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Article

Neither Body nor

Brain: ComparingPreventive Attitudesto Prostate Cancerand Alzheimers Disease

Annette LeibingUniversity of Montreal, Canada

Antje KampfUniversity of Mainz, Germany

Abstract

This article compares health promotion attitudes towards prostate cancer andAlzheimers disease. Our aim is to demonstrate that these two apparently distinctconditions of the aging body one affecting the male reproductive system, theother primarily the brain are addressed in similar fashion in recent public healthactivities because of a growing emphasis on a cardiovascular logic. We suggestthat this is a form of reductionism, and argue that it leaves us with a dangerousparadox: while re-transcending, at least partially, the conceptual separation of bodyand brain, it clouds much-needed discussion and research, such as contingentissues of socio-economic and socio-cultural disease disparities.

Keywords

Alzheimers disease, body/brain, cardiovascular logic, prevention, prostate cancer

Two Organs and a Third

A walk through a brain and a prostate is the title of a recent pressrelease describing the larger-than-life interactive models of human

Corresponding author:

Annette Leibing, University of Montreal, CP 6128, succ. Centre-ville, Montreal, QC H3C3J7,

Canada.

Email: [email protected]

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19(4) 6191

The Author(s) 2013

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DOI: 10.1177/1357034X13477163bod.sagepub.com

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organs used at the 2009 MEDICA exhibition in Dusseldorf, Germany

(Heimann, 2009). The text describes the educational purpose of thosemodels and mentions that only the heart could not be included in the

event: given that a scale model of the heart would have to stand 4.5meters tall, no room was high enough to hold it. The following year,

however, the organizers explained that the heart would get its meritedplace of honor in the courtyard of the Dusseldorf congress center.

While the title of the initial press release coincidentally mentionsthe two organs this article aims to discuss the brain and the

prostate it is this third organ that occupies a place of honor in ouranalysis: the heart, standing for cardiovascular health, which we per-ceive to be increasingly central to current biomedical thinking. Theromantic heart is often associated with an intuitive and true under-

standing of the world There is no instinct like that of the heart,said Byron and so can be broken with grief, perhaps through a lost

love. A more contemporary correlation is made between stress andheart disease, a notion which has held since the 1950s (Rothstein,2003).1 And while stress is a notion that mainly implies forces

beyond ones control such as modernization, society, and work

conditions cardiovascular health, as it is now often used in biome-dical reasoning, is intrinsically linked to individual acts of preven-tion. As several authors have shown, lifestyle choices and behaviorare ideally made by a responsible, reflexive individual the same

individual that neoliberal regimes posit as the ideal citizen (Burchell,1996; Castel, 1991; Crawford, 2006; Foucault, 1991; Greco, 2006;Petersen and Lupton, 1996; Rose, 1999a; Rose and Novas, 2005).Cardiovascular disease is generally described as an outcome of poorlifestyle choices, leading to conditions that involve narrowed or

blocked blood vessels that can lead to a heart attack, chest pain(angina) or stroke. . . . Many forms of heart disease can be preventedor treated with healthy lifestyle choices.2 These conditions arecentral to what we call a cardiovascular logic. By this we mean a

widespread and readily accepted etiological construct that explainsa growing number of health conditions and not only heart attack,

chest pain, or stroke most of which were previously consideredseparate pathologies. These conditions have become interconnected

through a common underlying cardiovascular pathway that canhardly be distinguished from attitudes towards prevention. It is remi-niscent of stress theory, set out in the mid 20th century, in its

62 Body & Society 19(4)

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unspecific way of explaining almost everything (Viner, 1999). In this

way, a cardiovascular logic draws attention to what we see as a specificbiomedical reductionism3 which can be found circulating in a variety of

texts and images, from the popular media to specialized biomedicalpublications. One example of this is the March 2010 issue of the Ger-

man newsmagazine Focus (2010). In large font the headline on itstitle page states that not only behavior (here, diet) prevents the mostdiverse conditions, but that the underlying cause of all these condi-tions is of a cardiovascular nature: The heart diet: the right nutrition

avoids cardiac disease, rheumatism, diabetes, and dementia.The growing importance of a cardiovascular logic does not replace

genetics or the neurosciences two fields thought by many socialscientists to dominate current biomedical reasoning, resulting in a

pervasive genetic worldview (Petersen, 2006), neurocentrism(Pitts-Taylor, 2010), or brainhood (Vidal, 2009). Instead, we see the

cardiovascular health paradigm as coexisting with, but increasinglydominating, health-related thinking, sometimes even effacing geneticsand the neurosciences as explanatory reference points. As one Canadiannutritionist puts it: Im amazed by the number of people who blame

genetics for developing disease. . . . Its as if it doesnt matter whetherwe . . . manage our weight, [and] eat whole foods . . . (Holly, 2005).

An important value that comes with a cardiovascular logic is theidea of having control over ones health, in line with current notions

of self-care in public health (Ziguras, 2004). In the field of geneticsthe more recent focus on epigenetics an antidote to the idea that weare hard-wired by our genes (Bird, 2007) has led, to a certaindegree, to the idea that an individual can have control over relatively

common causes of fatality due to genetic determinism. GeneticistThomas Lerner, for instance, states that a number of studies suggestthat epigenetic modifications impact behavior, and . . . those effectscan be reversed (cited in Carey, 2010). In a similar vein, cardiologistDonald Lloyd-Jones writes that: health behaviors can trump a lot of

your genetics. . . . This research shows people have control over theirheart health (Northwestern University, 2010).

Within the neurosciences, discoveries related to the plasticity ofthe brain (neuroplasticity), and the well-known mantra of brain

training through regular activities such as completing crosswordpuzzles or learning languages (use it or lose it), now lead scientiststo suggest that people can work on,and evenhave a certain control

Leibing and Kampf 63



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over, their own cognitive capacities. Yet, the certainty that people can

prevent cognitive decline is being challenged by studies suggestingthat these kinds of activities do not necessarily influence cognitive

health (Pap et al., 2009). And, as will be shown below, neuro-prevention is also increasingly linked to activities related to cardiovas-

cular health.A cardiovascular logic further implies a new holism, because it

transcends the more traditional division between mental and physicalhealth reinforced in most biomedical realms. The ubiquitous exam-

ple of exercise being generally associated with physical but not withmental health is now giving way as a result of this new holism toa belief that exercise impacts on conditions like depression or schizo-

phrenia. Titles such as Walking away the blues: Exercise for depres-

sion in older adults (Dang, 2010; see also Mead et al., 2008) or Eatright, keep fit the number two prevention recommendation of the

Canadian Mental Health Association (2010) show this change ofmind.4 However, there is some evidence that a greater part of the

putative therapeutic effect of exercise on depression is determinedby patient expectations, ongoing symptom monitoring, attention,

and other nonspecific factors (Blumenthal et al., 2007).5

In order to deepen our argument regarding the persuasiveness of acardiovascular logic, we will provide a short discussion on some ofthe many origins of this logic, followed by a comparison of recent

developments regarding two apparently very different conditions:Alzheimers disease and prostate cancer. Both conditions, when seenthrough the lens of a cardiovascular logic, lose their distinctiveness toa certain extent; they become different outcomes of a common etio-logical pathway. Beside the improvements that should come with

being fit, slim and non-smoking, this pathway also reflects a numberof interests unrelated to an improvement in health (such as a respon-sible individual becoming less dependent on state health provisionsor showing an increased need for certain medications due to a strong

emphasis on preventive pharmacological acts). The pathway furthergoverns people in that new groupings of morally good and bad

individuals come to life: these new emotional agendas (Rosenberg,1997) differ from earlier moral ideas linked to health in that nowadays

it is almost impossible to escape the responsibility to stay healthy.A cardiovascular logic, we argue, is creeping into every corner ofreasoning regarding health problems. Its moral impact is becoming




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unavoidable: Unlike geneticism or neurocentrism, which still involve

a measure of fate (ultimately we are not responsible for our genes orbrains), a cardiovascular logic leaves us almost no more opportunity

for just being sick (except maybe with a broken ankle).The following comparison is based on data stemming from the two

authors long-standing research on Alzheimers disease and prostatecancer, in which both have analyzed the sources of change regardingeach condition. Relying on this previous work, in which we appliedsome of the principles of discourse analysis to relevant documents,

our aim is to construct parts of the recent history (see Rose, 1999a,1999b) of the cardiovascular logic as an important paradigm in cur-rent public health. And although those kinds of data are not explicitlyused in this article, insights exposed in earlier publications on Alzhei-

mers disease certainly did draw upon empirical data stemming fromfieldwork in different clinical and national settings.

We are aware of the situatedness of biomedical facts, but our aimhere is to show a general trend that influences, to different degrees,an increasing number of individuals around the world. Even whenwe identify specific, seemingly isolated examples (such as the German

exhibition noted above), we see them as local manifestations of thisgeneral trend.

The Multiple Origins of a Cardiovascular Logic

A number of authors have described a new paradigm of health(Moore, 2010) or a new public health (Petersen and Lupton,

1996), starting more or less in the 1950s, a decade which saw a num-ber of changes in attitudes towards health, such as the developmentof a risk factor concept and at-risk groups, along with an increasedturn towards prevention with a specific focus on self-care and

behavior (e.g. Rothstein, 2003; Timmermann, 2011).6 According toArmstrong (2009, 2010), the idea that behavior is a medical prob-

lem gained currency at this time, when it started to become linked toan individuals agency and was situated as a central target of health

interventions (similar to lifestyle a notion that appeared at the endof the 1970s in western medical texts). During the 1950s, a growing

concern with human behavior (e.g. Konrad Lorenz on aggression;Alfred Kinsey on sexual behavior) paved the way for landmark stud-ies such as Friedman and Rosenmans (1959)research on the role of




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cholesterol in narrowing coronary arteries, which was then reformu-

lated in terms of human behavior (e.g. type A behavior). Thewidely cited Framingham Heart Study (cf. Levy and Brink, 2005;

Oppenheimer, 2005), initiated in 1948, when little was known aboutthe causes of coronary heart disease, had an important impact on

biomedical reasoning (see Mullner, 2007; Timmermann, 2006;Riska, 2000).7

In the 1980s particularly in North America a major concern wasthe adoption of a low-fat diet to prevent heart disease (a movement

which actually began in the 1940s): Many Americans subscribedto the ideology of low fat, even though there was no clear evidence thatit prevented heart disease. . . . Ironically, in the same decades . . .Americans in the aggregate were getting fatter, according to historian

of medicine Ann La Berge (2008).This lifestyle correctness movement (Leichter, 1998), which in

the last century was only promoted by those standing at the marginsof biomedical thinking (such as naturopaths), has within the last fewdecades become cutting-edge biomedical science merging in partwith an underlying contiguous sympathy for such approaches within

the popular realm of medicine.Another reason why a cardiovascular logic has become so compre-

hensively accepted in recent years is economic: fears that nationalhealth systems would no longer be economically viable has inspired

awareness campaigns emphasizing prevention through individuallifestyle changes the dropping of bad habits (Moore, 2010). Thistrend was eagerly picked up and nurtured by major pharmaceuticalcompanies. As Jeremy Greene (2007) and others argue, pharmaceu-

tical enterprises promoted and redefined a number of health condi-tions, especially previously untreated, often asymptomatic andflexibly defined conditions such as hypertension and diabetes (twoconditions at the core of the American Heart Associations [2010]recommendations) because of their direct link to bad heart-health.

In fact, a cardiovascular logic is also implicated in the marketingof new drugs and the reconceptualization of older ones, especially as

prevention. One example is statins cholesterol-lowering medica-tions which are theoretically ideal for a general prevention of

ill-health, based on a cardiovascular logic. Statins are currently themost widely prescribed medication group in the United States. How-ever, [c]holesterol medications . . . may not be as safe as preventive




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medicine as previously believed for people who are at a low risk of

heart attacks or strokes (Wilson, 2010). The strong emphasis on self-governance through prevention within a cardiovascular logic, in

combination with a general message of control over ones health,is tightly linked to pharmaceutical marketing regarding drugs that

now need to be taken for an extended period: not only by individualssingled out as being at risk, but increasingly by whole populationsthatmight beat risk (see Armstrong, 1995; Dumit, 2010). The recentsuggestion to hand out statins in fast-food chains in order to prevent

the cardiovascular risk of unhealthy eating is an example of thisgeneral attitude towards extended prevention (see Ferenczi et al.,2010). This turn towards primary prevention lies at the center of ourcomparative analysis of Alzheimers disease and prostate cancer.

Alzheimers Disease and Cardiovascular Logic

A recent book, Defying Dementia, written for the general public byneurologist Robert Levine (2010), exemplifies the emergent cardio-vascular logic in relation to Alzheimers disease. Levines argument

is that accelerated brain aging and neuronal damage become moreaccentuated through diabetes, obesity, hypertension, elevated cho-lesterol, smoking, excessive alcohol and drugs. In the afterword,Levine summarizes his arguments: Preventive measures should be

thought of as a three-legged stool needing all three legs to hold anyweight. The three legs are exercise, cognitive activities, and diet(2010: 21011).

The excitement about prevention as a new focus in dementia careresearch can be found in a number of recent initiatives. One of themwas the 2009 conference on Pathways to Prevention, organized bythe International Psychogeriatric Association, which took place inMontreal. The organizers noted that there was a sense of being at the

beginning of a new era in geriatric psychiatry in which prevention isbecoming an increasing focus (Rapoport and Mulsant, 2010).

Older publications on Alzheimers disease paint a different picture

one that is brain-centered, and in which, as a result, prevention andcardiovascular risk factors have no place. Probably the first NorthAmerican guide on Alzheimers disease for the general public, writ-ten by psychiatrist and geriatrician Barry Reisberg in 1981, does noteven mention the words prevention and lifestyle. For Reisberg




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and his contemporaries, Alzheimers disease was a degeneration of

the aging brain, and only interventions targeting brain biology andchemistry were conceivable treatment options. Cardiovascular fac-

tors played a role within the then carefully distinguished categoryvascular dementia a common division still in use, although the

boundaries between the two diagnostic categories have becomeincreasingly porous. Many specialists now practically merge thesetwo conditions, or speak of dementia as one category, instead ofsetting up a clear division: vascular dementia versus Alzheimers

(e.g. Kalaria, 2010).8

It is ironic that when awareness about Alzheimers started to grow(in the US this happened in the 1980s), older notions of atherosclero-sis were deemed ignorant by those raising the profile of this dis-

ease of the century (Campbell, 2004; see also Reisberg, 1981: 15).Today, however, dementia is in large part becoming atherosclerosis

again. Until the 1960s, dementia in elderly individuals was usuallycalled arteriosclerotic dementia, a name introduced by Binswangerat the end of the 19th century to define a condition of cognitivedecline secondary to the atherosclerosis of cerebral vessels (Battistin

and Cagnin, 2010). In 1974, neurologist Vladimir Hachinski criti-cized this as misleading, and proposed the term multi-infarct demen-tia (MID), introducing the idea that cognitive decline needed anaccumulation of cerebral infarcts. Alzheimers disease, however

especially following the influential UK Newcastle study conductedby neurologist Martin Roth and his colleagues (e.g. Roth et al.,1966) became a separate entity seen as based on brain degenerationand its biological markers (especially plaques and tangles).

Could HDL cholesterol the good kind linked to lower heart dis-ease risk also protect people from dementia? was the question

posed in a recentNew York Times article (Rabin, 2010), a questionanswered by recourse to the same logic set out in the Levine book.9

This logic is even having an impact on non-medical fields, such as

the new generation of motion games that follow the model of Ninten-dos Wii. The Microsoft Kinect program called Body and Brain

Connection is, in the publishers words, a prevention program basedon research that has shown that not just puzzles . . . can help your

brain, but if you add a physical element [i.e. exercise] to that, it canjumpstart it and have even better, and more fun, results (quoted inSnider, 2010).


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In fact, the correlation between cardiovascular risk and dementia

has been noticed before, but only now has it received particular atten-tion from researchers. The APOE (apolipoprotein E) gene, and espe-

cially its allele E4, (e.g. Slooter et al., 1997; Tanzi and Parsson,2000), understood to elevate the risk of developing dementia, is also

involved in heart disease APOE is responsible for the transportingof fat in the body. This causal relationship had been already identi-fied in the 1980s (e.g. Yamamura et al., 1984), but was widelyignored until 1993, when Duke University neurologist Allen Roses

(2006) described the heterogeneity of APOE and its link with spora-dic Alzheimers (the most common form, in which heredity playsless of a role than in the rarer, familial form). Nevertheless,although there were earlier recommendations regarding dementia

and lifestyle (e.g. Friedland, 2001), only in the last few years has thisbecome more commonplace. The question is: why is it only now

that this existing knowledge has become salient (cf. Daston,2000: 69)? One reason might be that in the 1990s, when Rosesestablished the link between cardiovascular factors and dementia,hope for salvation through the new cholinesterase inhibitors was

growing: in 1993, Tacrine, the first Alzheimers medication, arrivedon the market. Tacrine, and to a certain degree also its four successordrugs, has recently lost a greater part of its credibility (see Leibing,2006, 2009a, 2009b). However, now that prevention has become a

well-accepted issue in dementia research, already existing drugs, ordrugs with similar mechanisms, can be (re)marketed (see Cyranoski,2011), while statins and other drugs influencing cardiovascular riskfactors can be offered as additional treatment options (Sparks

et al., 2010).The recently developed Dubois criteria, dividing Alzheimers

disease into three phases (Dubois et al., 2007, 2010), are among themany mechanisms that helped to embed (Latour, 2000) a cardio-

vascular logic into scientific reasoning. For many years at leastsince the 1960s (e.g. Kral, 1962) the concept of mild cognitiveimpairment (MCI) was loosely attached to dementia, indicating a

transitional period between normal ageing and the diagnosis of clini-cally probable very early Alzheimers Disease (Petersen, 2004).

This concept, with its well-known limitations of predictive unspeci-ficity (not all individuals with memory problems develop dementialater on; cf. George and Whitehouse, 2009),10 and the concomitant


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danger of a pathologization of normal forgetfulness, has now become

officially accepted as a second phase of dementia. A third, preclinicalphase even more preclinical than MCI is especially relevant for

the discussion of a cardiovascular logic:

[L]arge cohort studies have implicated multiple health factors that

may increase the risk for developing cognitive decline and dementia

thought to be caused by AD. . . . In particular, vascular risk factors

such as hypertension, hypercholesterolemia,and diabetes have been

associated with an increased risk of dementia. (Sperling et al.,

2011: 282, emphasis added)

This third stage, after Khachaturian (2011), has . . . brought thefield to the threshold of a new frontier the struggle toward primary

prevention. And in fact there has recently been an abundance of new

ways of predicting and preventing dementia, not only throughgenetic testing. The American Alzheimers Association founded theAlzheimers Early Detection Alliance (AEDA), which is designed to

educate people about the signs of Alzheimers, the importance ofearly detection and the resources available to help them (AlzheimersAssociation, 2010). AGlobe and Mailarticle on the different ways to

ensure early detection of Alzheimers risk declared:

It is also possible that early diagnosis may help patients make lifestyle

changes that delay the onset of the disease. Studies suggest that exercise

and a healthy diet may be protective. Both measures are widely advo-

cated by doctors to prevent heart disease and stroke. (McIlroy, 2010)

The idea that a preclinical condition needs to be made concrete anddetectable simply in order to exist can be shown by the extent to

which the discussion about the Dubois criteria centers on biomar-kers. The revision of the diagnostic (and research) criteria for Alzhei-mers disease is largely discussed in terms of visibility, such as brainscans (e.g. PET amyloid imaging) that reveal structural changes, and

test results that show the presence of biomarkers visible under themicroscope. For example, Janssen Pharmaceutica, together with GE

Healthcare, announced in December 2010 that they were developinga non-invasive assay for detecting biosignatures (the beginnings of

the formation of two biomarkers, amyloids and tau-tangles) to facil-itate early diagnosis and intervention (Johnson & Johnson, 2010).The Australian Imaging Biomarkersand Lifestyle Study revealed the




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importance of visibility, and demonstrated the growing emphasis on

lifestyle (see Sperling and Johnson, 2012). Early detection in the pre-clinical phase was also the target of the professorship for the preven-

tion of dementia and Alzheimers-related diseases, financed byPfizer Pharmaceuticals at Montreals McGill University (Pfizer,

2010). Pfizer announced that, together with the company DiaGenic(see DiaGenic, 2010), it was developing a technology that identifies

blood-based biomarkers for early onset of Alzheimers disease. Ifsuccessful, this would certainly mean earlier (and therefore lon-

ger) use of the already existing dementia drugs, such as Aricept(see AllBusiness, 2007).

These changes in understanding dementia may also influence animportant ethical discussion. For a long time, a heated debate existed

about whether early signs of dementia risk particularly riskrevealed by genetic testing should be revealed to the affected indi-

vidual and her family. While some argued that results should bemade known, so that necessary precautions could be undertaken(e.g. the last will and testament, or other legal and emotional acts),others argued that, since nothing curative could be done, and because

the revelation could lead to discriminatory practices (e.g. by insur-ance companies), social stigma, depression, or even suicide, doingso would only cause distress. This is quite apart from the fact thateven for the familial form of Alzheimers, genetics cannot predict

with certainty whether dementia will happen (see Pedersen, 2010).With the emergence of a cardiovascular logic regarding dementia,however, concrete preventive measures could now be undertaken;therefore, revealing the identification of vulnerability early would

mean that individuals could actively engage in diet and other lifestylechanges, as Gauthier et al. (2011) suggested:

In any case, the presence of [first] memory complaints offers an

important opportunity to review cardiovascular risk factors, and coun-

sel the individual on healthy lifestyle issues including tobacco cessa-

tion, regular physical and mentally stimulating activities which

together may help deter the onset of dementia.

These recommendations are not completely disease-specific; they

can be found targeting a number of health conditions. In the follow-ing section we will show an almost identical prevention rhetoricregarding prostate cancer.




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Prostate Cancer and Cardiovascular Logic

Visiting the website of the American Cancer Society (2011), one will

find under the guide to prostate cancer the heading prevention, inwhich one learns that [s]cientists have found some substances intomatoes (lycopenes) and soybeans (isoflavones) that may help pre-vent prostate cancer. In a similar vein, medical information provided

by the Mayo Clinic website advises visitors that they may reduce. . . [their] risk of prostate cancer by making healthy choices, suchas exercising and eating a healthy diet (Mayo Clinic, 2011),although it cautions that theres no proven prostate cancer preven-

tion strategy. There is now an abundance of popular manuals onprostate health, which specifically spread the word on nutritionalguidance and lifestyle behavior changes, encouraging men to regainProstate Power (Nixon and Gomez, 2007: 19; see also Mroz et al.,2011).

The role of lifestyle in cancer prevention has been well documen-ted (Bekkering et al., 2006; Chan et al., 2005; Czene et al., 2002).What is noteworthy at this point is that approaches to prostate cancer,

which have so far been dominated by medical solutions and interven-tions with a focus on therapy, are now also emphasizing primary pre-vention (Kampf, 2010)11 based on a cardiovascular logic.

This trend has not always been especially overt. The reinventionof multi-causal explanations of the emergence of cancer including,

for example, nutritional and dietary approaches in the 1960s thatwere in line with the establishment of chronic disease epidemiology(Cantor, 2007: 23) triggered a public and academic debate about

possible risks stemming from environmental and/or behavioralfactors (such as nutrition). However, this relationship was notaddressed in connection with prostate cancer, which remained out

of the spotlight (Kampf, 2009), while more visible cancers (whichalso targeted younger patients), such as lung and breast cancer,received the immediate attention of the early anti-cancer campaigns(Aronowitz, 2009; Bell, 2010). Studies on prostate cancer and health

disparities have only recently been published (e.g. Gilligan, 2005;

National Cancer Institute, 2012).Throughout the 20th century, early detection and treatment were

portrayed as forms of cancer prevention (effectively secondary preven-

tion), and prostate cancer was no exception. The focus on preventing




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the dire consequences of late-stage prostate cancer involved finding

ways to stop it from becoming fully developed: secondary preventiontests (e.g. rectal examinations, PSA tests, urine tests, and biopsies)

have now become central to medical dealings with prostate cancer.12

However, diagnostic tests (such as microarray and PSA) have been

repeatedly questioned by health professionals, especially because ofover-diagnosis and consequent unnecessary treatments. In fact, by2011, the United States Preventive Services Task Force recommendedno screening for healthy men, including men of African-American

background (identified as having an increased risk of disease incidenceand mortality; Harris, 2011).

The advent of screening tests does, however, illustrate the rise ofneoliberal health policies, with a shift in responsibility for provision

of health from the state to insurers (Rose, 1999a, 1999b) a respon-sibility which was then passed on to the medical profession. The pre-

ventive approach to prostate cancer has recently been driven forwardand refined by two new concepts that draw on existing detectiontechnologies: Watchful waiting (WW) for older patients (above65 years of age) and active surveillance (AS) for younger patients.

These concepts have not been without controversy, given that inthe US few health care professionals recommend WW or AS asviable options, even though they are endorsed in other countries,such as Germany. Studies have suggested, however, that despite

these academic controversies, men have been receptive to thesepreventive technologies for making sense of their uncertainty(Bell and Kazanjian, 2011; Kampf, 2010). This has led to mentaking a stronger participatory role in their prostate health (Davison

and Goldenberg, 2011).Today, primary prevention privileges a cardiovascular logic, as we

have seen. This approach is currently entering prostate cancer dis-courses, a noteworthy development given the hitherto predominantfocus on secondary prevention. The so-called metabolic syndrome,

the apparent scourge of the 21st century, which includes obesity,Type 2 diabetes, high blood pressure, and dyslipidemia, is now

linked by some researchers to failing prostate health and the develop-ment of prostate hyperplasia (understood to be a possible risk for the

onset of prostate cancer). Studies recently conducted seem to suggesta link between the metabolic syndrome and high-grade Gleasonscores (a histological staging characterizing cell differentiation,




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thereby indicating tumor presence) found in cell cultures taken from

prostate biopsies (e.g. De Nunzio et al., 2011). Obesity is now seen asa risk factor for coronary heart disease, both in health care and health

promotion debates in the United States and Canada (Fletcher, 2010;WHO/EU, 2006), but it is also linked to the risk of prostate cancer.

This is because western high-fat diets and sedentary lifestyles affecthormone levels that are considered crucial in the disease progressionof prostate cancer.13 In turn, an increasing number of studies promotethe potential benefits of certain nutritional agents and compounds,

such as green tea, isoflavone, lycopene, cruciferous vegetable, andomega-3 polyunsaturated fatty acid in the prevention of prostate can-cer (Hori et al., 2011; Richman et al., 2011; for a critical discussionsee Lippman et al., 2009).

Bodily fitness, previously associated with primary preventionapproaches in cardiovascular health campaigns (and in other cancer

types), has now filtered into campaigns for the prevention of prostatecancer. Exercise may be good for the prostate as well as the heart.

New research shows [that] older men who exercise regularly havea much lower risk of dying from prostate cancer, suggests one

researcher (Warner, 2005). One important line of research currentlyentertains the idea of advocating male pelvic health: encouragingmen to reduce the possible risks of urinary tract infections and erec-tile dysfunction and possibly prostate cancer by exercising

(Kaplan, 2007). Standard procedures for treating men identified ashaving a genetic predisposition to the disease, which included activesurveillance and early surgery or radiation (similar to the pre-emptive strikes used in breast cancer prevention; see Lowy 2010),

have gradually been rejected. A UCLA study has summed up thewidening possibilities now open to (aging) men: prostate cancer can

be prevented not only through risk education and by embracing test-ing for early detection, but also by eating a healthy diet, watchingcholesterol levels and taking exercise (Giovannucci et al., 2005; see

also Johnsen et al., 2009; Moore et al., 2009).The forcefulness of the new cardiovascular focus, as it affects

prostate cancer and lifestyle, is illustrated by how quickly it has beentaken up beyond its origins in North America. The US has generally

been much more persistent in its debates about obesity and choles-terol levels than, for example, Europe, but we can now detect a

profound shift from secondary to primary prevention in Europe as




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well. For example, the Austrian urologists association encourages its

members to advise their patients on behavior, lifestyle, and nutri-tional changes as part of a primary preventive approach, a concept

trademarked as Androcheck (Berufsverband osterreichischer Uro-logen, 2007).

This recent shift from secondary to primary prevention withinhealth promotion and medical research is, however, still very muchin the making and in part inconclusive: researchers have not estab-lished a direct link between obesity and the metabolic syndrome and

incidence of prostate cancer (Dimitropoulou et al., 2011); likewise,there is not yet a proven causal connection between antioxidants andthe lowering of prostate cancer risk.14

The parallels between Alzheimers and prostate cancer and a car-

diovascular logic may seem unlikely. But they can also be illustratedby the emergence of new preclinical conditions: what certain social

science studies have called a pre-disease state. These factors havelowered the threshold for intervention (cf. Aronowitz, 2009: 426;Lowy, 2011). Researchers are looking for precursors to Alzheimersdisease, and a condition called high-grade prostatic intraepithelial

neoplasia (HGPIN) has been identified in relation to, and is charac-terized by, cellular proliferations similar to those seen in prostatecancer. Arguably, HGPIN serves as a mechanism that, just like theDubois criteria for Alzheimers disease, helps to embed (Latour,

2000) a cardiovascular logic into scientific reasoning. Evidence sup-porting the relationship between HGPIN and prostate cancer hascome from immunohistochemical, morphometric, molecular, andgenetic studies. HGPINs presence is not established by PSA tests,

but with biopsies.

It does not come without controversy, however. There is a decidedlack of knowledge on the timing of transformation into prostate can-cer, and so HGPIN comes with never-ending surveillance circles (i.e.repeat biopsy 06 months after initial biopsy, then every six months

for two years, and then every 12 months for life). The classic treat-ment strategies of prostatectomy or radiation are contra-indicated

as of yet, but at-risk men (i.e. showing HGPIN) are advised to partakein clinical trials of chemopreventive agents (Cheng et al., 2004). A

number of research studies are now investigating the efficacy ofantioxidants, statins, catechins, and natural compounds (Bettuzziet al., 2006; Ozten-Kandas and Bosland, 2011),as well as medications




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belonging to a drug class called 5-alpha-reductase inhibitors (5-ARIs),

which are currently recommended for preventive treatment by theAmerican Society of Clinical Oncology and the American Urological

Association.The increase in health promotion, coupled with the promotion of

primary prevention as a new means to deal with the threat of prostatecancer, is inseparable from a multimillion dollar industry addressingan anti-aging market, largely catering to aging (and prosperous)

baby-boomers who care about their lifestyle choices (Kampf and

Botelho, 2009). At times the advice given by the anti-aging advo-cates is paradoxical. Since the 1980s, the use of an estrogenic-androgenic hormonal substitute (Gynodian Depot [DHEA]) a

product now available in supermarkets in the US has been recom-

mended for strengthening the vitality and good health of membersof the third age, but hormonal substitutes have started to come

under scrutiny for possible connectiontoprostate cancer (Wagener,2004). This scrutiny has in turn resulted in the development of newmarkets, such as plant technologies (intended as food additives to

produce high levels of cancer-preventive agents), or as pharmaceu-

ticals alongside already existing dietary supplements (nutriceuti-cals). This follows Isabelle Fletchers argument that there has

been no simple shift from older, public health, environmentalresponsibility to new individual responsibility for preventing the

onset of disease, but that what we are witnessing is predominantlythe expression of environmental concerns about food consumed(Fletcher, 2010: 76).

Advanced age remains the most well-established risk factor for

prostate cancer (and Alzheimers): by age 70, about 65% of menhave at least microscopic evidence of prostate cancer. Nonetheless,the current trend in preclinical diagnosis (and treatment) has shiftedthis focus to younger men (typically above age 30). This is

despite the fact that prostate cancer usually grows very slowly,and older men with prostate cancer typically die of somethingelse (see note 10). Yet, of course, the lowering of the diagnostic

threshold has also lowered the mean age of diagnosis and inter-vention. Discussions about the adverse effects of PSA screening

for older men now touch upon its possible benefits for youngermen (Harris, 2011), who, as some argue, are also easier toencourage to make lifestyle changes.




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So What? Some Heartless Conclusions

We have juxtaposed two diseases (or syndromes) in order to show an

emergent and all-encompassing, commonly held reasoning we havecalled a cardiovascular logic. While this logic is applicable to a num-

ber of syndromes, Alzheimers disease and prostate cancer are idealtypes in that they are both typically found in older individuals who

are also at greater risk of cardiovascular diseases. In a world that isaging in an unprecedented way, arguments insisting on the urgencyand importance of such reasoning are easily made and communi-cated. In both cases it could be shown that a cardiovascular logic

widened the field of targeted individuals: Younger at-risk individualsare now being linked to what were once deemed diseases of agingthrough a newer emphasis on primary prevention. Studies on otherage groups, for instance the childhood obesity epidemic and thediscussion around the use of statins for children, would provide sub-

stance for further studies eventually providing data on how a cardi-ovascular rhetoric might transform future children into preventingindividuals. The fact that Ritalin is now also being marketed as a

treatment for severely obese children shows, once more, the widen-ing of the scope of certain medications due to a cardiovascular logic.Without disputing the important task of developing ways to detect

disease onset and progression early or, ideally, even to prevent dis-ease we see the current turn towards primary preventive approaches

(sometimes merging with secondary prevention) under the banner ofa cardiovascular logic as problematic. The oversimplification ofcomplex disease pathways close to what Narayan (2010) has called

a risk factor silo not only hinders research on other biologicalmechanisms, it also clouds a number of factors that transcend the

purely biological.

Ethnic, gender, and class issues drift out of sight (see note 7), themore that public health campaigns insist on a cardiovascular logic.For example, in prostate cancer research, explanations for theracial/ethnic disparities in the incidence of prostate cancer, with

disproportionate numbers of African-American men developing the

disease, are inconclusive. Recent quantitative studies suggestinggenetic predisposition (and not life conditions, for example) para-doxically go hand in hand with newer recommendations against

screening of all men, regardless of ethnicity (e.g. Cheng et al., 2009).




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Likewise, some have recently pointed to the narrow scope of

the discussion on public health, with the result that environmentalissues such as pollution have been widely ignored. This is the

case for cardiac diseases in general (e.g. Reeves, 2011), as wellas more specific illnesses, including Alzheimers disease (Morgan

et al., 2011) and prostate cancer (Pedersen, 2010; Ramis et al.,2011). Refocusing on environmental issues would place moreresponsibility in the hands of governments, industries, and themedical profession responsibilities that easily get hidden with

an emphasis on self-care.But what is most striking is that public health campaigns now tar-

get almost everybody through a unified cardiovascular logic. In fact,there is certainly a social preoccupation, inscribed in research and

campaigns, with cardiovascular health and its concomitant healthconditions. Studies on epigenetics, for example, link genes to envi-

ronment, as do the new neurosciences in their emphasis on the socialbrain. Once individualized notions of risk become social questions,such as the finding that our peer groups are deemed responsible forwhether we are fat or not (Is obesity contagious?; see Lopez,

2008). The recent mushrooming of so-called neighborhood studiesencapsulates the rather simplistic public health idea that governmentsonly need to build more parks and public markets in order to ensurethat individuals will do more exercise, and eat more vegetables

instead of fast food.However, the social in this health issue continues to be treated as

a matter of individual behavior and willpower. We are not talkingabout the kind of medical reductionism that George Engel (1977)

once accused of lacking a biopsychosocial component. What webelieve is happening is the acknowledgment of the social context,which immediately gets retranslated into one basic biologicalmechanism. Further studies, we hope, will build upon our more con-

ceptual discussion to provide more culture-specific data, showinghow a cardiovascular logic is being integrated or contested in specificcontexts, such as national public health campaigns, but also how it is

used and retranslated by different local players: politicians, doctors,patient groups, researchers, and pharma-managers producing clinical

guidelines, research protocols, and other relevant documents, andhow these finally impact on individuals embodying such narrativesof risk.




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Acknowledgements

We would like to thank theDeutscher Akademischer Auslandsdienst

(DAAD), the Canadian Institutes of Health Research (CIHR) and theSocial Sciences and Humanities Research Council (SSHRC) forfinancing our research. We are also extremely grateful for thereviewers stimulating input.

Notes

1. Historians have noted that the origin of correlating stress with

heart dysfunction dates back to military medical dealings withinconscription practices and warfare in the early 20th century (seeWoolley, 2002).

2. See Mayo Clinic at: http://www.mayoclinic.com/health/heart-

disease/DS01120 (accessed April 2011); see also Health Canada(2010).

3. Reductionism here means that a single explanatory system hasbecome common sense, excluding other possible explanationsdue to its epistemological force. This does not mean that allexplanations relying on reductionism are wrong.

4. This holism is drawing unwittingly on a connection establishedbetween body and mind within medicine that received a newtwist with Cartesian thinking. For an introduction to the vast lit-erature on the subject, see Hagner (2008). See also Ecks (2009).

5. However, a Cochrane review shows that [e]xercise seems toimprove depressive symptoms in people with a diagnosis ofdepression, but when only methodologically robust trials are

included, the effect sizes are only moderate and not statisticallysignificant (Mead et al., 2008).6. One of the reviewers pointed out that the focus on lifestyle

shares many continuities with older, clean living move-ments such as the late 19th-century US efforts to control

alcohol consumption, tobacco use, and female reproductivehealth (see Bell et al., 2011; Engs, 1991; Petersen et al.,2010).

7. The aims of early cardiovascular prevention campaigns werein part gender-specific, in that risk concepts were based pre-dominantly upon a research focus on male patients (seeRiska, 2000). Within the last two decades there has been aconsiderable effort to draw attention to a gender-specific




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preventative campaign against cardiovascular diseases, but

we believe that a cardiovascular logic merges gender-specific issues (see conclusion of this article). For example,

the specifically female symptoms of heart attack, or femalesmoking as related to higher prevalence rates of heart dis-

ease, we see as unifying acts.8. Kalaria (2010: S74), writing about dementia in general, states

that:

There is ample evidence to indicate vascular risk factors are also

linked to neurodegenerative processes preceding cognitive decline

and dementia. . . . Several modifiable risks such as cardiovasculardisease, hypertension, dyslipidemia, diabetes, and obesity enhance

the rate of cognitive decline and increase the risk of Alzheimers

disease in particular.

9. Regular physical activity, in general, is believed to improvebrain function, both by increasing blood flow to the brain andby stimulating the production of hormones and nerve growthfactors involved in new nerve cell growth. Exercise also raises

levels of good HDL cholesterol (Rabin, 2010).10. It is interesting to read that George and Whitehouse (2009: 17)

compare MCI with prostate cancer: When does a patient getprostate cancer? The abnormal cells that can be labelled can-

cerous are found in most men who die in late age most ofwhom will have neither been diagnosed in life nor suffered anyconsequences from the cells. On the basis of fairly nonspecific

blood tests, some men will have had surgery that impairs theirquality of life without clear evidence that the cancer would havebeen life threatening.

11. There are three levels of preventive medical strategies in publichealth. They are generally defined as: primary prevention (inhi-

biting the onset of disease altogether), secondary prevention(early diagnosis and screening measures to detect onset ofdisease before it becomes symptomatic), and tertiary prevention

(aiming at reducing disability and restoring function once aperson has been affected by disease).

12. This corresponds, in part, to the late 20th-century surgicaloptions offered as preventive therapy in cases of genetic predis-

position to breast cancer (Lowy,2010). The taboo and stigma of




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prostate cancer and the gendered aspects of the health-seeking

behavior of men may have contributed to the slow developmentof preventive campaigns (together with the diseases unclear

etiology) (George and Fleming, 2004: 3). Others point out thatlittle has been done so far in terms of providing public health

promotion for older men, with screening programs predomi-nantly centered on female bodies (Aronowitz, 2007; Lowy,2007).

13. This is most often discussed alongside studies on the differences

between the Asian diet and the US diet and the respective mor-tality rates of prostate cancer (http://www.unisci.com/stories/20013/0911013.htm; accessed 10 March 2011).

14. See www.cancer.gov/cancertopics/pdq/prevention/prostate/heal

thprofessional#Section_101, www.cancer.gov/cancertopics/eatinghints/page3#C17 (accessed February 2011).

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