The exaggeration that is “food as medicine”

Let food be thy medicine and medicine be thy food.

Who said anything about medicine? Let’s eat!

Who hasn’t seen or heard Hippocrates’ famous quote about letting food be your medicine and your medicine your food? If you have Facebook friends who are the least bit into “natural” medicine or living, you’ve almost certainly come across it in your feed, and if you’re a skeptic who pays the least bit of attention to what’s going on in the quackosphere you will almost certainly have seen it plastered on a picture as a meme, either using a picture of Hippocrates or pictures of plates of green, leafy vegetables, or both. I like to view the worship of “food as medicine,” to cite Hippocrates (if he or his followers even said it), as one of the best examples out there of the logical fallacy known as the appeal to antiquity; in other words, the claim that if something is ancient and still around it must be correct (or at least there must be something to it worth considering).

Of course, just because an idea is old doesn’t mean it’s good, any more than just because Hippocrates said it means it must be true. Hippocrates was an important figure in the history of medicine because he was among the earliest to assert that diseases were caused by natural processes rather than the gods and because of his emphasis on the careful observation and documentation of patient history and physical findings, which led to the discovery of physical signs associated with diseases of specific organs. However, let’s not also forget that Hippocrates and his followers also believed in humoral theory, the idea that all disease results from an imbalance of the “four humors.” It’s also amusing to note that this quote by Hippocrates is thought to be a misquote, as it is nowhere to be found in the more than 60 texts known as The Hippocratic Corpus (Corpus Hippocraticum).

As Diana Cardenes points out:

But Hippocratic doctors clearly saw a difference between food and medicines. In fact, food was considered as a material that could be assimilated after digestion (e.g. the air was also food) and converted into the substance of the body. For example, food was converted into the different parts of the body such as muscles, nerves, etc. By contrast, the concept of medicines at the time was a product which was able to change the body’s own nature (in terms of humor quality or quantity) but not be converted into the body’s own substance. Thus a food wasn’t considered a medicine. A possible root of the food-medicine confusion is the following cryptic phrase found in the work On Aliment: “In food excellent medication, in food bad medication, bad and good relatively”.³ This text is nowadays attributed to the Hellenistic period, but was considered to be Hippocratic in Antiquity by Galenus in particular.

Now, it is certainly true that Hippocrates and his followers used diet to treat many illnesses, it’s not really clear what sort of success they had. However, this ancient idea that virtually all disease could be treated with diet, however much or little it was embraced by Hippocrates, has become an idée fixe in alternative medicine, so much so that it leads its proponents twist new science (like epigenetics) to try to fit it into a framework where diet rules all, often coupled with the idea that doctors don’t understand or care about nutrition and it’s big pharma that’s preventing the acceptance of dietary interventions. That thinking also permeates popular culture, fitting in very nicely with an equally ancient phenomenon, the moralization of food choices (discussed ably by Dr. Jones a month ago).

Let food be thy medicine and medicine be thy food?

This idée fixe that diet can fix everything even leads respectable doctors to write stories that are in some ways balanced but in other ways maddeningly credulous, like this story published last week in The New Republic by Dr. Sushrut Jangi, an Instructor in Medicine at Beth Israel Deaconess Medical Center, entitled “The Nutrition Gap.” You can tell right away that there are going to be…problems…with the article by its summary:

In America, where the pharmaceutical industry is king, many doctors dismiss nutritional therapies as quack medicine. But many patients disagree, and they’re taking matters into their own hands—sometimes to the detriment of their health. Can food cure disease? And are doctors ready to think outside the pillbox?

Yes, the trope is there, that pharma rules all and nutritional therapies are dismissed as quackery. Of course, one has to distinguish between different nutritional therapies because many nutritional “therapies” promoted by alternative medicine are quackery. Unfortunately, Dr. Jangi can’t quite bring himself to do that properly. Before I get to the most egregious examples of that failing, first I must in all fairness acknowledge one thing that he gets right, and that’s his pointing out that there is a “nutrition gap in America, a disconnect between how patients and clinicians perceive diet,” a gap that has “been largely filled by opportunists like Gwyneth Paltrow and Dr. Mehmet Oz, obscuring many meaningful advances in understanding how nutrition influence health.” Right on! There are so many quack nutritional therapies out there, so many diets, so many claims, and so little science to back them up that it’s no wonder that it’s hard for a nutritional therapy to break through.

As is usually the case with articles like this, Jangi begins with a human interest anecdote, about a woman who is identified only as Helen who unexpectedly developed multiple myeloma at an age far younger than the disease usually strikes. Multiple myeloma is a cancer of plasma cells, immune cells that make antibodies. Because of this, as the disease progresses, multiple myeloma can cause kidney failure due to it secretion of excess antibodies and components of antibodies, proteins that can damage the kidney at high concentrations. It can also cause bone pain and fractures due to its secretion of a factor that activates cells that break down bone. Life expectancy can vary considerably, depending on age and how aggressive the tumor is. Survival rates have been increasing steadily, however, over the last 15 years, particularly in younger patients like Helen. Indeed, given improvements in treatment, after the initial treatment with chemotherapy, it is possible that one day in the not too distant future multiple myeloma could be treated as a chronic disease, as Dr. Jangi himself points out.

If you’ve been reading this blog and stories like this long enough, you’ll know what’s coming next:

…Helen began to wonder if this was her fault—if she had done something wrong. Still a young woman, married, employed, with two children at home, she exercised regularly, never smoked, rarely drank, and hardly ever got a cold. What in my life, she wondered, was to blame?

Helen’s doctors encouraged her to look forward. Her hematologist, at Massachusetts General Hospital in Boston, explained that her bone marrow had become overgrown by cancerous immune cells, and that the treatment required high doses of chemotherapy. The doctor described the litany of consequences from the powerful medications: hair loss, infections, and a probable bone marrow transplantation. Helen sat in the clinic of the busy Boston hospital, surrounded by expert oncologists with their novel clinical trials in dismay. She faced either the threat of a serious, potentially life-limiting disease or a heavy-duty regimen of drugs that she felt would similarly poison her body. “There had to be another way,” she said. “I didn’t want chemotherapy.”

Helen did choose another way, based on her suspicion about why she had fallen sick in the first place. “It had to be my diet,” she told me. So, against all professional medical advice, she started an experiment on herself.

Humans crave explanation, as I have pointed out so many times before. When someone as young as Helen is diagnosed with a life-threatening disease that’s pretty uncommon to begin with but very uncommon in patients her age, the natural thing for her to do is to look for possible explanations, just as, for example, the mother of Tiffany Frantz did when Tiffany was diagnosed at age 21 with breast cancer. She ended up incorrectly blaming her daughter’s keeping her cell phone in her bra. Also, as I’ve said so many times before about so many other patients, I don’t blame Helen for being afraid. High dose chemotherapy followed by stem cell rescue (i.e., a bone marrow transplantation) is a brutal, brutal regimen that requires prolonged hospitalization and guarantees some nasty side effects. I understand, at least as much as anyone who hasn’t himself been faced with such a choice. However, there is little good evidence connecting diet with elevated risk for multiple myeloma, other than one study in which risk correlates with obesity and negatively correlates with cruciferous vegetables and fish. In such an uncommon disease, rare in her age group, the likelihood that the small absolute risk reduction from a dietary change would have made any difference is exceedingly small. In any case, before too long we learn that Helen headed for the Mexican border and went to Baja to begin “nutritional therapy for her cancer.” That therapy? You guessed it: Gerson.

Here’s where Jangi goes off the rails. For one thing, I hate it when Gerson therapy is just described as “nutritional” therapy or “dietary therapy.” So vague. So bland. It doesn’t tell you just exactly what the Gerson protocol involves. It’s something I’ve discussed in detail; so I don’t feel a need to go into great detail, but let’s just briefly recap what the Gerson protocol involves:

• Thirteen glasses of fresh, raw carrot/apple and green-leaf juices prepared hourly from fresh, organic fruits and vegetables.
• Three full plant-based meals, freshly prepared from organically grown fruits, vegetables and whole grains. A typical meal will include salad, cooked vegetables, baked potatoes, Hippocrates soup and juice.
• Fresh fruit and vegetables available at all hours for snacking, in addition to the regular diet.

The Gerson therapy requires enormous amounts of these fruits and vegetables to make these juices and meals, up to 20 lbs. per day or even more, as well as these supplements:

• Potassium compound
• Lugol’s solution
• Vitamin B-12
• Thyroid hormone
• Pancreatic enzymes

To top all this off (I know, old joke), the Gerson therapy involves coffee enemas, lots and lots and lots of coffee enemas, usually five a day. To be fair, Jangi does describe some of this and how it took three weeks at the Gerson Clinic to learn the protocol, which she followed for two years. She even quoted Helen as saying, “I was actually pretty exhausted that whole time.” However, instead of making the Gerson protocol sound quacky (which it is), he makes it sound downright rational (which it isn’t). For instance, he portrays poor Max Gerson as persecuted, having come up with his idea as the “pharmaceutical industry entered its golden era”:

While in Germany, Gerson had created a regimen devoid of processed foods and had published several cases of patients forever cured of migraines, arthritis, and even forms of tuberculosis. He surprised himself most when, in 1928, a patient with cancer of the bile ducts asked for his diet. Initially, he refused, but caved to her persistence. Six months later, he announced her cure. Two more cancer cures followed.

Dr. Jangi desperately needs to read Peter Moran’s excellent deconstruction of Max Gerson’s “50 cases” that he used as evidence that his protocol could cure cancer. Seriously. There is no excuse to portray Gerson’s nonsense this way, no excuse at all, much less to go on to write:

But Gerson ran into resistance when he began applying his dietary regimen at Gotham Hospital in New York City in the 1940s. Suspicious of his methods, the Journal of the American Medical Association asked for copies of Gerson’s data. When he failed to provide the reputed medical journal the requested information, the editors responded. In a widely read 1946 JAMA article, editor Dr. Morris Fishbein (who actually made much of his reputation busting medical flimflammery) denounced the Gerson diet as lacking significant evidence in the treatment of cancer. In a follow-up editorial in 1949, Fishbein published a criticism of Gerson’s approach in a review entitled “Frauds and Fables,” labeling Gerson a charlatan.

Gee, Jangi writes this as though what Dr. Fishbein did were a bad thing! Or that it were a bad thing that the American Medical Association and the American Cancer Society blacklisted the Gerson regimen and insurance companies stopped providing compensation for the therapy! It wasn’t. None of it was. In fact, the whole tone of Dr. Jangi’s article is irritating to the extreme to anyone who knows the actual history of Max Gerson and his “alternative cancer cure,” painting Gerson as an unfairly persecuted visionary who was driven unjustly from his country. Heck, Jangi even uses the word “persecution” when he observes that after Gerson’s death his daughter Charlotte “founded a place to administer his therapies at a hospital near Tijuana, free from the persecution of American medical societies.” She’s still there, decades later. None of this stops Jangi from making Gerson sound like the brave maverick doctor persecuted by the medical establishment who just didn’t see his genius. Oh, sure, ten patients were admitted to hospitals in Southern California with Campylobacter fetus sepsis, believed to be a side effect of the liver injections that accompany the older versions of the therapy, none of them cured of cancer. And there were a bunch of other complications and fatalities, too, as documented in this article.

Of course, that doesn’t seem to bother Jangi as much as this:

In 1992, JAMA published a “special communication” again denouncing the therapy. “The poisons in processed foods that proponents of the Gerson therapy say cause cancer have never been identified,” they wrote, disputing the idea that a diet of fruits and vegetables could prevent the process of cancer development. “This makes the Gerson therapy impossible to accept,” they wrote.

I can’t get an article from JAMA that old through my institutional subscription, so I can’t evaluate it for myself in context. However, the many criticisms of the Gerson protocol from that era and before that I have read generally emphasize its extreme biological implausibility given how it is based on an idea of how cancer forms from the early 1900s that had long since been shown to be incorrect; the lack of evidence, basic science or clinical trial, that it works; and the harm caused to patients. It’s well-accepted that diet can decrease the risk of certain cancers; what’s not well-accepted, mainly because there is little or no good evidence, is that dietary interventions can impact the progression and course of cancer. Remember, that is what Gerson claimed, that a radical diet, a boatload of supplements per day, and coffee enemas could cure cancer. Indeed, a deceased proponent of the Gerson protocol, Jess Ainscough, reported that over the two years she did the Gerson protocol she had consumed 8,760 glasses of juice, 1,460 baked potatoes, 1,460 bowls of Hippocrates soup, 33,580 supplements, and 174 shots of castor oil, while giving herself 2,920 coffee enemas. Two years include 730 days; so you can do the math yourself.

In other words, the reason the Gerson protocol is viewed as quackery (at least by physicians who even know what it is in the first place) is quite simple. It is quackery. Max Gerson was not some poor, misunderstood, persecuted visionary. He was a dangerous quack, and his daughter continues to carry on that quackery. Yet the average reader only gets a very minimal inkling of this possibility, if any at all, from Dr. Jangi’s article.

Food versus medicine

As much as the whole Gerson business irked me, what really frustrated me about this article is that there are some insights in there. This could have been a good article explaining to the lay public what is known and what isn’t known about nutrition and disease and why it’s difficult to evaluate such treatments. He takes a stab at that when he points out how difficult it is to do randomized controlled studies of dietary interventions because it’s almost impossible to blind them and they require one group to make a major change to their lifestyle that could take years before an effect is observed. Still, such studies have been done, such as the study of the Mediterranean diet published in the NEJM in 2013 that showed a Mediterranean diet supplemented with extra-virgin olive oil or nuts reduced the incidence of major cardiovascular events by 30% in high risk patients.

Jangi also mentions work by Gary Wu, the associate chief of research in the Division of Gastroenterology at the University of Pennsylvania, who has studied elemental diets—a regimen composed of components of food in its simplest form—as a treatment for inflammatory bowel disease. His results suggest that the therapy works almost as well as TNF inhibitors, although Jangi didn’t make a couple of important things clear. First, as far as I can tell, there has as yet not been a randomized controlled trial. The most recent clinical study by Dr. Wu I could find was a prospective observational study. He also neglects to note that these “elemental diets” are liquid diets that sometimes have to be administered through a feeding tube. They’re not exactly great as far as lifestyle goes. They’re not “normal” in the sense that they don’t allow the patient to eat what most would refer to as “real” food. They’re also nothing new. These sorts of diets have been studied in inflammatory bowel disease and other gut disorders on and off for a long time. I remember endless debates in my ICU rotations in the 1990s over whether using elemental diets, parenteral nutrition, diets with medium chain triglycerides, or various other tube feeding formulas best prevented and/or healed gut dysfunction in critically ill patients.

Oh, and Dr. Jangi falls a bit for the magical thinking so many are layering on the emerging field of epigenetics. Ugh. (Click the links if you want to see why his brief discussion of epigenetics is a misfire.) He also greatly exaggerates the promise of substances like curcumin, whose reality (in my not so humble opinion) hasn’t really lived up to the hype of several years ago, citing a seven year old article.

One area that could also have used a bit more explanation is the recent FDA guidelines about whether a human study can be conducted without an investigational new drug application (IND). It’s a topic that I might have to take the time to do an entire post about after reading the entire draft guidelines and looking up some analyses. Basically, he has a germ of a point when he writes:

But recent guidance from the FDA similarly requires that foods being tested for the management of illness also mandate submission of an IND if those foods are to be studied in humans, a significant hurdle for academics and researchers who cannot invest in such a potentially expensive gamble. Consequently, nutritional therapies have a hard time reaching the stage of serious clinical trials. They never receive the FDA’s blessings and stagnate in the dark corner of the local vitamin shop, lost to the mainstream.

On the one hand, I can understand the FDA’s rationale if the intent of the food use is to treat a disease; in that case, it is arguably being used as medicine. On the other hand, what about diets that don’t necessarily involve what the FDA refers to as “medicinal foods” (e.g., curcumin for cancer prevention or treatment), such as exclusion diets for inflammatory bowel disease, or, for that matter, the Mediterranean diet, which doesn’t include any specific single “medicinal food” but rather broad types of foods in certain proportions? One also can’t help but wonder whether this confusing morass has a lot to do with how dietary supplements were handled 20 years ago by the DSHEA of 1994? For instance, I have seen supplement manufacturers complain that these guidelines make it possible for the same supplement to be considered simultaneously a drug if it’s in a clinical trial after an IND is obtained and a supplement. Of course, I rather suspect that they doth protest a bit too much because they don’t want to do clinical trials anyway when the DSHEA lets them sell their supplements with minimal regulation. Why would they want to dive into this morass, when it could only hurt their profits? Be that as it may, requiring an IND makes sense when it’s a defined supplement or manufactured diet (such as the aforementioned elemental diet) but makes a lot less sense for diets like the Mediterranean diet.

In the end, Dr. Jangi sweeps around again to his human interest element, Helen. Happily, she is still alive and doing well six years later:

Yet her appearance, however glowing, belied her five-year struggle—her trip to Baja, to various clinics, hospitals, and rehabilitation centers; her inner conflicts between her own philosophies and those offered by conventional doctors and alternative practitioners; blood-test results that made her question her decision to forgo chemotherapy. Yet nutrition continued to be a centerpiece of her life. A volunteer at her children’s elementary school, she saw what other children were eating and worried about her own kids’ health. At home, her family followed her lead in dietary change. “Now my husband and children eat real food,” she said, citing almond-flour pancakes, oatmeal, honey, whole grain breads, bananas, berries, kale, spinach, red carrots, and grass-fed meats.

I really wish that Dr. Jangi had read a bit about these alternative cancer cure testimonials before featuring Helen so prominently. I found what is almost certainly her blog, given her timeline. It wasn’t hard, but since Dr. Jangi didn’t want to reveal who she is I will honor that. What I did learn is that she was into alternative therapy from the beginning, given that she went to her naturopath to evaluate her initial complaints that ultimately led to her being diagnosed. Thankfully for her, her naturopath was one of the more reasonable ones and noticed that a lot more was going on than he could handle. After she finished Gerson therapy (which she described as the “two hardest years of my life”), her disease was merely “stable,” as she described it, and she was clearly disappointed. In the process she had had to have all her amalgam fillings removed, which left her with extreme sensitivity to hot and cold.

So she moved on to the Gonzalez protocol, where she takes 160 supplements per day, fewer coffee enemas than the Gerson protocol, and a lot of the same other woo, given the considerable overlap between Gerson’s protocol and Dr. Gonzelez’s protocol. There’s also the usual stuff on there about how big pharma has no interest in “natural, safe, effective healing” as there is no way for them to “patent a nutritional product and reap large profits.” She also doesn’t vaccinate her children (a decision that Nicholas Gonzalez fully supported, telling her that childhood diseases “served a purpose”). Her disease has waxed and waned, and at one point it must have alarmed Gonzalez enough that he sent her to an oncologist who wanted to begin chemotherapy but was going to start her on Revlimid, a drug related to thalidomide, which has been found to be effective treating multiple myeloma. Overall, though, there are lots of posts about her IgA (she has IgA myeloma) going up and down and various dubious markers drawn by Gonzalez similarly going up and down. She keeps saying she’s getting better, but somehow the tumor never seems to go away and there’s always a story about her numbers “going in the wrong direction.” Her IgA level seems to bounce between 6,000 and 7,000. (Normal is 70-400.) The most parsimonious explanation is that Helen is fortunate enough to have an indolent tumor that is not really progressing much, despite her having a higher-risk subtype. It is, after all, known that there is a “clear heterogeneity amongst patients with myeloma as some individuals have a slow disease pace and can live decades and others have rapid disease progression, unresponsiveness to multiple therapies and short survival.”

Dr. Jangi clearly hasn’t dealt with alternative medicine cancer cure testimonials, as I have. All you have to do is to look at the comment section, where alt-med believers have descended to castigate big pharma and tout their alternative cures.

In the end, I can’t help but reiterate my disappointment. There is so much to discuss with respect to diet and cancer, but Dr. Jangi decided to structure his story around a run-of-the-mill alternative medicine cancer cure testimonial that didn’t tell anywhere near the whole story, much less enough to judge whether Helen is doing better than she should be expected to do. She is then represented as an example of a “nutrition gap” in which doctors and patients believe very different things about nutrition when in fact, all you have to do is to read her blog to see that she is an alt-med True Believer, hardly typical of the average person interested in nutrition and health. Then, the whole story is bolstered with alt med tropes that border on conspiracy mongering, in which pharmaceutical companies rule and doctors’ organizations ruthlessly suppress research into diet and health. There is promise in using dietary manipulations as medicine (“let food be your medicine”) for a variety of conditions; doctors have been doing it since Hippocrates. It does no one any favors to use a sympathetic portrait of an unfortunate alt-med true believer to stand in for the disconnect between what people think about food and health and what doctors think about it.

ADDENDUM: A nice article: The new religion: How the emphasis on ‘clean eating’ has created a moral hierarchy for food.