Justify Your Vice

You went into the doctor’s lounge, saw that you were alone, and quickly appropriated one-half of the last chocolate covered doughnut, leaving the remainder and a dried out bagel for the last poor joker of a doctor on the half-a-doughnut diet who wandered in. I know it was you. Being a doctor in a hospital and having recently remaintained your certification via a quality improvement study of your own hand-washing habits, fabricating exactly none of the data, you used a plastic knife and only minimally touched the remaining part of the pastry in question, which I later stuffed into my mouth whole hog and washed down with the last bit of coffee in the urn. I of course did not make more coffee; I’m a busy man and that’s not my job. Surely the surgeons are looking for an excuse not to round or the infectious disease folks will soon be stopping by to push Sisyphus’ rock up the hill of antibiotic choice for lateral neck abscesses. One of them can do it. I do, however, have time to stand around for a bit to facilitate my digestion and to peruse the pictures in the newspaper before I render the lounge bathroom unusable for the next 30 minutes.

We all have our guilty pleasures, some openly displayed for all to see, some hidden downstairs under the fluorescents for the inquisitive to discover,¹ and some merely housed in the back recesses of the mind. Maybe the occasional demon rum intake, maybe a surreptitious heist of the kids’ painstakingly obtained Halloween candy, maybe things we do not dare mention. The vices of the pediatrician pale in comparison with those of the average rock-souled criminal, or at least I would like to believe, but let us not pretend that we maintain the top ranking in propriety without fail, as pediatricians or as doctors.

I have an idea.² What if, by utilizing our vaunted position as faculty at a research-oriented institution of higher learning, we were to focus our wandering eye of scientific inquiry directly on our gustatory vices in a high-brow attempt to justify them?

OK, so that’s been done. Many, many times, in fact, although almost entirely within the last 30 years. Maybe we have entered into a luxurious era of human existence during which we can afford to take a close look at our leisure activities and discuss at length why we enjoy them. Or the pressures of faculty existence have forced the issue. Well . . . since we are on the subject, we might as well see what “The Literature” has to tell us about a few common ingestible vices. Specifically, the first three that I thought of: chocolate, alcohol, and caffeine, studies on which come up in the media with some regularity. Standard, obligatory disclaimer of political correctness: chocolate obstructing your trachea can be deadly; too much champagne can be embarrassing; too much coffee turns your tongue brown, gives you bad breath, and makes you sweat more than you would otherwise.

Starting with a historical perspective, we have this summation from the British Medical Journal in 1995 regarding what the authors surmised was one of the earliest historically noted positive health effects of drinking alcohol: “In 1721 four condemned criminals were recruited to bury the dead during a terrible plague in Marseilles. The gravediggers proved to be immune to the disease. Their secret was a concoction they drank consisting of macerated garlic in wine, which immediately became famous as vinaigre des quatre voleurs (four thieves’ vinegar). It is still available in France today.” Going to France might be more fun, but you could whip some up yourself in case there is a plague outbreak.³ It might also work for orangutan flu or whatever apocalyptodemic comes our way next.

Wine, and red wine in particular, appears to be the most thoroughly investigated of liquid vices. The first PubMed reference I could find regarding red wine and health came along in 1962, in the Bulletin de l’Academie Nationale de Medecine, titled: “On some biological changes produced, in the swine, by the daily consumption of red wine.” From the French, of course. In the late 1980s, someone tapped a keg of alcohol-related studies and the party has been going on ever since, most likely spawned by the introduction of the concept of the “French Paradox.”⁴

Why do the French, despite their high intake of cholesterol and saturated fat, suffer so lightly from the ravages of atherosclerosis? It cannot simply be genetics, which would be unacceptably unfair, so it must be the . . . ummmmm . . . wine? Yeah. It must be the wine. They do drink a lot of it: 47.7 L per person per year in 2012. They even give it to their pigs! For comparison, Americans drank 9.2 L per person in 2012, according to the International Organization of Vine and Wine (www.oiv.int), who need to update their stats. What is it about the wine, then? Other than the stress-relieving effect of the alcohol, of course. That would be too obvious.

We can let one Alfred de Lorimier, MD, tell us. From his article in the American Journal of Surgery, in November 2000:⁵ “There are components of wine, particularly red wine, that do not exist in spirits, and are in low concentrations in beer and malt whiskey. These components are phenols: flavonoids, polyphenols, and nonflavonoid phenols.” This is also just 1 meager reason for red wine’s superiority to other beverages, and in following, to red wine drinkers’ superiority to those uncouth drinkers of beer and whiskey, if I am reading between the lines correctly. Dr de Lorimier prefaced his article by stating that he had been growing wine grapes in California since 1972, but before you judge, know this: Dr de Lorimier was a pediatrician of sorts, the sole founder of the division of pediatric surgery at the University of California, San Francisco,⁶ and pediatricians are not susceptible to biases. He recounts no less than 15 disease states that are affected favorably by the intake red wine, each of which will not be recounted here. The scientific scrutiny has mostly settled on a polyphenol named resveratrol as the magical agent of supreme health, which you may already know but I did not.

As for chocolate, here is a study that even I could rip apart if I were running journal club, more memorable perhaps for its literal content than its scientific import: “Effects of Chocolate Intake on Perceived Stress; A Controlled Clinical Study.”⁷ The introduction offers a sobering view of medical education: “Nearly all medical colleges have an authoritarian and rigid atmosphere that encourages competition instead of cooperation among learners. Students are subjected to endless working hours and examinations.” We all know that this has not been true since right after you finished your training. Now it is all lollipops and napping.

The study: for 2 weeks, 60 medical students in Saudi Arabia were given 40 g per day of milk chocolate, dark chocolate, or white chocolate and a couple of questionnaires. Among the exclusion criteria: “Females who were expected to undergo menstrual phase of uterine cycle during chocolate eating phase.” What? An exclusion for premenstrual syndrome (PMS)?

And now I find myself on thin ice. Listen, it is not my study.

Anyhoo, after a “thorough probing of the results,” the authors arrived at a bold conclusion: “Dark and milk chocolate appear to be an effective way to reduce perceived stress in females.” This, of course, is due to the flavonoids found in milk and dark chocolate, but not in white chocolate. My conclusion is that white chocolate and PMS are not a good combo.

And now I have fallen through the ice. OK, OK. Men are too obtuse to perceive the subtle, soothing effect of a fine milk chocolate. Better? Try not to be so touchy. That, of course, completes my chocolate inquiry.⁸

What can we learn about caffeine? Well, caffeine research has largely focused on how it prevents some bad things and does not promote other bad things, most of which you can probably recite. That is just splendid, but my focus is on how much is too much, which will be much more useful to me tomorrow morning. Cutting right to the chase, PubMed lists 19 reported cases of fatalities due to excessive caffeine intake. From this we can reasonably surmise that such deaths are not terribly common.⁹ None of the individuals in this group were drinking coffee or energy drinks, at least not as their primary source of caffeine. The caffeine doses involved were not known in all cases, nor were the blood levels of caffeine, although when known the blood levels ranged from 117 to 350 mg/L and the doses were in the 5 to 10 g range. This translates to more coffee than you can ingest in the next 5 minutes.¹⁰ Go ahead, try it. Then call your mother and tell her you have acted poorly, once you are done vomiting. Coffee does not kill people.

But NoDoz can. Now we pause for silent reflection.

This page of the Archives of Internal Medicine (October 1979, volume 139, p. 1194) may be the most entertaining page of a medical journal ever produced, complete with an extraordinary diagram. You will thank yourself if you probe the Internet and extract this page.¹¹ Do It! The letter to the editor that I was digging out described the case of a man with ongoing nervousness, tachycardia, sweating, headaches, and chest discomfort, who after fruitlessly enduring the removal of an adrenal for “pheochromocytoma” (not my quotes), came to an endocrinologist for evaluation. Only later did he choose to divulge that he drank 30 to 40 cups of coffee daily, which is a much more reasonable goal than that mentioned earlier and does not involve the vengeful disciplinary actions of your mother. Naturally, further testing ensued, and his other adrenal was eventually removed.¹² From this single case report,¹³ we can conclude with confidence that a cup in the afternoon to facilitate paperwork, even after 20 or so cups on rounds in the morning, is not harmful. Just watch out for the surgeons and fess up to your caffeine intake if iatrogenic Addison disease is not on your bucket list, should it come to that.

Dark chocolate, caffeine, and red wine. Mmmm, yummy. These can be enjoyed together in a neat package called a “Sweet Pick-Me-Up.”¹⁴ Alternatively, you can get your resveratrol in pill form and slam some straight up ethanol, but popping a couple of pills and drinking jet fuel when you get home from a long day pediatricianing does not sound nearly as inviting as enjoying some winewhile reading Hospital Pediatrics¹⁵by the firein your barrister’s chairin the denwith your luxury dogon your lap.

But you do not really need any wine. Lounging on a lawn chair in the garage next to the rat hole in your underwear with a root beer, covertly perusing your back issues of Guns & Ammo may be may be just as pleasurable. You could also partake of a pot or two of coffee and no more than 40 mg of brownish chocolate, but you can do without these as well. How about just relaxing for part of the day moderately enjoying whatever you enjoy and not trying to justify it with some silly trumped-up evidence of its fortuitous benefits to your health?

Perhaps the scientific community should reorient some of its enthusiasm for vice-related study toward other, more pressing areas of inquiry, at least until we have solved cancer and eradicated scabies, for starters. As for me, my boss will probably agree that I have not demonstrated the necessary capacities and motivations for that kind of thing. And he might be right. So I’m off the hook. You, you . . . you are The Man.¹⁶

References

1. Model airplanes or bonsai, for instance.

2. Freak occurrence.

3. Four Thieves’ Vinegar:2 tbsp chopped fresh lavender flowers2 tbsp chopped fresh rosemary2 tbsp chopped fresh mint2 tbsp chopped fresh sage2 tbsp chopped fresh marjoram2 tbsp chopped fresh anise hyssop4 cloves garlic (peeled and crushed)1 quart white wine or apple cider vinegar (preferably raw)Instructions1. Toss herbs and garlic together in a one-quart mason jar, cover with vinegar and allow them to marinate for seven to ten days in a sunny location. After seven to ten days, strain the vinegar through a fine-mesh sieve into a second, clean 1-quart glass jar.2. Store at room temperature until ready to use and serve as you would any seasoned vinegar: as a basis for vinaigrettes or as a seasoning for braised meats and vegetables.3. Drink voluminously in case of plague.

4. Renaud S, de Lorgeril M. Wine, alcohol, platelets, and the French paradox for coronary heart disease. Lancet. 1992;339(8808):1523–1526

5. de Lorimier AA. Alcohol, wine, and health. Am J Surg. 2000;180(5):357–361

6. A nice tribute: http://pedsurg.ucsf.edu/about-us/alfred-a-de-lorimier,-md-1931-2009.aspx. Accessed April 2015

7. Al Sunni A, Latif R. Effects of chocolate intake on perceived stress; a controlled clinical study. Int J Health Sci (Qassim). 2014;8(4):393–401

8. I have a long list of other studies proving all of my assertions, 8a, 8b but let us not pretend that you will contact me to get this list.

8a. Eloquent words of wisdom from one of these articles: “Forgoing the possibility of a positive outcome may result in regret at a missed opportunity but nothing more, whilst failing to react to negative stimuli may be fatal instantaneously.” 8c Words to live by.

8b. Higdon J, Frei B. Coffee and Health: A Review of Recent Human Research. Critical Reviews in Food Science and Nutrition. 2006;46:101–123. I could not not reference an article that had an author named Balz Frei, which I believe is the German term for “commando.”

8c. Vasiljevic M, Pechey R, Marteau TM. Making food labels social: The impact of colour of nutritional labels and injunctive norms on perceptions and choice of snack foods. Appetite. 2015;Apr 1;91:56–6.

9. These case reports span from 2005 through the present. For comparison, hot dogs killed at least 16 children during the period of 1989 to 1998.9a Real dogs? About 17 per year.9b Is that comparing apples to oranges? Maybe. Death toll from apples during that period, by the way: 5.9a

9a. Altkorn R, Chen X, Milkovich S, Stool D, Rider G, Bailey CM, Haas A, Riding KH, Pransky SM, Reilly JS. Fatal and non-fatal food injuries among children (aged 0–14 years). Int J Pediatric Otorhinolaryngology. 2008;72(7):1041–1046.

9b. Dogsbite.org. Accessed June 2015. Your pit bull is ill-tempered, even if you raised it.

10. I lost the reference, but I swear that I did not invent this stat: Peak blood levels of caffeine are 2 to 4 mg/L after the ingestion of 120 mg of caffeine (a strong cup). Ergo: 90 cups of coffee = blood level of 300 mg/L. That would probably do it. Do not double-check my math; I was a mathlete.

11. Go to Pubmed.gov, enter exactly these words into the search engine: coffee stoffer, click on the Archives of Internal Medicine full text link, read carefully.

12. What I refer to as a “victim of overzealous medicine.” You likely know a few of these poor creatures.

13. Jenny McCarthy loves anecdoctal evidence; you do too. You Do Too. YOU DO TOO.

14. Ask your local bartender. Or look it up on seriouseats.com.

15. Shameless semi-self-promotion. Maybe you prefer National Geographic.

16. More thin ice. I mean the gender-neutral man, of course. Chris or Peyton, perhaps?¹⁶

• Copyright © 2015 by the American Academy of Pediatrics