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BMJ 2004;329:1447-1450 (18 December), doi:10.1136/bmj.329.7480.1447
The limits of medicine
The Polymeal: a more natural, safer, and probably tastier (than the Polypill) strategy to reduce cardiovascular disease by more than 75%

Oscar H Franco, scientific researcher1, Luc Bonneux, senior researcher2, Chris de Laet, senior researcher1, Anna Peeters, senior researcher3, Ewout W Steyerberg, associate professor1, Johan P Mackenbach, professor1

1 Department of Public Health, Erasmus MC University Medical Centre Rotterdam, PO Box 1738, 3000 DR Rotterdam, Netherlands, 2 Belgian Health Care Knowledge Centre (KCE), Wetstraat 155, B-1040, Brussels, Belgium, 3 Department of Epidemiology and Preventive Medicine, Monash University Central and Eastern Clinical School, Melbourne, Australia

Correspondence to: O H Franco o.francoduran@erasmusmc.nl

Abstract

Objective Although the Polypill concept (proposed in 2003) is promising in terms of benefits for cardiovascular risk management, the potential costs and adverse effects are its main pitfalls. The objective of this study was to identify a tastier and safer alternative to the Polypill: the Polymeal.

Methods Data on the ingredients of the Polymeal were taken from the literature. The evidence based recipe included wine, fish, dark chocolate, fruits, vegetables, garlic, and almonds. Data from the Framingham heart study and the Framingham offspring study were used to build life tables to model the benefits of the Polymeal in the general population from age 50, assuming multiplicative correlations.

Results Combining the ingredients of the Polymeal would reduce cardiovascular disease events by 76%. For men, taking the Polymeal daily represented an increase in total life expectancy of 6.6 years, an increase in life expectancy free from cardiovascular disease of 9.0 years, and a decrease in life expectancy with cardiovascular disease of 2.4 years. The corresponding differences for women were 4.8, 8.1, and 3.3 years.

Conclusion The Polymeal promises to be an effective, non-pharmacological, safe, cheap, and tasty alternative to reduce cardiovascular morbidity and increase life expectancy in the general population.

Introduction

Cardiovascular disease continues to be the leading cause of mortality and morbidity in Western populations.1 Although several risk factors for cardiovascular disease have been identified, its prevention is still suboptimal owing to high costs, low compliance, and side effects of treatment. In 2003 Wald and Law introduced the concept of the Polypill.2 The advocates of the Polypill selected six pharmacological components that by modifying different risk factors of cardiovascular disease multiplicatively might reduce the levels of cardiovascular disease in the population by more than 80%.2 In general, the medical community has welcomed the concept but questioned the potential adverse effects and costs of such an intervention.

Our objective was to define a safer, nonpharmacological, and tastier alternative to the Polypill in the general population: the Polymeal. We also wanted to calculate the potential effects of the Polymeal in terms of total life expectancy and life expectancy with and without cardiovascular disease.

Methods

The recipe
To optimise the Polymeal ingredients we used an evidence based diet conceptual framework, which follows similar principles to evidence based medicine.4 The constituting elements of a meal or recipe are selected on the basis of the best available evidence; the evidence available for each ingredient is graded according to the level of evidence. We searched PubMed, informed by expert advice, for nonpharmacological ingredients with evidence levels 1 or 2: randomised controlled trials, meta-analyses of randomised controlled trials, and meta-analyses of observational studies.5 To be included in the Polymeal, the ingredient had to have individually reported effects (not as an element of a diet) on reduction in cardiovascular disease events or modification of risk factors for cardiovascular disease. We checked papers retrieved for further possible ingredients. The following dietary elements met the inclusion criteria to be ingredients of the Polymeal: wine, fish, dark chocolate, fruits and vegetables, almonds, and garlic (Allium sativum).

Efficacy of the Polymeal
We obtained information from the literature on the benefits of the interventions (table 1). Daily consumption of 150 ml of wine reduces cardiovascular disease by 32% (95% confidence interval 33% to 41%).6 Fish (114 g) consumed four times a week reduces cardiovascular disease by 14% (8% to 19%).7 For chocolate, fruits and vegetables, almonds, and garlic, we found data on modification of risk factors for cardiovascular disease. One hundred grams of dark chocolate consumed daily reduces systolic blood pressure by 5.1 mm Hg and diastolic blood pressure by 1.8 mm Hg8; similar reductions in blood pressure correspond to a reduction in cardiovascular disease events of 21% (14% to 27%).9 A total of 400 g of fruit and vegetables consumed daily produced a reduction in blood pressure similar to that observed with chocolate (4.0 mm Hg systolic blood pressure and 1.5 mm Hg diastolic blood pressure), so we decided to assume the same reduction in cardiovascular disease effect as assigned for chocolate (21%).10


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Table 1 Effect of ingredients of Polymeal in reducing risk of cardiovascular disease



Daily consumption of garlic reduced total cholesterol concentrations by 0.44 mmol/l (17.1 mg/dl),11 12 corresponding to 66% of the reduction (0.66 mmol/l) that was found to be associated with a 38% reduction in cardiovascular disease at age 50.13 Therefore, we considered 66% of the effect previously reported and assumed a reduction of 25% (21.7% to 27.7%) in cardiovascular disease events for garlic. Most of the randomised controlled trials included in the meta-analysis used 600-900 mg/day of dried garlic powder preparations, equivalent to 1.8-2.7 g/day of fresh garlic.14 We selected 2.7 g/day of fresh garlic for the Polymeal. Consuming 68 g/day of almonds produced half the reduction in total cholesterol (10 mg/dl) observed with garlic,15 16 so we assumed a reduction in cardiovascular disease half the one assigned to garlic.

We calculated the combined effect of the ingredients of the evidence based diet Polymeal by multiplying their correspondent relative risk estimates. This is the same method that was used for the Polypill.