ESSAY
Justify Your Vice
Jeffrey Robert Van Blarcom, MD
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
www.hospitalpediatrics.org
DOI:10.1542/hpeds.2015-0149
Copyright © 2015 by the American Academy of Pediatrics
Address correspondence to Jeffrey Van Blarcom, MD, FAAP, Department of Pediatrics, Primary Children’s Hospital, 100 North Mario
Capecchi Way, Salt Lake City, UT 84113. E-mail: [email protected]
Division of Pediatric
Inpatient Medicine,
Department of Pediatrics,
University of Utah, Salt
Lake City, Utah
HOSPITAL PEDIATRICS (ISSN Numbers: Print, 2154-1663; Online, 2154-1671).
FINANCIAL DISCLOSURE: The authors have indicated they have no financial relationships relevant to this article to disclose.
FUNDING: No external funding.
POTENTIAL CONFLICT OF INTEREST: The author has indicated he has no potential conflicts of interest to disclose.
HOSPITAL PEDIATRICS Volume 5, Issue 12, December 2015
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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
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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
VAN BLARCOM
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.
3. Four Thieves’ Vinegar:
2 tbsp chopped fresh lavender flowers
2 tbsp chopped fresh rosemary
2 tbsp chopped fresh mint
2 tbsp chopped fresh sage
2 tbsp chopped fresh marjoram
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 wine
2 tbsp chopped fresh anise hyssop
4 cloves garlic (peeled and crushed)
1 quart white wine or apple cider
vinegar (preferably raw)
Instructions
1. 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.
while reading Hospital Pediatrics15
by the fire
in your barrister’s chair
in the den
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.
with your luxury dog
on 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 vicerelated 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. 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.
HOSPITAL PEDIATRICS Volume 5, Issue 12, December 2015
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 5 blood level of 300 mg/L.
That would probably do it. Do not doublecheck 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
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