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BEWARE OF THE COW
1334 Pseudotumors in patients with haemophilia will probably be less frequent in future because of replacement therapy. Nevertheless the rare case will still pose difficulty and the novel surgical approach proposed may be helpful. and less
P. BELLINAZZO L. SILVELLO M. T. CAIMI F. BAUDO F. DECATALDO
Departments of General Surgery, Orthopaedic Surgery, and Haematology, Ospedale Maggiore Cà Granda Niguarda, Milan, Italy 1.
Dohring S, Hofmann P. Haemophilic pseudotumors. In: Dohnng S, Schulitz KP, eds. Orthopaedic problems in hemophilia: symposium (Dusseldorf, 1985). Munich: W Zuckschwerdt Verlag, 1986: 81-92.
BEWARE OF THE COW
SiR,—The farmers and villagers who for centuries toiled in the countryside of Europe in order to eat, would have been greatly astonished to learn from Dr Turner (Oct 21, p 983) that "nobody needs cows". From the Swiss Alps to the Western Isles of Scotland were, and still are, an essential part of the rural economy. In the 1930s, the people of the Loetschental valley in Switzerland so valued the health-giving qualities of butter and cheese, made from the milk of cows grazing on the spring pastures near the snow line, that they held an annual thanksgiving church service for what they regarded as a unique gift of Divine providence.’ Without cows, how would these pasturalists have got dietary fats and proteins? The beans which Turner would have us eat do not always flourish on mountain sides a mile above sea level. Julius Caesar noted that most of the inland Britons "did not sow com but lived on milk and meat" and the Scottish Highlanders of the same era probably lived mostly off their herds of cattle.2 Until the 1920s in this area of Perthshire, many villagers kept their own household cows. Morning and evening milking were an essential part of the daily village routine; an elderly patient recently gave me an old rusty hom, once used by the herd boy whose job it was to call out the cows and take them to the common grazing ground. In Scotland the first case of coronary thrombosis was recorded in 1928 ;3 so only since the cows have gone and their good butter replaced by margarines, have we started to suffer from acute myocardial infarction. If dietary fats are to be blamed for the prevalence of coronary thrombosis, the history of the disease suggests that fabricated oils are the more likely culprits.’ In the Norwegian post-war programme for the prevention of coronary diseasethe widespread consumption of soya margarine in place of butter was followed by a steep rise in deaths from coronary thrombosis. The fish-eating Japanese, whom Turner would have us emulate, have the highest death rate from stroke in the world; they also suffer far more than do the British from stomach cancer.6 If we adopt a Japanese type diet, will we exchange our coronaries for stroke and stomach cancer? cows
Dulness, Aberfeldy, Perthshire PH15 2ET
W. W. YELLOWLEES
1. Price WA. Nutrition and physical degeneration. New York P B. Hoeber, 1939 2. Gauld WW. Native and Roman in Glenalmond. J Perthshire Soc Natural Sci 1987, 15: 31. 3. Gilchrist R. Edinburgh tradition in clinical cardiology Scot Med J 1972; 17: 284. 4. Martin W. Margarine (not butter) the culpnt? Lancet 1983; ii: 407. 5. Dedichen J. Cholesterol and atherosclerosis once more. J Norweg Assoc 1976; 16: 915-19. 6. World Health Organisation. WHO Q Rep 1988; 41: no 3/4.
SIR,-Your Aug 19 editorial and Dr Turner’s letter (Oct 21, p 983) constitute a dual attack upon the dairy industry. I declare my interest as a dairy farmer. Both attacks are based upon the premise, which is presented as though it were an unassailable truth, that saturated fats cause coronary heart disease (CHD) and should be replaced by polyunsaturated fats which do not. Probably the most authoritative statements to which a layman can turn for guidance are the reports of the Committee on Medical Aspects of Food Policy (COMA). The 1974 report, which took three years and ten drafts to prepare, says: "The Panel unanimously agree that they cannot recommend an increase in the intake of
acids in the diet as a measure intended to reduce the risk of the development of ischaemic heart disease. In their opinion the available evidence that such a dietary alteration would reduce that risk in the United Kingdom at the present time is
polyunsaturated fatty
convincing" (p 23, para 11.4). The COMA report of 1984, in examining consumption of saturated fat and CHD, stated that "the evidence falls short of proof, that the mechanisms that lead to CHD "are rarely known with a high degree of precision"; that within any one country "there is no convincing evidence of a relationship between diet and heart disease"; and that experiments in which the relation had been tested "show no convincing evidence of benefit". It seems that the case for substituting polyunsaturated fat for saturated fat in the diet is far from proven and that it is irresponsible to advise such a change. Indeed evidence is mounting (eg, Israel’s experience) that to do so may well be to put people at greater risk of CHD. All my farmer’s instincts lead me to suppose that a natural product like butter is likely to be healthier than an artificial product such as margarine. In the manufacture of margarine, oil and fats have to be refined to remove impurities, and this involves degumming, bleaching, deodorising, and neutralising; some fats are then hydrogenated to make them more solid at room temperatures; and finally colouring, flavouring, lecithin, monoglycerides, and vitamins are added. Butter is churned from natural cream with, usually, a little added salt-and that’s it. It brings a wry smile to the lips to read in a Lancet letter that the voices most often heard in defence of cows’ milk are "those of vested interests" and in a Lancet editorial that c23 million is spent annually on advertising margarine against /8 million on advertising butter. not
Muirhall Farm, Perth PH2 7BL
DAVID YELLOWLEES
OVERPROMOTION OF THE DIETARY THEORY OF CORONARY DISORDERS
SIR,-As members of a team practising cardiac rehabilitation we interested in the dynamic causes of myocardial ischaemia. In individual cases, psychological and social causes of fatigue, sleeplessness, emotional arousal, hyperventilation, overwork, or loss of social support appear to play an important part in the destabilisation of cardiovascular regulation, in the appearance of coronary arterial constriction, spasm, and thrombosis, and, consequently, in the production of angina pectoris, myocardial infarction, and sudden death. 1.2 Most coronary patients probably do not have risk factors,3 yet our therapists notice a diminishing interest these days in taking care of the important influences and a growing preoccupation with diet: it is almost as if patients have come to
are
blame cholesterol and not psychosocial factors for their cardiovascular instability. Our therapists’ observations are supported by opinion polls: in 1982, 6 % of those questioned mentioned high cholesterol levels as a cause of heart attacks4 whereas in 1989 70% believed scientists had proved that cholesterol-rich foods were bad for the heart.s This is a steep growth curve for a medical belief-system, and a testimony to the power of the media. Scientific belief in the dietary theory of heart disease has no such growth curve. Twelve years ago, Mann wrote "a generation of research on the diet-heart question has ended in a disarray",6 and Mitchell’s 1984 review was equally damning.’ In 1989 the American Heart Association has stated "despite the fact that dietary therapy is the first logical step of treatment, its efficacy has not been proven", and the editor of the American -7ournal of Cardiology, while acknowledging the importance of serum cholesterol, did not put diet on his list.9 Plasma cholesterol level is highly labile in some people, and can be expected to rise 8-65% above baseline in stressful conditions.’" Petch reported that patients with progressive coronary lesions had no significant differences of blood pressure, smoking habits, or serum lipid concentrations from those whose disease remained static," and McCormick and Skrabanek have argued that iatrogenic harm might be done through the premature translation of risk factor beliefs into action.12 We suggest that overpromotion of the diet-heart theory is encouraging individual patients to overlook important influences in
P. BELLINAZZO L. SILVELLO M. T. CAIMI F. BAUDO F. DECATALDO
Departments of General Surgery, Orthopaedic Surgery, and Haematology, Ospedale Maggiore Cà Granda Niguarda, Milan, Italy 1.
Dohring S, Hofmann P. Haemophilic pseudotumors. In: Dohnng S, Schulitz KP, eds. Orthopaedic problems in hemophilia: symposium (Dusseldorf, 1985). Munich: W Zuckschwerdt Verlag, 1986: 81-92.
BEWARE OF THE COW
SiR,—The farmers and villagers who for centuries toiled in the countryside of Europe in order to eat, would have been greatly astonished to learn from Dr Turner (Oct 21, p 983) that "nobody needs cows". From the Swiss Alps to the Western Isles of Scotland were, and still are, an essential part of the rural economy. In the 1930s, the people of the Loetschental valley in Switzerland so valued the health-giving qualities of butter and cheese, made from the milk of cows grazing on the spring pastures near the snow line, that they held an annual thanksgiving church service for what they regarded as a unique gift of Divine providence.’ Without cows, how would these pasturalists have got dietary fats and proteins? The beans which Turner would have us eat do not always flourish on mountain sides a mile above sea level. Julius Caesar noted that most of the inland Britons "did not sow com but lived on milk and meat" and the Scottish Highlanders of the same era probably lived mostly off their herds of cattle.2 Until the 1920s in this area of Perthshire, many villagers kept their own household cows. Morning and evening milking were an essential part of the daily village routine; an elderly patient recently gave me an old rusty hom, once used by the herd boy whose job it was to call out the cows and take them to the common grazing ground. In Scotland the first case of coronary thrombosis was recorded in 1928 ;3 so only since the cows have gone and their good butter replaced by margarines, have we started to suffer from acute myocardial infarction. If dietary fats are to be blamed for the prevalence of coronary thrombosis, the history of the disease suggests that fabricated oils are the more likely culprits.’ In the Norwegian post-war programme for the prevention of coronary diseasethe widespread consumption of soya margarine in place of butter was followed by a steep rise in deaths from coronary thrombosis. The fish-eating Japanese, whom Turner would have us emulate, have the highest death rate from stroke in the world; they also suffer far more than do the British from stomach cancer.6 If we adopt a Japanese type diet, will we exchange our coronaries for stroke and stomach cancer? cows
Dulness, Aberfeldy, Perthshire PH15 2ET
W. W. YELLOWLEES
1. Price WA. Nutrition and physical degeneration. New York P B. Hoeber, 1939 2. Gauld WW. Native and Roman in Glenalmond. J Perthshire Soc Natural Sci 1987, 15: 31. 3. Gilchrist R. Edinburgh tradition in clinical cardiology Scot Med J 1972; 17: 284. 4. Martin W. Margarine (not butter) the culpnt? Lancet 1983; ii: 407. 5. Dedichen J. Cholesterol and atherosclerosis once more. J Norweg Assoc 1976; 16: 915-19. 6. World Health Organisation. WHO Q Rep 1988; 41: no 3/4.
SIR,-Your Aug 19 editorial and Dr Turner’s letter (Oct 21, p 983) constitute a dual attack upon the dairy industry. I declare my interest as a dairy farmer. Both attacks are based upon the premise, which is presented as though it were an unassailable truth, that saturated fats cause coronary heart disease (CHD) and should be replaced by polyunsaturated fats which do not. Probably the most authoritative statements to which a layman can turn for guidance are the reports of the Committee on Medical Aspects of Food Policy (COMA). The 1974 report, which took three years and ten drafts to prepare, says: "The Panel unanimously agree that they cannot recommend an increase in the intake of
acids in the diet as a measure intended to reduce the risk of the development of ischaemic heart disease. In their opinion the available evidence that such a dietary alteration would reduce that risk in the United Kingdom at the present time is
polyunsaturated fatty
convincing" (p 23, para 11.4). The COMA report of 1984, in examining consumption of saturated fat and CHD, stated that "the evidence falls short of proof, that the mechanisms that lead to CHD "are rarely known with a high degree of precision"; that within any one country "there is no convincing evidence of a relationship between diet and heart disease"; and that experiments in which the relation had been tested "show no convincing evidence of benefit". It seems that the case for substituting polyunsaturated fat for saturated fat in the diet is far from proven and that it is irresponsible to advise such a change. Indeed evidence is mounting (eg, Israel’s experience) that to do so may well be to put people at greater risk of CHD. All my farmer’s instincts lead me to suppose that a natural product like butter is likely to be healthier than an artificial product such as margarine. In the manufacture of margarine, oil and fats have to be refined to remove impurities, and this involves degumming, bleaching, deodorising, and neutralising; some fats are then hydrogenated to make them more solid at room temperatures; and finally colouring, flavouring, lecithin, monoglycerides, and vitamins are added. Butter is churned from natural cream with, usually, a little added salt-and that’s it. It brings a wry smile to the lips to read in a Lancet letter that the voices most often heard in defence of cows’ milk are "those of vested interests" and in a Lancet editorial that c23 million is spent annually on advertising margarine against /8 million on advertising butter. not
Muirhall Farm, Perth PH2 7BL
DAVID YELLOWLEES
OVERPROMOTION OF THE DIETARY THEORY OF CORONARY DISORDERS
SIR,-As members of a team practising cardiac rehabilitation we interested in the dynamic causes of myocardial ischaemia. In individual cases, psychological and social causes of fatigue, sleeplessness, emotional arousal, hyperventilation, overwork, or loss of social support appear to play an important part in the destabilisation of cardiovascular regulation, in the appearance of coronary arterial constriction, spasm, and thrombosis, and, consequently, in the production of angina pectoris, myocardial infarction, and sudden death. 1.2 Most coronary patients probably do not have risk factors,3 yet our therapists notice a diminishing interest these days in taking care of the important influences and a growing preoccupation with diet: it is almost as if patients have come to
are
blame cholesterol and not psychosocial factors for their cardiovascular instability. Our therapists’ observations are supported by opinion polls: in 1982, 6 % of those questioned mentioned high cholesterol levels as a cause of heart attacks4 whereas in 1989 70% believed scientists had proved that cholesterol-rich foods were bad for the heart.s This is a steep growth curve for a medical belief-system, and a testimony to the power of the media. Scientific belief in the dietary theory of heart disease has no such growth curve. Twelve years ago, Mann wrote "a generation of research on the diet-heart question has ended in a disarray",6 and Mitchell’s 1984 review was equally damning.’ In 1989 the American Heart Association has stated "despite the fact that dietary therapy is the first logical step of treatment, its efficacy has not been proven", and the editor of the American -7ournal of Cardiology, while acknowledging the importance of serum cholesterol, did not put diet on his list.9 Plasma cholesterol level is highly labile in some people, and can be expected to rise 8-65% above baseline in stressful conditions.’" Petch reported that patients with progressive coronary lesions had no significant differences of blood pressure, smoking habits, or serum lipid concentrations from those whose disease remained static," and McCormick and Skrabanek have argued that iatrogenic harm might be done through the premature translation of risk factor beliefs into action.12 We suggest that overpromotion of the diet-heart theory is encouraging individual patients to overlook important influences in