Prevention versus Cure

The idea that ‘prevention is better than cure’ is often attributed to Erasmus, (1466-1536), who was a Dutch philosopher. This idea was later restated by Benjamin Franklin (1706-1790) in the form ‘an ounce of prevention is worth a pound of cure’, although in this case he was using the idea in the context of house fire prevention versus the cost of rebuilding. However, we might accept that it makes general sense, in any area of life, to prevent a problem rather than to let it happen, only then to incur the cost of fixing it. This can be especially true in the field of medicine, where even the simplest preventive strategy, e.g. washing your hands, may prevent many diseases from spreading. We might broadly attempt to initially summarise the benefits of prevention rather than cure in terms of the chart right.

So, is this apparent wisdom accepted by all?

While it might be initially assumed that there would not be much of a debate about prioritising prevention over cure, we might still need to consider whether business interests could have a different perspective, if it affected their ‘bottom line’ profits. While we do not normally think of our primary medical services as a ‘business’, we might realise that these services are surrounded by commercial interests, such that this essay will consider the idea that much of medical research is focused on cure rather than prevention, simply because it is more profitable to ignore prevention in some business models, such as the pharmaceutical and food industries.

Note: The pharmaceutical industry is responsible for the development, production and marketing of medications. In 2014, the total pharmaceutical revenues worldwide were estimated to exceed $1 trillion for the first time, where US pharmaceutical companies accrued the largest percentage of this global revenue. In contrast, the packaged food industry is estimated to be worth almost $1.6 trillion, although the World Bank in 2006 estimated the combined food and agriculture sector to be worth about 10% of the global gross domestic product (GDP), which in 2017 was estimated to be in the region of $80 trillion.

Without getting too preoccupied with actual figures, we might simply accept that these industries have enormous importance to the GDP of many nations and, as such, can wield considerable political influence on governments, who then define the laws, policies and regulations governing these industries. However, let us first consider the possible business rationale of the pharmaceutical industry, which may naturally want to increase the sales of its pharmaceutical drugs as a treatment for various diseases and, in some cases, may want to highlight new diseases to which an existing drug might be used. Within this business model there may be little incentive for the pharmaceutical industry to eradicate a disease, if in so doing, they possibly destroy an existing billion-dollar market. Likewise, even developing a one-off drug that might cure a disease could limit the long-term profitability of a drug that cost billions to develop. In this context, we might perceive why certain sectors of the pharmaceutical industry might favour developing drugs that may only relieve symptoms rather than offer an actual cure.

Note: While the summary above may appear to be a little too Machiavellian, the pharmaceutical industry has often been accused of suppressing or obstructing any perceived medical breakthroughs in order to make sure that diseases continue to provide profit revenue for existing drugs for as long as possible. Again, drug development can require years of profit to offset such costs, measured in billions of dollars. For these reasons, some claim that it explains why there have been so few genuine breakthroughs related to major diseases, such as cardiovascular disease, high blood pressure, heart failure, diabetes, cancer and osteoporosis.

Of course, we might assume that morality of the people, who work in the pharmaceutical industry, would never condone the suggestion in the note above, although much of human history suggests that this is possibly a naïve assumption – see Limits to Morality for more details. However, while accepting the speculative nature of some of these claims, history also appears to support the idea that many pharmaceutical companies are reluctant to disclose full information about drug trials, especially in regard to the risks and side effects, which are inherent in almost all drugs. Likewise, it is also clear that the pharmaceutical industry employs many lobbyists, who try to influence legislation being developed by the various regulatory agencies worldwide, although redirection might be a more accurate description. Finally, there is the more covert and worrying issue of the manipulation of medical research and education.

Note: In a 2018 article entitled ‘Medical Research in US Today’ it is claimed that an estimated 60% of biomedical research and development in the US is now privately funded, and two thirds of academic institutions have equity ties with outside sponsors. As such, universities and other academic institutions are relying evermore on funding from the pharmaceutical industry with estimates suggesting that over half of medical research conducted at universities is done with funding that comes from the pharmaceutical industry. However, see video ‘Financial Conflicts of Interests and the End of Evidence-Based Medicine’ for more details about the scope of this problem.

If we use the US as our example population of the implications of modern life, then it appears to suggest a growing health crisis, which is then fuelling a need for ever more drugs being supplied by the pharmaceutical industry. For statistics suggest that nearly 70% of adults are overweight or obese, which then leads to an increased risk of type-2 diabetes, heart disease, high blood pressure, fatty liver disease, osteoarthritis, cancers and strokes. Again, the incentive for the pharmaceutical industry is possibly more orientated to produce drugs that only treat the symptoms of these problems rather than the cause.

Note: It is estimated that the total 2017 spending on prescription drugs in the US by the government, consumers and insurers was $333 billion. The estimate in 2007 was $236 billion suggesting a 41% increase over the previous decade. By way of an additional footnote, it is estimated that the global spending on prescription medicines will reach nearly $1.5 trillion by 2021.

However, there are many ideas forwarded as to why people have become so unhealthy, especially in more developed societies, over the last 50 years. Typically, the focus is directed to the more sedentary life-styles of both adults and children with the suggestion that this situation has been compounded by the availability of higher calorie foods now on offer from the processed food industry. While we might initially assume that each individual within any population is responsible for their own health, we might also consider the phrase ‘you are what you eat', which is first attributed to Jean Anthelme Brillat-Savarin as long ago as 1826. Even in this historic context, Brillat-Savarin was highlighting a need for a low-carbohydrate diet as he believed that sugar and white flour to be the root cause of most obesity and argued for a diet that avoided starch, grains, sugar and flour, while recommending meats, root vegetables, cabbage and fruit. To quote his words:

Carnivorous animals never grow fat. Herbivorous animals do not grow fat easily, at least until age has reduced them to a state of inactivity; but they fatten very quickly as soon as they begin to be fed on potatoes, grain, or any kind of flour. The second of the causes of obesity is the floury and starchy substances which man makes the prime ingredients of his daily nourishment. As we have said already, all animals that live on farinaceous food grow fat willy-nilly; and man is no exception to the universal law.

If we follow this general line of thought, we might start to question what has changed leading to the alarming suggestion that nearly 70% of US population are either overweight or obese. While the pharmaceutical industry may have only been profiting from this effect without necessarily being the cause, we might still question its role in formulating the US dietary recommendations over the last 50 years. However, at this point, we will turn our attention to the other focus of this discussion, i.e. the food industry.

So, where does the incentive of the food industry fit into this argument?

Again, we might start with the fairly obvious fact that the food industry also needs to make a profit to stay in business. However, before pursuing this line of questioning, we possibly need to briefly outline what we mean by the word ‘food’, which at a very basic level is what we, as humans, ingest to provide the necessary calorific energy to sustain life. We might then extend this description by highlighting that the nutrition value of food can be subdivided into 3 primary classes known as carbohydrates, fats and proteins along with a multitude of vitamins and organic minerals. Of course, this outline does not really explain what food has got to do with the prevention or cure debate, although we might extend this technical outline by providing a basic definition of a drug as a natural or synthetic substance, which when taken, affects the functioning of the body’s metabolism. While illegal stimulant or narcotic substances might be included in this description, they are not the focus of this discussion, although we might realise that many legal drugs, prescribed for medical reasons, may also contain stimulant or narcotic substances, which can cause addictive and harmful side effects. However, within this broad description of a drug, it might be accepted that all foods affect the functioning of our metabolism in that they act as a source of energy that keeps us alive. While the sum total of all the processes associated with food digestion in the gut and subsequent absorption into the blood stream is well beyond the scope of this discussion to even summarise, let alone detail, many foods can be addictive and harmful to our metabolism. Of course, we might realise why the food industry might not necessarily want to highlight such problems, especially if it could hurt the profitability of some products. However, before addressing which types of food might be harmful to human health, we possibly need to have a wider perspective of the various diets recommended in the past.

Note: While not directly relevant to this discussion, we know that profound changes started to occur in the human diet over 10,000 years ago associated with both agriculture and animal farming. In many respects, these dietary changes were in conflict with our original hunter-gather biology, although subject to many generic variations due to regional and cultural differences. These changes affected a number of crucial nutritional factors in our diet, which are simply listed for reference: glycaemic load, fatty acids, macronutrients, micronutrients, acid balance, sodium-potassium ratio and fibre content.

 Of course, most of us do not perceive food in such historic or technical terms, but rather as the things we enjoy eating, which might then be moderated by what we believe are medically recommended. However, in the 1970’s, the US government began promoting a change to the American diet based on the belief that saturated fats should be drastically reduced, based on the assumption that cholesterol caused heart attacks. However, as a consequence of this change, they also  recommended that the shortfall in calories could be replaced by eating more carbohydrates, e.g. flour and sugar, and that natural animal fats should be replaced by vegetable oils, which later turned out to contain trans-fats. The basic composition of this diet is shown below.

Note: It might be recognised that this diet is in almost complete contradiction to the recommendations of Brillat-Savarin given over 100 years earlier. So, whether by accident or design, we might see that the American diet is dominated by what are essentially processed foods, e.g. bread, cereals and pastas, all products of the food industry. This diet also led to an increased consumption of trans-fats, which are produced in an industrial process that adds hydrogen to vegetable oil, such that it becomes a solid at room temperature. These vegetable oil products originally form the basis of most margarines that started to replace the animal fats in the form of butter. However, it was the increase in carbohydrates, especially in the form of sugar, which would have the most far reaching effects on health.

For the moment, we might assume that the American diet was simply a well-intentioned, but misguided government recommendation. However, it is not unreasonable to highlight that the American food industry was, and still is, the world’s biggest producer of soya bean oil, which started to replace animal fats. It might also be highlighted that many process food manufacturers saw the use of vegetable oil as a way of producing lower-cost products with longer shelf life. However, what now appears certain is that this American diet led to increasing health problems in the form of obesity, diabetes, hypertension, high cholesterol, heart attacks, strokes, which are the primary causes of premature deaths. In addition, despite much research over the last 40 years highlighting these health problems, the main recommendations of this diet did not really change, although it appears that the portion size was allowed to grow ever larger.

Note: Today, many are now more critical that this diet was the deliberate product of misinformation, which was compounded by a flood of dietary books and food supplements, often sponsored by various sections of the food industry. Of course, at the same time, the food industry also lobbied government to allow unsupported dietary claims in respect to super foods, probiotics, herbs, exotic juices and vitamins. As a consequence, the public were denied clear and accurate guidelines that could have prevented many health problems that have now reach epidemic proportions.

 While the debate concerning what exactly constitutes a healthy diet continues, there does seem to be a growing convergence towards low-carbohydrate, high-fat diets, as illustrated below.

Note: One of the assumptions of the original  American diet was that many deaths from heart disease could be linked to animal fats, which leads to an elevation of cholesterol in the blood. Therefore, if not regulated by a low-fat diet, cholesterol could narrow and block arteries preventing blood from reaching your heart, brain, or other organs. Ultimately, it was assumed that this condition could lead to strokes, heart attacks, or even heart failure. However, see video ‘The Cholesterol Conundrum’ for more details of the cholesterol metabolic process.

 This discussion will also reference the work of Dr Jason Fung, who published a book entitled the ‘The Obesity Code’ in 2016 in which he describes obesity as a hormonal disorder of fat regulation linked to insulin. The role of insulin is often described in terms of it being the fat storage hormone associated with any excess of glucose in the blood. While there can be multiple causes of obesity, it is now known that carbohydrates, specifically sugars, can cause elevated levels of glucose in the blood, which over time can lead to insulin resistance – see video ‘A New Paradigm of Insulin Resistance' for more details.

Note: The chart above shows the relative levels of insulin in response to food types, i.e. carbohydrates, protein and fat along with an insert graph of the elevated level of insulin as a function of time associated with a normal metabolism as opposed to insulin resistant or type-2 diabetic. Without insulin returning to near zero, fat loss cannot occur. See video ‘The Story of Fat: Why we were Wrong about Health’ for more background information.

Again, this discussion cannot detail all the actual complexity of all the human metabolic systems regulated by hormones – see list of human hormones for an overview of this complexity. However, it might simply be said that a ‘hormone’ is a molecular string, typically in the form of a protein, produced by one organ or gland as a signalling mechanism that invokes action in other cells and organs of the body. While many of these signalling hormones can be produced by certain mental states, e.g. stress, many others are triggered by the types of food we eat, e.g. sugar causes the pancreas to secrete insulin. Therefore, the public might rightly expect that their government would endeavour to provide open and transparent access to the latest medical research without commercial bias. Whether this assumption is true, even today, might be questionable, as open and transparent information does not appear to be in the interest of many business models. Of course, even if some of these criticisms were accepted, the general public might still want to table a question for the experts:

Is there a prevention that might circumvent the need for a cure?

 Based on the general outline provided, it may not be unreasonable to proceed on the assumption that neither the pharmaceutical or food industries are necessarily going to help the general public answer the question tabled, if it affects the profitability of their business models. However, despite some of the negative connotations of this discussion, there are many dedicated researchers now attempting to prioritise prevention by looking for some of the possible root causes leading to many of today’s most serious diseases, e.g. heart attacks, strokes, type-2 diabetes, dementia and even cancer. As a result, there is now much research looking at the role of inflammation being caused by our modern lifestyle, which we might attempt to illustrate in terms of the diagram below.

While there are many potential causes for all types of inflammation in the body, this discussion will only attempt to outline a few possibilities, but first we need to clarify what is implied by the word ‘inflammation’. Normally, we perceive inflammation as an external redness or swelling, although it might be better described as the result of the body’s natural defense system against viruses and bacteria. It might also be highlighted that there are two basic types of inflammation, i.e. acute and chronic, where the former is essentially short-term and the latter much longer term. However, from a preventive perspective we need to consider whether there might be any underlying root cause to the inflammation being suggested, such as unhealthy diets. As already outlined, when we eat food, it sets in motion a very complex chain of metabolic reactions, which involve both the immune system and various hormone actions and responses.

Note: Again, it might be highlighted that research has now identified certain types of foods that can trigger inflammation, e.g. trans-fats, hydrogenated fats, sugar, refined carbohydrates, processed foods, toxins, pollutants and stress. However, another cause of inflammation can often be traced to an imbalance of bacteria in your gastrointestinal tract and food allergies – see The Gut Microbiome in Health and Disease for more details.

While there are many potential causes for inflammation in the body, this discussion will only attempt to outline a few possibilities. First, by way of summary, each of the line items listed below is linked to a video that provides a wider overview of some of the technical issues that may cause various types of inflammation in some individuals due to both diet and genetic makeup.

As such, this discussion will not attempt to replicate any detailed information, but simply state that what we eat, i.e. our diet, is potentially the root cause of many diseases because it can trigger an inflammation response within our body. So, while in reality, there are a multitude of potential causes leading to disease in any given individual, the idea of the Pareto 80/20 principle might simply suggest that changing to a sensible low-carb, high-fat diet could be a very good preventive strategy for many people.

Note: As on all matters, this discussion does not claim to have any authority to make recommendations about dietary health. However, as this discussion has simply tried to point out, the recommendations issued over the last 50 years by what might have been assumed to be authoritative sources have failed to provide good health advice to the general public. As a result, health services around the world have seen an increasing level of chronic diseases affecting the wider population, which while possibly profitable to the pharmaceutical and food industry is bankrupting the national health services. Therefore, to close, the reader may wish to extend their own research by reviewing the information in the following videos ‘Dietary Guidelines’ and ‘Intermittent Fasting & Losing Weight