An Aspirin a Day?

It’s crazy when you think about all of the different kinds of foods we eat.  We just swallow – and hope it all works out for the best. Well – as it turns out there are better ways to think about keeping our bodies humming healthfully along. Welcome to Nutrition Facts – I’m your host Dr. Michael Greger. 

Feeling lousy? Well, take two aspirin and call me in the morning. OR…not. Today, on the podcast, we take a closer look at the health effects of regular aspirin use. 

In our first story, we weigh daily aspirin use against the risk of internal bleeding.

Salicylic acid, the active ingredient in aspirin, has been used for thousands of years as an anti-inflammatory painkiller in the form of willow tree bark extract, which Hippocrates used to treat fever and to alleviate pain during childbirth. It became trademarked as a drug in 1899, and remains, to this day, probably “the most commonly used drug in the world.” One of the reasons it remains so popular, despite the fact that we have better painkillers now, is that it also acts as a blood thinner. Millions of people now “take aspirin on a daily basis to treat or prevent [heart] disease.”

It all started back in 1953, with the publication of this landmark study in the New England Journal of Medicine: “Length of Life and Cause of Death in Rheumatoid Arthritis.” The paper started out with the sentence: “It has often been said that the way to live a long life is to acquire rheumatism.” They found fewer deaths than expected from accidents—which could be explained by the fact that people with arthritis probably aren’t out, you know, going skiing—but, also, significantly fewer deaths from heart attacks. Maybe, it was all the aspirin they were taking for their joints that was thinning their blood, and preventing clots forming in their coronary arteries, in their heart. And so, in the 1960s, there were calls to study whether aspirin would help those at risk for blood clots. And, in the 1970s, we got our wish—studies suggesting regular aspirin intake protects against heart attacks.

Today, the official recommendation is that low-dose aspirin is recommended for all patients with heart disease. But, in the general population, for those without a known history of heart disease or stroke, daily aspirin is only recommended when the heart disease benefits outweigh the risks of bleeding.

The bleeding complications associated with aspirin use may be considered “an underestimated hazard in clinical [medical] practice.” For those who’ve already had a heart attack, the risk/benefit analysis is clear. If you took 10,000 patients, daily low-dose aspirin use “would be expected to prevent approximately 250 major vascular events”—such as heart attacks, strokes, or, the most major event of all, death. But, that same aspirin would be expected to cause approximately 40 major extracranial bleeding events—meaning bleeding so bad you have to be hospitalized.

“Thus, the net benefit of aspirin for secondary prevention”—meaning like preventing your second heart attack—”would substantially exceed the bleeding hazard. For [every] 6 major vascular events prevented, [only about] 1 major bleeding event would occur.” So, “the value of aspirin for secondary prevention is not disputed.”

But, if you instead took 10,000 patients who had never had a heart attack or stroke—yet—and tried to use aspirin to prevent clots in the first place (so-called primary prevention), daily low-dose aspirin would only be expected to prevent seven major vascular events, at the cost of causing a hemorrhagic stroke (bleeding within the brain), along with three other major bleeding events.

So then, the benefits are only like two to one, which is a little too close for comfort—which is why the new European guidelines do not recommend aspirin for the general population, especially given the additional risk of aspirin causing smaller bleeds within the brain as well.

If only there were a safe, simple, side effect-free solution. And, there is. Ornish and Esselstyn proved that even advanced crippling heart disease could not only just be prevented and treated, but reversed, with a plant-based diet, centered around grains, beans, vegetables, fruits, with nuts and seeds treated as condiments—and no oils, dairy, meat, poultry, or fish.

Bill Castelli, long-time director of the longest running epidemiological study in the world—the famous Framingham Heart Study—was once “asked what he would do to reverse the [coronary artery disease] epidemic if he were omnipotent. His answer? “Have the public eat the diet…described by Dr. T. Colin Campbell.” In other words, he told PBS, if Americans ate healthy enough, “the whole [heart disease epidemic] would disappear.” Though, Esselstyn clarifies, we’re not just talking about vegetarianism. “This new paradigm” of heart disease reversal means “exclusively plant-based nutrition.”

Next up – we discover how the aspirin compounds naturally found in plant foods may help explain the lower cancer rates among those eating plant-based diets.

In people without a personal history of cardiovascular disease, the “risks of aspirin [may] outweigh [the] benefits.” But, aspirin may have additional benefits, as well.

“We have long recognized the preventative role of daily aspirin for patients with [heart] disease; however, it now appears that we can [hatch two birds from one egg].” Daily low-dose aspirin may also help prevent certain forms of cancer, as well.

In an analysis of eight different studies “involving more than 25,000 [people], the authors found a 20% decrease in risk of death from cancer among those…randomized to [a] daily aspirin.” You know, the search for effective and safe treatments for cancer remains an enormous, burdensome challenge. “If only we could stop cancer in its tracks—prevent it before it strikes.” Well, “[p]erhaps we can,” with this plant phytonutrient—salicylic acid—found in aspirin.

How does it affect cancer? Well, the Nobel Prize in Medicine went to the team that discovered how aspirin works. Enzymes named COX, cyclooxygenase, take the pro-inflammatory omega-6 fatty acid arachidonic acid that our body makes—or, we get directly in our diet, from mainly chicken and eggs—our enzymes take the arachidonic acid and turn it into inflammatory mediators, like thromboxane, which produces thrombosis (clots) and prostaglandins, which cause inflammation.

Aspirin suppresses these enzymes, though. So, less thromboxane means fewer clots. And, less prostaglandin means less pain, swelling, and fever. But, prostaglandins can also dilate the lymphatic vessels inside tumors, allowing cancer cells to spread. So, one of the ways cancer tries to kill us is by boosting COX activity.

That’s one of the ways we think aspirin can help prevent cancer—by counteracting tumor attempts to pry open the lymphatic bars on its cage, and spread throughout the body—because “the reduction in mortality due to some cancers occurred within 2 to 3 years after [aspirin was started].” That seems “too quick to be accounted for by an effect only on” the genesis (formation) of cancer. Cancer can take decades to develop.

So, the only way aspirin could save us that fast is by suppressing the growth and spread of tumors that already exist. Aspirin appeared to cut the risk of metastases in half—particularly for adenocarcinomas, like colon cancer.

So now, what about everyone taking a daily baby aspirin? Previous risk/benefit analyses did not consider the effects of aspirin on cancer, instead just balancing cardiovascular benefits with bleeding risks. But, these new cancer findings may change things.

If this was just the reduction of colon cancer risk, then the benefits might not outweigh the harms for the general public. But, now we have evidence that it works against other cancers, too. Even a 10% reduction in overall cancer incidence “could tip the balance” in favor of benefits versus risks.

So, how does the cancer benefit compare? As we saw before, using aspirin in healthy people just for cardiovascular protection is kind of a wash. By contrast, the cancer prevention rates might save twice as many lives. So, the benefits may outweigh the risks. If you put it all together, heart attacks, strokes, cancer, and bleeding, aspirin comes out looking protective overall—potentially extending our lifespan.

Yes, higher risk of major bleeding, even at low-dose aspirin, but fewer heart attacks, clotting strokes, and cancers. So, it maybe beneficial overall.

Now, note these age categories only go up to 74 years old, though. That’s because the risk of bleeding on aspirin increases steeply with age; and so, may tip the balance the other way. But, in younger folks, these data certainly have the research community buzzing. “The emerging evidence on aspirin’s cancer protection highlights an exciting time for cancer prevention.”

“In light of low-dose aspirin’s ability to reduce mortality from both vascular events and cancer to a very notable degree, it is tempting to recommend” low-dose aspirin for nearly everybody. However, aspirin pills, even at low doses, have “a propensity to damage [the lining of our stomach and intestines], and increase [the] risk for gastrointestinal bleeding; this fact may constrain health authorities from recommending aspirin for [the general population].” Recent meta-analyses estimate that just a single “year of low-dose aspirin therapy will induce major gastrointestinal bleeding…in one…out of 833 [people].”

If only there were a way to get the benefits, without the risks. The aspirin phytonutrient isn’t just found in willow trees, but throughout the plant kingdom. This explains why the active ingredient in aspirin is found normally in the bloodstream even in people not taking aspirin.

Then, drink just one fruit smoothie, and within an hour and a half, your levels rise. One smoothie ain’t going to do it; you need regular, daily fruit and vegetable consumption.

But, are these kinds of aspirin levels sufficient to suppress the expression of that inflammatory enzyme implicated in cancer growth and spread? Well, using umbilical cords and foreskins—where else are you going to get human tissue?—they found that even those low levels caused by smoothie consumption significantly suppressed the expression of that inflammatory enzyme at a genetic level.

Well, if this aspirin phytonutrient is made by plants, we might expect plant-eaters to have higher levels. And, indeed, not only did they find higher blood levels in vegetarians, there was an overlap with people taking aspirin pills. Some vegetarians had the same level in their blood as people actually taking aspirin. Vegetarians pee out as much of the active metabolite of aspirin as aspirin-users do, just because they’re eating so many fruits and vegetables.

“Because the anti-inflammatory action of aspirin is probably the result of [this active ingredient in aspirin—salicylic acid—], and the concentrations of [salicylic acid] seen in vegetarians [have] been shown to inhibit [that inflammatory COX enzyme] in vitro, [it’s] plausible that dietary salicylates may contribute to the beneficial effects of a vegetarian diet, although [they say] it seems unlikely that most omnivores would be able to achieve sufficient dietary intake of salicylates to have a therapeutic effect.” Though, they could certainly eat more fruits and veggies, too.

With effectively all that aspirin flowing through their systems, plant-eaters must have high ulcer rates, right? Aspirin can just chew through our gut. But no, vegetarians appear to have a significantly lower risk of ulcers, for both men and women.

So, for the general population, by eating plants instead of taking aspirin, we may not just get the benefits without the risks, we can get benefits—with benefits! How is that possible? Because in plants, the salicylic acid may come naturally pre-packaged with gut-protective nutrients.

For example, nitric oxide from dietary nitrates exerts stomach-protective effects by “boosting blood flow” and protective “mucus production” in the lining of the stomach—”effects [that] demonstrably oppose the pro-ulcerative impact of aspirin…”

“Dark green leafy vegetables…are among the richest dietary sources of nitrate.” But, of course, the researchers go on to say that, “Since it may be unrealistic to expect people to eat ample servings of [greens] every day,” we should just give people pills with their pills, right? Nitrate pills with their aspirin pills.

But, why not just eat our greens? People who’ve had a heart attack should follow their physician’s advice, which probably includes taking aspirin every day. What about everyone else? I think everyone should take aspirin—but, in produce, not pill form.

Finally today –­_­ we ask, “Should the active ingredient in aspirin be considered an essential vitamin?”

“The results of the recent aspirin meta-analyses—suggesting a reduction of cancer mortality by about one-third in subjects taking [daily low-dose] aspirin…, can justly be called astounding. Yet, the protection from ‘Western’ cancers enjoyed by [those eating more traditional plant-centered diets] is even more dramatic.”

Before the Westerization of their diets, animal products made up only about 5% or less of the Japanese diet. “Note that age-adjusted death rates from cancers of the colon, prostate, breast, and ovary were on the order of 5-10 [times] lower in Japan than in the US: [with] mortality from pancreatic cancer, leukemias, and lymphomas…3-4 fold lower. But, this phenomenon was by no means isolated to Japan; Western cancers were likewise comparatively rare in other…societies [where]…people ate plant-based diets.”

“The cancer protection afforded by lifelong consumption of a plant-based diet, in conjunction with leanness and insulin sensitivity [that tends to come along with it] may be very substantial indeed. Therefore, a “lifestyle protocol for minimizing cancer risk” may include a “whole-food plant-based diet.”

Now, if part of this cancer protection arises out of the aspirin phytonutrients in plants, are there any plants in particular that are packed with salicylates? Though salicylic acid, the main active ingredient in aspirin, “is ubiquitously present in fruits and vegetables,…herbs and spices contain the highest concentrations.”

Chili powder, paprika, turmeric have a lot, but cumin is like 1% aspirin by weight. Eating a teaspoon of cumin is like taking a baby aspirin. “Consequently, populations that incorporate substantial amounts of spices in foods may have markedly higher daily intakes of salicylates. Indeed, it has been suggested that the low incidence of colorectal cancer among Indian populations may be ascribed in part to high exposure to dietary salicylates throughout life from spice consumption.”

“The population in rural India” has “one of the lowest [rates of colorectal cancer] in the world, and a diet that could be extremely rich in salicylic acid”—given the “substantial amounts of [plant foods] flavored with large quantities of herbs and spices.” Some have proposed it’s the curcumin in the spice turmeric; but, maybe it’s the salicylic acid in cumin. And, the spicier, the better.

A spicy veggie vindaloo may have four times the salicylates of a milder Madras-style veggie dish. One meal, and you get a spike in your bloodstream like you just took an aspirin. So, eating flavor-filled vegetarian meals, with herbs and spices, may be more chemoprotective—meaning more protective against cancer—than just regular, more bland vegetarian meals.

We may also want to eat organic. “Because salicylic acid is a defense hormone of plants, the concentration…is increased when plants become stressed”—like when plants are bitten by bugs, unlike pesticide-laden plants. And, indeed, soups made from organic vegetables were found to have nearly six times more salicylic acid than soups prepared from conventionally-grown ingredients.

We should also choose whole foods. Whole-grain breads, which are high in salicylic acid, contain about a hundred times more phytochemicals than white bread: 800, perhaps, compared to 8. That does raise the question, though: what about the other 799?

“Interest in the potential beneficial effects of dietary salicylates has arisen, in part, because of the extensive literature on the disease-preventative effects of Aspirin™. However, it should not be forgotten that plant products found to contain salicylic acid are generally rich sources” of a whole long list of other phytonutrients—many of which have marked anti-inflammatory and antioxidant activity, as well. “Their potential protective effects should [therefore] not be overlooked.”

“In this context, the importance of dietary salicylic acid should not perhaps be over emphasized. Indeed, some believe that ‘salicylic acid deficiency’ has [such] important public health implications that it should be classed as an essential vitamin—namely ‘Vitamin S’.”

But, what they’re really saying is that we should all just have to eat a lot of plants.

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