Learning Medicine from Maneka Gandhi


Not many moons ago Maneka Gandhi wrote an article (which was published in her regular page "Write to Live", in "The Island" of October 3 entitled "Fish oil ruins your heart") where she said there is no evidence to say that fish oil protects the heart. In fact, she went a step further, and said it could be harmful to the heart.

O tempora! O mores! This is not what we doctors were made to believe. We were taught that fish oil and specifically the omega-3-fatty acids in it, is cardio protective (protects the heart).

Baffled by what Ms. Gandhi wrote, I inquired from some of my doctor friends, some who were specialists in their chosen fields, about the validity of her claim. Although some of them knew that fish oil may not be beneficial on heart, none of them knew it could be harmful.

Gandhi, citing clinical trials on omega-3-fatty acids points that while omega-3s can in laboratory settings (in-vitro) increase blood flow, reduce blood pressure and give neurons structural strength, these properties don’t translate into any benefits in the human body (in-vivo). She went on to say that a review in JAMA (Journal of the American Medical Association), involving almost 70,000 people, found no compelling evidence linking fish oil supplements to a lower risk of heart attack , stroke or early death.

Exposing the controversy, Gandhi cited the 1970s study by Danish scientists Dr. Hans Olaf Bang and Dr. Jorn Dyerberg, which claimed that Inuits living in Greenland had low rates of cardiovascular disease, which was attributed to an omega-3-rich diet consisting of fish, seal and whale blubber. This research was disproved by Dr. George Fodor, a cardiologist at the University of Ottawa, who showed that Inuits had as much heart disease as any high risk population. However, by then the fish oil industry was in full swing!

Gandhi quoted Prof. Preston Mason of Cardiology Division, Department of Medicine, Harvard Medical saying, "Fish oil is extracted as a by-product from oily fish like anchovies. As the fish are crushed, they’re exposed to air, meaning the oil becomes oxidized. Oxidized fish oil contains oxidized lipids, which can trigger changes inside human cell that lead to health problems like cardiovascular disease". In Mason’s work and in other previously published studies, researchers have found that the type of fish oil that’s sold in stores often has high levels of oxidation.

Gandhi also quoted another study, carried out in Wales in 1990 linking fish oil intake with a longer life, and its follow-up. In 2003, the follow-up study found that out of 3,000 Welsh men with angina — a chest pain caused by coronary heart disease — who were advised to eat oily fish or take fish oil supplements, were more likely to die. "The excess risk [of cardiac death] was largely located among the subgroup given fish oil capsules," the study has concluded.

Maneka Gandhi, among very many other things she is, is a prolific writer. Time and again, she has written on many important issues, generally having bearing on animal rights and environmental concerns. This time around, she has brought to the fore an issue that impinges on human health, that’s worth discussing for many reasons apart from its face value.

Firstly, there could be many vital evidence based scientific information on human health that the medical community is far from privy to. And it happens even in this age of information superhighway.

Secondly, while the truth is being swept under the carpet, bogus claims could be portrayed as the gospel truth, and presented on a silver platter by the parties with vested interests. Much to the regret of the medical community, this may take place so connivingly that doctors may dare even to raise an eyebrow about some of the claims that are presented to them.

After all, one could expect these dynamics to operate exactly in this way. None other than the father of capitalism Adam Smith’s famous parlance goes as "It is not from the benevolence of the butcher, the brewer, or the baker that we expect our dinner, but from their regard to their own interest". That is the bottom line we should expect of the industry. It would try out all tricks up its sleeve to further their business interests.

Gandhi confirms how this happens. People are being told repeatedly by the advertisements, and by doctors paid by the industry. As for the economics of all this, fish oil is now the third most widely used dietary supplement, after vitamins and minerals. (According to US/ India based Transparency Market research, the global fish oil market in 2011 stood at USD 1.1 billion and is expected to reach 1.7 billion in 2018).

Further to Maneka Gandhi

Apart from fish oil there are many other substances, some prescription drugs and others not (ex. nutraceuticals), which are vigorously marketed with claims of far-reaching health benefits. Today these have swamped the market. The gullible public easily fall prey to these dishonest claims.

Health benefit claims of these may range from arrest of (post menopausal) osteoporosis, cartilage regeneration, improving glow of the skin to enhancing sexual performance and even cognition (brain power). (Even there is a "Brain Viagra" now). While many of these are OTC (over-the-counter) products, some are even promoted through the help of doctors. All these products lack authentic verification for their claims. On top of that, they might be having effects that are quite contrary and opposite to what they claim as what Gandhi has brought to light with regard to fish oil.

The horror story of Thalidomide

The horror story of Thalidomide is quite known even to the public outside the medical community. Thalidomide was first marketed as a tranquilizer (sleeping pill) and later as a pill for morning sickness, vomiting experienced by women in early pregnancy.

Around 1960s, an Australian obstetrician, Dr. William McBride, discovered that the drug also alleviated morning sickness. He started recommending this "off-label" use of the drug to his pregnant patients, setting a worldwide trend. (Prescribing drugs for off-label purposes, or purposes other than those for which the drug was approved, is still a common practice in many countries. For example, these off-label prescriptions include prescribing depression medication to treat chronic pain).

The manufacturers advertised their product as "completely safe" for everyone, including mother and child, "even during pregnancy," as it "could not find a dose high enough to kill a rat." The sales of this OTC medicine soared across the world in a short time with its sales matching that of Aspirin onetime.

In 1961, McBride began to observe severe birth defects among the babies he delivered, whose mothers were given thalidomide during early pregnancy for morning sickness. The observed birth defects include phocomelia - shortened, absent, or flipper-like limbs. A German newspaper too soon reported similar birth defects among babies born to mothers with history of taking thalidomide during early pregnancy. This led the makers of the drug—who had ignored reports of the birth defects associated with it—to finally stop distribution within Germany. Other countries followed suit and, by March of 1962, the drug was banned in most countries where it was previously sold.

Vitamin C – the age-old panacea

for all ills

Along the same lines, in the good old days Vitamin C (Ascorbic acid) was adored the sure remedy for the common cold and many other ailments. The claims of two-time Nobel Prize winner (in Chemistry and Peace) Dr. Linus Pauling, who touted the benefits of Vitamin C from fight against cancer to prevent heart disease, strongly influenced this notion. But many of Pauling’s dramatic claims were not borne out in research done since his time. And by the time he died in 1994, some in the medical establishment had labeled him a quack.

A 2013 review of dozens of studies on Vitamin C published in the US National Institute of Health’s PubMed journal revealed that vitamin C reduces the duration of colds by 8 percent in adults, and 14 percent in children. Considering that the average cold lasts about a week, that reduction translates to about one less day of symptoms. For people in the general population, vitamin C didn’t ward off colds, the researchers also found. But among people under intense physical stress — such as marathon runners, skiers and soldiers exercising in the Arctic — those who took vitamin C supplements were about half as likely to get colds as those who did not, the researchers found. Most of the studies that the researchers reviewed were double-blinded, neither the participants nor the doctors who ran the study knowing which participants were taking the vitamin supplement and which were getting a sugar pill.


HRT – in and out, and in again?

Similarly, Hormone Replacement Therapy (HRT), which first came to use in the 1940s, but had a period of lay off due to possible association with uterine cancer, gained momentum again following combined estrogen/progestin hormone therapy introduced during the 1980s. (Initially HRT was only with estrogen). It was seen as the panacea for women around the menopausal period of life and claimed, among other things, to allowing women to maintain their femininity indefinitely.

The other beneficial claims of HRT include prevention of osteoporosis, coronary heart disease, dementia and decreased all-cause mortality. In 1992, the American College of Physicians recommended HRT for prevention of coronary disease. But around 2000s, it turned out to be a Pandora Box that led to many untoward complications. Several randomized trials in older women suggested coronary harm and that the risks, including breast cancer, outweighed any benefit.

However, reanalyzes of the randomized trial data, using age stratification, as well as newer studies, and meta-analyses have shown that younger women, 50-59 years or within 10 years of menopause, have decreased coronary disease and all-cause mortality; and did not have the perceived risks including breast cancer. This has brought about a "timing" hypothesis for benefits and risks of HRT, showing that younger women may have more benefits and few risks, particularly if therapy is predominantly focused on the estrogen component. This is an excellent of example of how the "uncertainties" swing a pendulum this way that way with the medicines we use. Needless to say, this demand rigorous inquires by the medical community, about the claims made by some manufacturers and continuous mindfulness about further research findings on their efficacy and safety.

Chondroitin Sulfate and Glucosamine Supplements - benefits may be modest


Chondroitin Sulfate and Glucosamine Supplements are two other compounds that are marketed profusely as effective in the treatment of pain and loss of function associated with osteoarthritis (OA). However, evidence has gathered through studies assessing their effectiveness that they give about only modest to no improvement compared with placebo in either pain relief or joint damage.

The US based Arthritis Foundation, a leading nonprofit organization dedicated to addressing the needs of people living with arthritis testifies this. Even the American College of Rheumatology in their osteoarthritis treatment recommendations published in 2012 does not recommend chondroitin or glucosamine for the initial treatment of osteoarthritis. It says chondroitin and glucosamine supplements alone or in combination may not work for everyone with osteoarthritis. However, it advises the patients who have seen improvements with these compounds to continue taking them, and has asserted they are safe to take long-term.


Reliance on medication

As it was said by Gandhi in her article the patients develop dependence on the medicines and supplements at the cost of life style and diet modifications. They seek the easy way out – not to exercise and not to stop overindulgence in eating, drinking and smoking, but to take medicines and supplements that claim to give out of this world benefits.

Gandhi has painted a perfect backdrop against which the medical community of this country could kindle further discussion on "what we should be prescribing, (devoid of certain industry’s claims)?"

Thank you Madam Gandhi, in fish oil, you have given us food for thought.


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