Shehryar R. Sheikh
Cleveland, Ohio, United States

 

Portrait of Hippocrates from the Magni Hippocratis Coi opera omnia. Credited to Lugduni Batavorum, 1665. Wellcome Library (London).

In my opinion, nobody would have even sought for medicine, if the same diets (διαιτήµατα) had suited both the sick and those in health.”¹ – Hippocrates, from the treatise “Ancient Medicine” written around 400 BCE

His edict on food is as well known as the tenets of the oath that carries his name: let food be thy medicine, and medicine thy food. But for all the adulation given to the “first physician,” his decree on the importance of food in the practice of medicine has carried little weight in the training of the modern physician. Hippocrates’ contemporary disciples in the United States received less than twenty hours of didactic training in nutritional science during their four years of medical school,² and only 15% of early-career physicians feel comfortable to provide nutritional counseling to their patients.³ But where medical schools give perilously little attention to the role of food in medicine, popular health science is only too happy to fill in, adopting the language of wellness and holistic healing. Kale smoothies help clear “toxins,” quinoa is a “super food,” and apple cider vinegar lowers cholesterol—such are the providential purported properties of the contents of your grocery cart. Does it follow, then, that the modern gurus of wellness, armed with their chia seeds and organic avocados, are more loyal adherents of Hippocrates’ edicts than those who swear his oath? And perhaps more importantly: does it matter?

The Corpus Hippocraticum, composed of the sixty odd texts attributed to the great physician and his disciples, is broad and far-reaching; it is no trivial task to distill a unifying philosophy of this ancient brand of medical science. Nonetheless, it is reasonable to suggest that the essential element of Hippocratic medicine was the notion that disease was a “natural” part of the human condition and not the result of stochastic and capricious divine intervention.^4,5 This is perhaps nowhere better exemplified than in his discussion of the “falling-sickness”:

“Epilepsy is not more divine a disease than any other disease. People call it divine because they do not understand it. But if we call divine all things we do not understand, then divine things will be endless.” ^4,5

For Hippocrates, the natural cause of disease was an imbalance between the fundamental humors: blood, phlegm, yellow bile, and black bile. A realignment of the humors was all that was needed to restore the patient to health. To this end, food fulfilled a fundamental imperative: if it was adequately prepared and constituted to the specificities of a patient’s disease, it could cause a humoral re-balancing and be curative. Essential to the role of food as a curative agent was its ability to become part of the human body. That which was ingested metamorphosed and relinquished its “itness” to become part of the substance of man (a paradigm not unlike that of a young rabbi who would appear some four centuries later with talk of transubstantiating bread and wine).

The Hippocratic physician may well view with consternation the notion that food was only that which was ingested—for the air itself would enter the human and become a part of the body and was thus no less a member of the category.⁶ The nature of food, then, was entirely at odds with that of medicine. While food changed itself to become human substance (muscles, nerve, membrane etc.), medicine changed the substance itself in order to restore balance in the quantity or quality of the humors.⁶ Food and medicine, then, constituted two entirely distinct avenues of treatment for the disciples of Hippocrates. The dietetic road was available to change the humoral balance through careful modulation of food, drink, and the environment. Medicine, meanwhile, was an intervention that changed the substance of the patient itself and was considered only in the face of infirmity. How, then, do we reconcile this paradigm of food and medicine as entirely distinct entities with the famously Hippocratic notion of “food as medicine”?

The simplest answer to this apparent conundrum is that Hippocrates never actually made the illustrious claim that is so effortlessly credited to him. There is no phrase in the Corpus attributed to Hippocrates himself that closely approximates the oft cited “let food be thy medicine.”^6,7 The closest formulation that we can find lives in a post-Hippocratic text entitled De alimento:

In food excellent medication [pharmakeiē], in food bad medication [pharmakeiē], bad and good relatively.^6,8

The text from which this phrase is sourced is believed to be of the Hellenic age, written at least a century after the time of Hippocrates. Nonetheless, it falls squarely into the realm of antiquity and is worthy of consideration as evidence of the notion that food and medicine were not as distinct in the classical tradition as we may at first have thought. This phrase introduces the subtle nuance that while food and medicine may be distinct in their roles in the treatment of disease, there may be instances of overlap. A second and vital textual reference that emphasizes the role of diet in antiquity medicine is found in the edicts of the “the Oath”:

“I will apply dietetic measures for the benefit of the sick according to my ability and judgement; I will keep them from harm and injustice.”⁹

It is a strange irony that while much of the contemporary public is likely to know little more of Hippocrates than that the Oath is attributed to him, there has never been any evidence that Hippocrates even knew of the text—let alone that he wrote it or approved of it in any way.¹⁰ The time when it was written is itself substrate for ample debate, though 400 BCE is a popular estimate. Irrespective of the veracity of its authorship, however, the mention of dietetic measures in the oath speaks volumes for the ancient reverence of diet as a force for improving the human condition.

The contrast between the priority given to diet in the pre-modern medical tradition and the cursory way in which it is treated in modern medical education is striking—no less so in light of the current public health pandemic of obesity and the chronic metabolic syndrome.¹¹ As this is well understood to be amongst the most important modifiable risk factors in contemporary medicine, one is compelled to ask why we continue to provide such limited focus on nutritional health in the training of modern day physicians. One explanation seems to be particularly worthy of consideration. The physician of today is trained to accomplish a task that is altogether different from that envisioned by the likes of Hippocrates. The modern physician largely focuses on  restoring patients to a state of health; the task of building a body that is pre-emptively fortified against disease by its very constitution and “substance” belongs to others. That is not to say that modern clinics are not the site of discussions about healthy dietary choices. Indeed, an annual check-up (in societies where such luxuries are available!) is likely to feature at least a cursory mention of portion-size and glycemic index. Nonetheless, the emphasis of modern preventive medicine continues to be on inoculations and screening rather than on dietary modulation as a course of treatment. To many physicians, the sobering reality is that there is simply no good way to reliably produce changes in dietary behavior. Where the patient of antiquity might have taken seriously the physician’s prescription to give up bread, a contemporary patient may be more likely to live with the cognitive dissonance of knowing what he should do while feasting at will.

If physicians have left vacant the post of using diet to ensure health, it is not surprising that others have taken up the mantle. An ever burgeoning industry offers cures through “holistic wellness,” promising liberation from “toxins” and “inflammation”—and also from the need for allopathic intervention. The situation is made worse by the abhorrence many physicians harbor for the presumed charlatanry of the “wellness industrial complex”;¹¹ the very mention of a “detox cleanse” may be enough to make a modern physician reel. Yet modern medicine has focused so intently on the sympathy of “popular health” for non-evidence based treatments that it has failed to notice something that the wellness gurus are clearly doing right: they are talking about food as medicine. In so doing, they are endowing food with the same importance, priority, and gravity that the ancient physicians did. While Hippocrates may have seen meaningful differences between food and medicine, it is uncontested that both were of primordial importance in the treatment of the patient. Clearly, a return to an emphasis on the role of food in the health of our patients is not only necessary given the current public health crisis—it is a long-awaited return to the historical roots of our craft.

 

References

1. Jouanna J. De l’ancienne médecine. Vol 1: Les belles lettres; 2003.
2. Adams KM, Kohlmeier M, Zeisel SH. Nutrition Education in U.S. Medical Schools: Latest Update of a National Survey. Academic medicine : journal of the Association of American Medical Colleges. 2010;85(9):1537-1542.
3. Vetter ML, Herring SJ, Sood M, Shah NR, Kalet AL. What Do Resident Physicians Know about Nutrition? An Evaluation of Attitudes, Self-Perceived Proficiency and Knowledge. Journal of the American College of Nutrition. 2008;27(2):287-298.
4. Yapijakis C. Hippocrates of Kos, the father of clinical medicine, and Asclepiades of Bithynia, the father of molecular medicine. Review. In vivo (Athens, Greece). 2009;23(4):507-514.
5. Jones W. Hippocrates Collected Works I. Cambridge Harvard. University Press; 1868.
6. Cardenas D. Let not thy food be confused with thy medicine: The Hippocratic misquotation. e-SPEN Journal. 2013;8(6):e260-e262.
7. Witkamp RF, van Norren K. Let thy food be thy medicine…. when possible. European journal of pharmacology. 2018.
8. Joly R. De L’aliment. . Paris: Belles Lettres; 1967.
9. Edelstein L. The Hippocratic Oath: text, translation and interpretation. Ancient medicine: selected papers of Ludwig Edelstein. 1943:3-63.
10. Miles SH. The Hippocratic Oath and the ethics of medicine. Oxford University Press; 2005.
11. Gunter J. Worshipping the False Idols of Wellness. The New York Times2018.

 

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SHEHRYAR R SHEIKH, BA is a fourth year medical student at the Cleveland Clinic Lerner College of Medicine. Originally from Lahore, Pakistan, he completed his undergraduate training at Harvard College. He hopes to pursue post-graduate training in neurosurgery.

 

Highlighted in Frontispiece Volume 11, Issue 1– Winter 2019

Summer 2018  |  Sections  |  Food