American Association of Endocrine Surgeons Presidential address: Beyond surgery
Caldwell B. Esselstyn, Jr., MD
From the Cleveland Clinic Foundation, Cleveland, Ohio
References

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.