ACP Internist Blog


Friday, January 19, 2018

What about cheese?

Blessed, so Monty Python tells us, are the cheese makers. They go on to clarify that this particular Messianic assertion in the ”Life of Brian“ is allegorical, and actually connotes all participants in the manufacture of dairy products. I have colleagues who agree emphatically with that contention, others who just as emphatically denounce it. So it tends to go in all matters of religious fervor, diet salient among them these days.

The reactions from both camps to a new meta-analysis of observational studies of cheese intake suggesting a health benefit from “some” (stay tuned for more on that) cheese in the diet are entirely as one would expect. The perennial proponents of all things dairy are cheering, and evidently ignoring all of the concerns they raise routinely about both observational studies and meta-analyses of such studies, whenever they happen not to like the conclusion. The we-are-way-too-cheesey-as-is crowd has been quick to point out the flaws in observational epidemiology, and meta-analyses of such studies, which they are far more prone to overlook when they favor the conclusions.

And, of course, click-bait headlines are telling people just what they want to hear: eating cheese is good for you now! But is it, really?

That's complicated because diets are complicated, diet research is complicated, and cheese is complicated.

Let's start with cheese. In general, cheese is a highly concentrated source of saturated fat, which despite the spate of pop culture nonsense over recent months, remains reliably implicated in crimes against coronary arteries. Cheese is also a concentrated source of animal protein, which some, notably T. Colin Campbell, contend is the actual health threat saturated fat appears to be. Since the two reside in foods together so routinely, it is challenging at best to disentangle their effects. Some large studies addressing that matter have found higher rates of premature death from all causes with increases in either saturated fat, or animal protein.

Then there's the salt. Here, too, the truth is clear despite a lot of sound and fury: consumers of modern, highly processed diets consume way too much. A massive study examining all deaths in the United States in 2012 and dietary factors associated with them identified excess salt intake as the number one dietary peril. For reference, there is more than 300 mg of sodium in less than one ounce of Feta cheese.

Finally, in the tally of negatives, cheese is a concentrated source of calories- which, of course, do count, and contribute to the ever-rising rates of obesity. Unlike plain nuts, where energy density has been shown to be offset by a high capacity to satiate, a compensatory satiety benefit to exonerate the calories of cheese is less evident.

But, cheese is a fermented product. That means there are active, fermenting cultures, as with yogurt, and that may change everything. Fermented and cultured products, from cheddar to kimchi, have potential effects on the microbiome. These effects can be beneficial, and when they are, may enhance the other beneficial effects of a food, or compensate partly or fully for harmful effects. The net effect of cheese ingestion on health is thus likely born in a mix of both adverse and favorable factors, and depends on what cheese displaces in the diet, and perhaps on the native state of your microbiome as well.

Moving on from dairy, then, to data, we have the complications of observational epidemiology and meta-analysis. Observational studies can reveal associations, but have important limitations with regard to establishing cause and effect. The particular studies included in this analysis made highly variable adjustments for dietary factors other than cheese. Some analyzed variation in just a few, select foods. Others analyzed variation in a wide array of foods. Still others made no allowance at all for dietary variance. That's a serious limitation.

Did “cheese eaters,” and in particular dose-attentive cheese eaters (the apparent benefits of cheese in the new study, despite the wildly hyperbolic headlines, were both very modest, and capped at 40 grams daily; above that, benefits disappeared and harms emerged. That 40-gram dose is less than two slices of Swiss cheese) have better dietary patterns overall? Did they eat fewer chips, or fries?

Observational epidemiology is always challenging, and never more so than when applied to diet. Among the routinely ignored but essential questions about any given food, ingredient, or nutrient, is: instead of what? In what overall context of diet and lifestyle?

Imagine a study about standing up a few times a day, concluding that doing so is good for our health. In fact, no need to imagine; we've seen just such studies. The obvious question they raise, though, is: good for us compared to what? In the case of a “stand up from time to time” study, that comparison is built in from the start: sitting all day long. Obviously, just standing up occasionally is NOT good for us compared to walking briskly, or hiking, or biking, or swimming. Standing up is relatively good for us compared to the prevailing, and quite awful alternative: spending unending daily hours on our backsides.

Just the same question should assert itself in a study of cheese, or any aspect of diet. Compared to what? While it may be tempting to think that eating cheese is an alternative to “not eating cheese,” that's naïve, since everyone eats 100% of what they eat. If less of that total is cheese, then more of it is … something else. What something else? In modern diets like those of the U.S. the answer is unlikely to be lentils, kale, or raw walnuts. The answer is far more likely to be donuts, French fries, and Coke. Is a bit of cheese better in the place of any of those? Almost certainly.

Meta-analyses are complicated, too; and perhaps particularly meta-analyses of observational dietary studies, which must aggregate datasets as holey as Swiss cheese itself. This could be a lengthy topic, but let's simply note that pooled data are never better than the data being pooled. Meta-analyses can be quite powerful, but also epitomize the perils of “garbage in, garbage out.”

This new meta-analysis does not and cannot tell us what foods cheese replaced. It does not and cannot tell us how variation in cheese intake correlated with overall diet quality. It cannot, because it is pooling data from prior studies, and those studies failed to answer these questions consistently, and in many cases, did not address them at all.

Real cheese (as opposed to cheese-like stuff) is pricey; maybe habitual cheese intake is a marker for the health benefits of affluence. Perhaps a small daily intake of cheese indicates an effort to adopt the famously healthful Mediterranean diet. If that were true (and we neither know that it is, nor that it isn't), then any apparent health benefits of modest cheese intake would actually indicate the health benefit of moving away from a typical American diet, and toward a Mediterranean diet.

I suppose I might typify that scenario personally. My wife is from southern France, and uses small amounts of cheese in some of her recipes. I would thus show up in the cheese data as a dose-attentive cheese eater. However, my diet is overwhelmingly made up of vegetables, fruits, whole grains, beans, legumes, nuts, and seeds. I drink plain water when I am thirsty. I consume very little dairy overall, some fish and seafood, poultry almost never, and mammals not at all. I drink no soda, eat no fast food, and, by the way, exercise vigorously every day. I might show up in a data set suggesting health benefits of “a bit of cheese,” but that would seriously misrepresent what's going on with my diet and lifestyle. Cheese makes a cameo appearance.

So, are the eaters of cheese blessed with less heart disease? Probably not because of cheese if so. Certainly, there are far better ways to reduce your risk of heart disease than by adding cheese to your diet. Ditch soda and drink water. Replace beef with beans. The list goes on.

But this study does suggest that the inclusion of a small amount of cheese in the diet is not necessarily harmful, and might confer modest, selective benefit. That makes sense, since a small amount of cheese turns up in some, but not all, of the diets associated with the famously enviable Blue Zone combination of longevity and vitality.

Leaving aside the environmental and ethical implications of dairy production, very important topics in their own right, my conclusion is that diets associated with optimal health outcomes can include or exclude cheese, but are never optimal because of cheese. Still, that means we have choices, and that, I suppose, is a blessing.

David L. Katz, MD, FACP, MPH, FACPM, is an internationally renowned authority on nutrition, weight management, and the prevention of chronic disease, and an internationally recognized leader in integrative medicine and patient-centered care. He is a board certified specialist in both Internal Medicine, and Preventive Medicine/Public Health, and Associate Professor (adjunct) in Public Health Practice at the Yale University School of Medicine. He is the Director and founder (1998) of Yale University's Prevention Research Center; Director and founder of the Integrative Medicine Center at Griffin Hospital (2000) in Derby, Conn.; founder and president of the non-profit Turn the Tide Foundation; and formerly the Director of Medical Studies in Public Health at the Yale School of Medicine for eight years. This post originally appeared on his blog at The Huffington Post.
Thursday, January 18, 2018

5 reasons communication is so often suboptimal in health care

Many of the everyday coalface problems we face in health care are simply due to suboptimal communication. It could be the patient or family member who doesn't know what's going on in the hospital, the nurse who is confused about orders, or the doctor who doesn't understand the reasoning behind the seemingly terrible administrative directive they are receiving.

Take it from me, as someone who has seen health care at close quarters on four different continents, this is a universal problem, and not a uniquely American one. So why is this? Why is health care notoriously so poor at times compared with other industries? Here are five reasons:

1. The fast-paced nature of health care

Medicine is an unpredictable and rushed environment, especially in the hospital. Physicians (and nurses) are rushed off their feet from start to finish, there are several things going on at any one time, and they have to multitask to the extreme. It would be wonderful to spend an hour with every patient, but that ain't realistically going to happen. In our ever-squeezed time slots (taking away the whole other discussion about bureaucratic and reimbursement reasons), we have to remain focused and to the point, and that inevitably means that there's not enough time to make sure everything is dealt with and explained as well as it could be.

2. There are too many things going on to keep track

In hospital, patients will be subject to tests, procedures, and a stream of different doctors seeing them. I've previously named this problem “Too Many Cooks in the Kitchen Syndrome”. If we consider too that most of our patients are on the older side, it's easy to see how things quickly become a confusing haze.

3. Complex problems that we are unprepared for

People don't plan to be sick. Even fewer people are well-versed in medical terminology and the decisions that have to be made during acute medical illness. It may also be unrealistic to expect that even a highly educated member of the general public, would understand everything that they are told by their physician. It's not like serving people food in a restaurant or fixing their sink.

4. Physician communication skills

A further aspect to this problem, that is not talked about nearly as much as it should be, is that physicians do not receive adequate communication skills training in medical school. What little amount of teaching that's given, is woefully inadequate to prepare for life as a “customer service facing professional” (and yes, whether doctors like the term or not, that is what we are). The same applies to nursing school curriculums and most other healthcare professionals: we simply don't put enough emphasis on the importance of solid communication in our everyday professional life.

5. Health care organizations have been slow to catch up

Health care institutions typically lag well behind other industries in applying communication and branding principles to their organizations. They frequently don't communicate their message to patients effectively, tell the right stories, and even their internal communication tree from administration downwards, leaves a lot to be desired.

The solutions to the above problems lie with a complete rethink within many health care organizations and a shift in internal culture. Simple common sense answers lie at the heart of most of our communication deficits in the trenches. As health care continues its tumultuous and ever-changing journey, we need to always stay focused on how we communicate with our patients (both at an individual and organization level). Their experience matters, and is crucial to their full recovery and motivation. It's not about satisfaction scores or meaningless tick boxes, but fundamental to delivering amazing health care.

Suneel Dhand is an internal medicine physician, author and speaker. He is the founder of DocSpeak Communications and co-founder at DocsDox. He blogs at his self-titled site here.
Monday, January 15, 2018

The Emperor of Performance has no clothes

Our greatest and worst attribute is seeing and saying that the Emperor has no clothes. It requires intellectual honesty, a willingness to overcome confirmation bias and perhaps some hubris. Often we make others uncomfortable with the raw honesty of such proclamations.

For years many blogs have decried performance measures. I have written about this problem for over 10 years. Currently I serve on ACP's performance measure committee. In this capacity I have reviewed well over 100 performance measures. Most performance measures have the potential for harming patient care. The committee has given a thumb down to many; you can find them here categorized by disease.

We have argued about performance measures. The best positive argument is that one can use them to assess their patient population. But almost all agree that using them as a payment strategy has dangers and some believe that current strategies are just schemes to decrease physician payment.

As I was considering this problem and old Beach Boys song entered my thoughts: “Wouldn't it be Nice?” With apologies to Brian Wilson:
Wouldn't it be nice if we could measure physician quality?
Wouldn't it be nice if patients had one disease that we could treat perfectly?
Wouldn't it be nice if patients believed our recommendations and could afford their treatments?
Wouldn't it be nice if patients had no side effects?

Of course we do not live in a perfect world. So here are some of the problems of performance measures as a payment strategy:

Performance measures can only measure part of one dimension of quality. And even in that dimension we do not measure performance with all patients. Donabedian stated: “Which of a multitude of possible dimensions and criteria are selected to define quality will, of course, have profound influence on the approaches and methods one employs in the assessment of medical care.”

We can measure management of some diseases, but only common ones. This means that we must exclude a proportion of patients from any measurement.

We cannot measure diagnostic accuracy, and without diagnostic accuracy performance measurement is useless. Multiple times I have had patients admitted to the hospital on perfect treatment for presumed systolic dysfunction, but since the patients really had COPD, OSA and right side heart failure, the treatment was inappropriate. Yet the treating physician received a perfect score for treating a disease that the patient did not have. So you say, why not create diagnostic measures. Researchers and clinicians smarter than us have tried without success.

Performance measures clearly have unintended negative consequences. The added cost to the health care system involved in documenting these measures is immense. These costs are both financial and time costs. Anything that distracts physicians from their patients decreases patient care quality. We all know the 4-hour pneumonia rule story. We have heard of the overtreatment induced with aggressive hemoglobin A1c targets for all patients.

Performance measures are almost never tested prior to adoption. The Emperors of Performance Measures just know that we cannot improve quality without metrics. And they know that metrics are therefore good. Unfortunately these Emperors do not understand patients. Here are a few of the problems:

Patients rarely have one disease, and the other diseases may influence how we treat and prioritize management. Patients have different belief systems. Pediatricians in Mississippi have much higher vaccination rates that those in Davis, Calif. Patients have differing financial situations that impact their ability to buy medications.

We know from the recent Annals of Internal Medicine article that physicians treating underserved populations have worse performance scores than those who work in wealthy suburbs. We know from the NHS studies in Great Britain that focusing on some performance measures leads to deterioration of those measures not required.

Performance measurement as a flawed concept. The Emperors never do a premortem analysis. Practicing physicians all understand the flaws. Imposing these measures without understanding the unintended consequences is akin to practicing medicine without a license. Primum non nocere.

Fortunately, physicians and researchers are finally focusing on this problem. Unfortunately, it is not clear that the Emperors are listening. Perhaps if we scream louder.

db is the nickname for Robert M. Centor, MD, FACP. db stands both for Dr. Bob and da boss. He is an academic general internist at the University of Alabama School of Medicine, and the former Regional Dean for the Huntsville Regional Medical Campus of UASOM. He still makes inpatient rounds regularly at the Birmingham VA and Huntsville Hospital. His current titles are Professor-Emeritus and Chair-Emeritus of the ACP Board of Regents. This post originally appeared at his blog, db's Medical Rants.
Friday, January 12, 2018

Diet, as a matter of taste

Some years ago, I found myself at a corporate meeting of Kraft. I don't recall exactly how or why I wound up on that guest list, but I recall that the meeting was rather surreal.

Kraft had sent their senior executives and their nutrition director to Manhattan to gather with nutrition authorities and get insights into consumer trends for the upcoming 5 years. The corporate ambition for the meeting was to get their R&D ahead of such trends. We, the nutrition experts, were there to read our tealeaves.

The meeting began with personal introductions around the perimeter of a very large conference table. Everyone said hello, who they were, and generally something complimentary about Kraft.

When my turn came, I said hello, and that I must be on the wrong bus. I certainly had nothing complimentary to say about Kraft, a signature participant in the invention of “junk food.” I said as politely as I could that if I remained at the meeting, I would tell them the truth as I perceived it, and that they might not like hearing it. I fully expected a burly, Velveeta-fueled bouncer to throw me out. For reasons I understand no better now than then, they smiled, nodded, and kept me.

And so we did talk about consumer trends. I grew ever more incredulous as the Kraft team feigned passive responsiveness to such trends. My view was different, based on some rather damning and high-profile intel: Kraft, along with the rest of Big Food, was crafting consumer trends. They were adulterating the prevailing American palate by careful design, and then feeding it accordingly.

I knew less about all that then than we all know now, thanks in particular to Michael Mossand and his incisive writing on the topic. But still, I knew enough to challenge them. I suggested that by creating dubious concoctions of refined wheat, sugar, salt, and the worst varieties of fat, they were creating a demand for ever more of the same, since familiarity is among the more potent determinants of taste preference. I quoted one of my favorite sayings to them: “The best way to predict the future is to create it.”

How about, I suggested, they helped shape favorable consumer trends by formulating better products? As things stood, they were creating the demand to which their supply was the answer, and profiting at the expense of public health.

I vaguely recall an answer from one of the Kraft executives involving a beatific smile, outstretched arms, and this rejoinder: “Yes, it's true; we do sell people what they want to buy!” I don't recall any progress past that point. The meeting came to its natural conclusion, and in the years since, Kraft has never called me again, nor have I expected much of them.

Reflecting back on that meeting these years later, as someone who writes truth about food to power almost every week, I can't help but wonder if what is true of our still adulterated food supply is also true of our mainstream food for thought on the same topic. Specifically, we receive the information about diet we allegedly want, but maybe the information we receive conditions our cognitive palate.

Diet books in general, and in particular those that make best-seller lists, share a formula, just as junk foods share the salient entries in their ingredient lists. The gist of that formula is to cherry-pick your citations so your case seems unassailable and erudite; speak only in absolutes; identify a scapegoat, silver bullet, or preferably, both; hint at conspiracy and privileged knowledge delivered courtesy of rare courage to defy the system; offer the moon and stars by means of some effortless legerdemain.

But publishers are reluctant to deviate from the pattern, claiming just what Kraft claimed: they need to satisfy the public's native preferences. But are such preferences for nonsense truly native? Might they be acting instead like Kraft in creating the very demand that demands exactly what they supply?

These parallel scenarios remind me of a favorite episode of the original Star Trek series. The Enterprise is called in to help address a planet-wide plague compounded by a failing supply of the necessary treatment. They eventually discover that the plague is not cured by the drug, but created by it. The drug is addictive, and the symptoms of the “disease” that emerge when the drug is not provided are, in fact, signs of withdrawal. The responsible cartel withholds this information, of course, until they are outed, all the while concocting the “disease,” to peddle the remedy.

The media and publishing industries may be, whatever their motivations, that very cartel (There goes my next publishing deal! Oh, well).

Let's be clear: where people around the world reliably derive health and vitality from food, they don't do so courtesy of morning shows offering an ever-changing flavor-of-the-week approach to truth. They do not focus on the dizzying discord where details are hotly debated ad infinitum; they rely, instead, on the stable perch of common ground. They get to health not on the basis of headlines, hyperbole, and hooey, but heritage. Their practices have stood the test of time and generations, are informed by both sense and science, and are the stuff of global expert consensus.

Here, we are sold an endless parade of quick-fix pretenders, which of course never fix anything. Invoking variations on much the same theme of false promises, scapegoats, and silver bullets each time- they fail us, leaving us a little older, a little fatter, and a little more desperate. Desperate for what? For the next quick fix, and false promise. Thus, the media-publishing complex propagates and profits from this perennial effect, while peddling its cause.

For our information about diet and health, as for our food, our demand is being manufactured for us by the suppliers; our taste preferences are being shaped by those selling what they teach us to crave, and require. In principle at least, we could change our demand for the better, and thereby force the supply to keep pace. Until or unless we do so, however, our minds like our bodies are apt to remain overfed, and poorly nourished.

David L. Katz, MD, FACP, MPH, FACPM, is an internationally renowned authority on nutrition, weight management, and the prevention of chronic disease, and an internationally recognized leader in integrative medicine and patient-centered care. He is a board certified specialist in both Internal Medicine, and Preventive Medicine/Public Health, and Associate Professor (adjunct) in Public Health Practice at the Yale University School of Medicine. He is the Director and founder (1998) of Yale University's Prevention Research Center; Director and founder of the Integrative Medicine Center at Griffin Hospital (2000) in Derby, Conn.; founder and president of the non-profit Turn the Tide Foundation; and formerly the Director of Medical Studies in Public Health at the Yale School of Medicine for eight years. This post originally appeared on his blog at The Huffington Post.