STANDING BEFORE YOU at this moment, I am overwhelmed
with a sense of pride and gratitude at the honor of being your President.
Although many of my predecessors have taken this opportunity to reflect on
surgical achievements, past and future, that will not be my topic today.
Today I am asking you to look with me beyond surgery. We
are going to examine that which is being overlooked by the medical field.
Please do not misunderstand me. Like you, I have a great sense of pride in
surgery that is well performed and that achieves a positive result and
relieves suffering.
Yet, even more important issues seem to face us today.
Although surgery may eradicate disease, it is hardly the optimal path to
health. Operations are looked on by patients with fear. Often pain,
disability, and some disfigurement are involved. Present day costs of
surgery are significant and contribute to a national health bill that
consumes 12% of our gross national product and threaten the foundations of
medical care as we know it today.
Surgery does not deal with the basic molecular
foundation of disease. It is a mechanical approach to a biologic problem.
For those of us who are considered experts in the areas of coronary
disease and breast, prostate, and colorectal cancer, what an embarrassment
to admit that coronary artery disease still remains the leading cause of
death of men and women in this country. Breast, prostate, and colon and
rectal cancer are still increasing in frequency. Looking beyond surgery
alternate ways to health are emerging, and we, as surgeons, providers of
health care, must more fully recognize and incorporate these alternate
ways into our own lives and those of our patients.
Although coronary artery disease remains the leading
killer in our society, it is still unknown and will never be heard of by
four of the five billion people world wide. It is strictly an illness of
Western civilization and those of other cultures who have adopted the
affluent Western lifestyle.
Let me share with you some sobering facts. Americans
consume 135 pounds of fat per year, one ton for every 15 years, and 4 tons
of fats and oils have been consumed by age 60. It is little surprise that
the body develops vascular and neoplastic illnesses when asked to contend
with that burden of fat. Simply stated, just as you need stone to build a
stone wall, you also need a specific level of cholesterol and fat in your
bloodstream to narrow and occlude your arteries with atherosclerois.
William Roberts,1 an accomplished
investigator of cardiovascular disease and the Editor of the American
Journal of Cardiology, has recently concluded in an editorial that
only one true risk factor exists in coronary artery disease, namely the
lifetime presence of a serum cholesterol level of over 150 mg/dl. With a
cholesterol level persistently below 150 mg/dl, regardless of the family
history, hypertension, obesity, smoking, maleness, and other common risk
factors, within the serum enough substrate simply does not exist to
initiate and progressively increase atherosclerosis. The risk factors can
accelerate the disease as serum cholesterol levels rise greater than 150
mg/dl.
Regularly maintaining a cholesterol level of less than
150 mg/dl makes one practically heart attack proof and insures against
further progression of the disease. In some cases this may reverse the
process of atherosclerois. In a small study, I have followed 12 persons
with severe coronary artery disease for 4 to 5 years. They have achieved
serum cholesterol levels of under 150 mg/dl through a combination of
significant dietary changes, cholesterol-lowering drugs, and stress-
reduction techniques. In all patients who have under gone follow-up
angiography, no progression of disease has been found. Coronary artery
disease investigators, Brown et al.2 in Seattle, Wash., Ornish et al.3,
and Kane et al.4 in San Francisco, Calif., and Blankenhorn et al.5 in Los
Angeles, Calif., have independently shown arrest and, in some cases,
reversal of coronary artery disease in patients who have followed
significant diet changes and/or drugs or lifestyle changes.
When such a life-threatening disease can be promptly
arrested, it is perplexing to note the continued emphasis of mechanical
measures to treat the disease, that is, lasers, angioplasty, and bypass
surgery. When creative nutritional therapy is coupled to the usual medical
therapy, equivalent results can be achieved. This approach is safer, less
costly, and less immediately life threatening. Granted, one must always
take into account the fact that a significant number of persons will
simply fall through this type of safety net and may require urgent
invasive techniques to avoid an otherwise life-threatening situation.
Presently, Western civilization has the luxury of
complete knowledge of what accounts for the leading cause of death in men
and women. No further techniques or inventions are needed. The providers
of medical care must creatively deploy this information in their own lives
and the lives of their patients. The present superficial approach of no
red meat and taking the skin off chicken is a meaningless insult to
scholars of nutritive science who recognize the need for sophistication
and individualization to prevent this disease. Our lethargy of acceptance
of atherosclerosis as inevitable is no longer tolerable in light of
present knowledge, which can prevent this and many other diseases of
affluence.
Turning to the biliary tract, the prevalence of gall
stones makes cholecystectomy one of the most common surgical procedures.
Considerable interest has been generated among surgeons in mastering the
technique of percutaneous cholecystectomy. Of much greater interest is a
recent Lancet article by Tamimi et al.,6 which de scribes a 978%
increase in cholecystectomy rates in Riyadh Central Hospital in Saudi
Arabia between 1977 and 1986. Particularly significant was the concomitant
dietary change noting increases in consumption of total calories by 81%,
fat by 197%, sugar by 164%, and a decrease in high fiber grain of 75%.
Although percutaneous cholecystectomy is fashionable like the more
affluent Saudi diet, it is apparent that cholelithiasis is part of the
price of achieving the Western way of life.
Of greater concern are the breast cancer rates that have
steadily increased from 1of 19.1 American women in 1961 to 1 of 9 in 1991.
Although precise reasons for this increase remain unclear, proponents of
the theory that increased dietary fat is responsible have strong
arguments. Nations that consume greater amounts of dietary fat per person
have the highest mortality rates from breast cancer.7 When persons migrate
from a nation of low incidence of breast cancer to a nation of higher
frequency, these immigrants will have the same high rate of breast cancer
as their new nation by the second and third generation.8 Even with a
country of low risk, such as Japan, further correlations exist. Women in
rural Japan who consume a low fat diet experience less breast cancer than
urban women with a higher fat diet. The role of estrogen as a possible
promoter has been made more clear by recent studies revealing decreased
serum estradiol levels in women who eat regularly or who switch to a low
fat diet.9' 10 This concept receives further support from the observation
of increased rates of breast cancer in women who are obese and who have a
decreased sex hormone--binding globulin and higher rates of conversion of
androstenedione to estrone by aromatase found in adipose tissue.11 That
fat may have a direct tumor-growth affect independent of estrogen has been
shown in the laboratory when castrated rats receive a high fat diet, which
replaces the requirement of the tumor for estrogen for its growth.'2 Now
turning to a more direct human application, we note that linoleic acid
(which comprises 65% of corn oil) will stimulate the growth of human
breast cancer cells in tissue culture.13 Rose, Director of the Division of
Nutrition and Endocrinology at the American Health Foundation, recently
found (Rose D. March 1991. Unpublished data) that corn oil, in appropriate
amounts, will stimulate growth and pulmonary metastases of human breast
cancer cells transplanted into athymic nude mice. These data provide a
compelling argument against high fat diets because basic science now
reinforces earlier epidemiologic observations.
The male analogue to breast cancer is carcinoma of the
prostate gland, which closely correlates with the epidemiologic factors of
breast cancer in terms of fat con sumption.14' IS Carcinoma of the
prostate gland was extremely infrequent during the 19 SOs in Japan with
only 18 deaths, autopsy proven, in 1958.16 It has steadily in creased
since then because the percent of fat in the Japanese diet has increased
from 15% in the 1950s to 26% at the present time. The migration pattern of
leaving a nation of low incidence of prostate cancer for one of high
incidence and noting an increase in the incidence of prostate cancer is
similar to that we have seen in breast cancer.17 Although the incidence of
histologic prostate cancer is the same in native Japanese and native
Americans, a marked discrepancy is noted in the higher rate of progression
to clinical cancer in Americans.18 Whereas it is unclear what factors are
responsible for this conversion from histologic to clinical cancers, some
authors, such as Hill et al.,'9' 20 have implicated diet and its hormonal
changes. It will be of interest to see if human prostate cancer cells in
tissue culture or athymic nude mice will exhibit a growth response to corn
oil as has been observed with breast cancer.13
Of equal significance is the association of fat with an
increased incidence of carcinoma of the colon, which has been suspected in
epidemiologic studies. This has recently received further support from the
prospective study of Willett et al.,2' evaluating 88,000 nurses. Women who
consume red meat daily had a 2.5 times risk of colon cancer compared to
those who ate red meat less than once a month. No associated increased
risk was noted with vegetable fat. Dr. Willett was quoted as saying, "If
you step back and look at the data, the optimum amount of red meat you
should eat is zero." A recent study found that the same evidence of a diet
high in an imal fat was implicated in the increased rates of colorectal
cancer in male and female Chinese Americans, when compared to Chinese in
the Peoples Republic of China.22 Possible mechanisms include the
observation that diets high in fat increase the excretion of bile
acids,23'24 which have been noted in persons with higher rates of colon
cancer and polyps.2' Bile acids act as a tumor promoter.26 This affect is
encouraged by enzymatic activity of intestinal flora, which are found in
populations with higher rates of colon cancer.27' 28 Conversely, bile acid
modification by intestinal flora is decreased in vegetarians and those who
reduce their beef fat intake.28
The preceding has been a review of disease related to
excess fat; we now turn to osteoporosis, a disease of protein excess.
Osteoporosis runs rampant through Western civilization with our elderly
fracturing their spines and hips at an unprecedented rate. Conventional
wisdom teaches us that we are not getting enough calcium and exercise,
that we are smoking too much or drinking too much coffee or, in the case
of women, that we lack estrogen. A closer examination of the evidence
would agree that these are contributing factors, but the primary culprit
lies elsewhere. The women of Bantu who are over 60 years of age do not
have osteoporosis. They have a huge calcium drain, having an average of 10
children and nursing each child for 14 months. Their diet includes 440 mg
of calcium per day, half of our recommended daily allowance.29'30 They are
protected because they eat only 50 gm of protein daily. When they move to
civilization their protein intake increases and they develop
osteoporosis.31 The mechanism of this is further clarified by viewing the
Eskimo diet.32 The Eskimo consumes a diet that is high in protein (250 to
400 gm per day) and a diet high in calcium (2000 mg per day); yet, despite
much physical activity, they have one of the highest rates of
osteoporosis.32 These two contrasting cultures of the Bantu and the Eskimo
illustrate the osteoporotic effect of a high protein diet. Ammonia and
urea (the breakdown products of protein) initiate a calcium diuresis, the
mechanism of which is still not clearly understood.33' During the past 25
years this observation has been increasingly scientifically documented,
but poorly publicized. A long-term study noted a negative calcium balance
in persons daily ingesting 75 gm of protein despite a daily intake of 1400
mg of cal cium.35 The conclusion of Allen et al.3': "Our data in dicate
that high protein diets cause a negative calcium balance to occur even in
the presence of more than ad equate dietary calcium. Osteoporosis would
seem to be an inevitable outcome of continued consumption of a high
protein diet." Millions of Americans have osteoporosis, accounting for
190,000 hip. fractures annually.36 Fifteen thousand women die each year as
a result of hip fractures. Despite such data, osteoporosis is unknown in
many countries around the world except in Western civilization, which
consumes two to three times more protein than required. It would appear
that osteoporosis is a disease of chronic dietary protein excess.37
Time does not permit a discussion of hypertension, adult
onset diabetes, and gout, which are among other diseases that can be
prevented or improved by nutritional lifestyle changes. Clearly the voice
of prevention must be heard. The diseases I have been discussing today are
rare or unknown in countries whose lifestyles are consistent with that for
which human beings were genetically adapted through millions of years of
evolution. These diseases were infrequent in industrial society until the
turn of the century. This bitter harvest of the affluent lifestyle is the
vascular, neoplastic, and metabolic disease that overwhelms Western
civilization and its ability to treat it. As Churchill stated in another
setting, "We are victims of the curse of plenty." No amount of
sophisticated treatment by surgeons or internists will alter the incidence
of these diseases, but treat ment unfortunately is the present emphasis of
Western medicine. Articles in this year's Annals of Internal
Medicine38' tragically reveal physician failure in terms of personal
health habits, as well as physician in ability to counsel this information
to patients. The development of effective health promotion will require
commitment from multiple disciplines. The insurance industry must develop
incentives for health aware patients and reward physicians committed to
prevention practices. Lawmakers must distinguish among vested lobbies of
the food and agriculture industries and select only those that are in the
interests of health. The culinary institutes and the food and restaurant
industry must offer safe and tasteful foods and avoid misleading
advertising. The medical profession, including surgeons, must take the
lead role. While learning and practicing sound health habits in their own
lives, physicians can similarly counsel their patients. We know this goal
is achievable when we witness the positive public education efforts
accomplished on smoking and acquired immunodeficiency syndrome. We have
the knowledge of what it is that must be prevented, and the voice of
medicine in the aggregate can translate that into meaningful action for
the public good. The misplaced emphasis of Western medicine is best
illustrated by an example of Burkitt,40 "If people are falling over the
edge of a cliff and sustaining injuries, the problem could be dealt with
by stationing ambulances at the bottom, or erecting a fence at the top.
Unfortunately, we put far too much effort into the provisioning of
ambulances and far too little into the simple approach of erecting
fences."
"Beyond surgery" does not mean one must relinquish the
cherished burden of operative responsibility, but it does imply that we
must participate in the endeavor to eliminate and prevent diseases by
nonsurgical methods of lifestyle changes. For medicine to do less than
disseminate the knowledge of how to avoid these killing diseases would
give a hollow ring to the integrity that must remain the driving force of
our profession. It is imperative that we find within ourselves the mandate
to eliminate diseases for which we know the cure.
In conclusion, as President of the American Association
of Endocrine Surgeons, I look at our past accomplishments with pride.
However, I urge you to recognize these important is sues
that face us today. It is critical that the medical profession be in the
forefront, taking a proactive position in this important concept--beyond
surgery.
The author gratefully acknowledges the assistance of
Evelyn Oswick in the preparation of this manuscript.