floats around the blood stream which might have severe side effects, probably for people being treated for leukaemia and arthritis, women being treated for ectopic pregnancies and men with a family history of bowel cancer (Anthony et al 2007). It also has been found to increase the risk of re-stenosis after coronary stenting – against expectations according to physiological models (Lange et al 2004). Some even fear a genetical selection with negative consequences for the future (Lucock/Yates 2005). Also all cause mortality was about a fifth greater in women with high doses of supplemental folate, and the risk of deaths attributable to breast cancer was twice as great (Charles et al 2004). Another study found that the incidence of breast cancer was lower in these women who drank regularly alcohol and took folate (Baglietto et al 2005). An accidental correlation or a causal connection?

In this atmosphere of autistic – undisciplined thinking many different opinions prevail as demonstrated by BMJ. They range from: “Folic acid fortification remains an urgent health priority” (Oakley/Mandel 2004), to: “Let food be thy medicine and medicine be thy food” (Smith 2004a).

The nutrition discourse might become sounder when certain epistemological principles are applied. First, the context under which a certain intervention is investigated has to be defined more clearly. This shall be demonstrated with the following example: It has been shown that multivitamin preparations slow down the progression of HIV- patients receiving antiretroviral drugs (ARV) in an African region where patients have no safe water or food (Fawzi et al 2004). There is, however, no hint that multivitamins are helpful under any other circumstances. An equivalent therapy would be to provide better social conditions and some Africans demand: "If you give us ARVs, please give us food, just food." (Marston /de Cock 2004). Do not give multivitamins. Again, we see a second order problem, as there is no reason, at first, to choose the multivitamin or the food option. Is the aim to treat HIV? To improve general health? To promote certain therapies? At which cost? There are also serious voices expressing the concern that giving food only prolongs the misery of Africans. Are their arguments applicable here? This is a complex situation in many regards.

Mediterranean diet is attributed to health and longevity. Reductionist research suggests many factors, from essential fatty acids to vitamins to be ‘causal’ for this finding. But, who ever saw the practical life in Mediterranean villages before 1970 knows the most important characteristic of the Mediterranean diet: there was very little to eat. A proverb says: A donkey would starve, but two Greeks can live from it. And these people with an already a low intake of so many factors that current science regards as essential also fasted several times a year out of religious reasons. This might even be the main ‘cause’ for the effectivity of the Mediterranean diet (Sarri et al 2004), as animal research claims that calorie restriction is the main measure to induce health and longevity (Roth et al 2004). This reflection refutes already simple linear assumption, but the posed problem is even more complex.

In malnourished rats with a severe lack of vitamins the symptoms of avitaminosis vanished if certain components are further reduced and reappeared if the components are given again (Kollath: 38). Or: In rats with experimental rickets the administration of Calcium might lead to more severe symptoms, even in presence of vitamin D (Kollath: 161). That is, in malnutrition a supplement thought of to be beneficial might be harmful. Unexpected events appear where a lack of events or the vanishing of events was expected.

Kollath’s results remind a little bit the ‘excesses’ described by Sacks in neurology (chap. 2.2). Unexplainable reactions arise all over in our medical practice – when looked at carefully enough and are due to the nonlinearity and unpredictability of complex adaptive systems.

When we go back to the malnourished Africans suffering from AIDS and receiving multivitamin drugs or to the women drinking alcohol and taking folic acid, and ask whether these interventions are helpful, the answer is rather simple: we just do not know. Reductionist experiments and statistical trails are not able to give decisive answers.

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