American College of Physicians: Internal Medicine — Doctors for Adults ®

Monday, February 20, 2012

Chewing on the best diets

U.S. News and World Report released a list of "best diets" to coincide with the annual bumper crop of weight loss resolutions as the new year begins. I was privileged to be one of the 22 judges.

We worked in isolation of one another, so none of us knew what the others were thinking. This is good in some ways, because our opinions were unbiased by one another's passions or pet peeves. But it is bad for the same reasons. Anyone who has seen any version of 12 Angry Men knows how potent, and valuable, an exchange of ideas can be.

Be that as it may, we submitted our reports independently. Each of us based our judgments of each of 25 diets in seven different categories on published papers, online materials, and personal clinical experience. U.S. News and World Report submitted very helpful summaries to us, including links to recent and important studies, but we were encouraged to go beyond this material, and I am confident all of us did.

I get the sense we agreed more than we disagreed, and am fairly comfortable with most of the outcomes. That said, the results represent the panel's consensus and don't correspond perfectly with my worldview, nor, I suspect, with that of any of my colleagues.

Overall, the rankings were a ringing endorsement of balanced, sensible approaches to weight control. No diet based on a gimmick or on wild distortions of a healthful dietary pattern scored well. Those diets that did score well were generally conducive both to losing weight and finding health. Big winners included Weight Watchers, which came in first for both weight loss and ease, and DASH, a diet developed at the NIH for blood pressure control and has since shown to confer other health benefits. The Mediterranean diet and the low-fat, plant-based diet developed by my friend Dean Ornish placed highly as well.

However, different diets did come in first for health, weight loss, diabetes and heart disease, and personally, I find that a bit silly. Weight loss by healthy means is among the most important ways of reducing risk for diabetes and heart disease. A diet that reduces diabetes risk reduces heart disease risk. A diet that reduces risk of heart disease and/or diabetes, two of the leading public health perils of our time, is obviously good for health. A diet cannot be good for health unless it reduces the risk of heart disease and diabetes. Diets that help prevent inflammation fight heart disease, diabetes and cancer.

I trust you see where this logic leads. A good diet is a good diet, period. A good diet is conducive to health promotion, the prevention of chronic disease and the control of weight. A good diet is sensible, balanced, pleasurable and sustainable. And a good diet is suitable for the whole family so that while you are losing weight on the "____" diet, you don't have to wonder: What the heck are my kids eating?

This same logic extends from the level of diet, to foods, to nutrients. What's good for us is good for us, and what isn't, isn't. Unfortunately, physicians, who historically are not well-trained in nutrition, have confounded this issue pretty badly.

Cardiologists have cautioned hypertensive patients against sodium intake, often overlooking the fact that an excess of sugar, starches and calories leading to weight gain would cause blood pressure to go up. Diabetics have been cautioned against sugar, but they are prone to hypertension and need to be mindful of sodium intake as well. Patients with high cholesterol have been counseled to avoid trans fat, saturated fat, and dietary cholesterol, but excesses of sugar and salt can propagate vascular injury as well.

Health cannot be achieved, and with the exception of deficiency syndromes, disease cannot be avoided- one nutrient at a time. The overall nutritional quality of a food is what truly matters. Broccoli is not highly nutritious because it is free of trans fat; broccoli is highly nutritious because it is broccoli!

And, of course, a diet is made up of foods. A high quality diet is made up of high quality foods, and we do, indeed, have evidence in 100,000 people that such dietary patterns are associated with both weight control and better health overall: less cardiovascular disease, less diabetes and less risk of dying prematurely of any cause.

So we can, and should, establish some logical parameters for gauging the quality of a diet. We can, and have, devised metrics specific to that mission with newer and better ones in the works. But can we actually say what diet is "best"?

I have weighed in on that topic before, and basically said no. We have abundant evidence to support a basic theme of healthful eating, and almost none to say which of the several reasonable contenders (Asian, vegan, Mediterranean, etc.) is truly best.

The logistics of a decisive trial to tell us which diet is truly best, if indeed one is, are sufficiently daunting that we may confidently anticipate doing without such evidence for the long term. Would you be willing to be randomly assigned to a vegan diet, a Mediterranean diet or a Paleolithic diet for the next 30 years? Unless a whole lot of people answer "yes," the trial we need cannot be done.

In some ways, that's good, because it means that while we do have a very well-substantiated, evidence-based theme of healthful eating conducive to weight control, chronic disease prevention and vitality, we are left with considerable room for variations on that theme. There is benefit in such doubt, because it allows for customization and the indulgence of your personal preferences and priorities. You are, as you should be, the boss.

But let's be clear, there IS a theme, and though you are the boss, you abandon the theme at your likely peril, at least in the long term. The fundamentals of the theme have been captured by Michael Pollan as well as by anyone: "Eat food, not too much, mostly plants."

Eating food means real food. Pronounceable food. If it glows in the dark, you probably shouldn't eat it. The longer the shelf life of the product, the shorter the shelf life of the person eating the product. Out on Jan. 9, 2012 is a paper suggesting that eating real food reduces the risk of ADHD in our kids, while highly-adulterated foods have the opposite effect. Science, meet intuition!

"Not too much" might seem like hard advice to take, but quality control provides for quantity control. Many processed foods are of the "betcha' can't eat just one" variety and specifically engineered to be so. Wholesome foods, an apple, for instance, are of the "betcha' won't eat more than one" variety. In fact, I've recently learned of a mom who lost 115 lbs. due almost entirely to use of the NuVal system in her supermarket, and simply trading up to more nutritious choices in each aisle. By addressing quality, quantity and weight mostly took care of themselves.

"Mostly plants" is pretty straight-forward. An emphasis on plant foods is evident in almost all diets associated with both weight control and health, and is, into the bargain, important for the health of the planet. Ultimately, being thin and healthy won't count for much if we don't still have a viable planet to call our own.

As noted, Weight Watchers won the laurels in several of U.S. News and World Report's categories: best for weight loss, best commercial program and easiest/most convenient. I am a proponent of Weight Watchers because their programming clearly works for weight loss (on the U.S. News site, each diet now has statistics attached to it, and those reporting Weight Watchers worked for them outnumber those who say it didn't by two to one; the ratio is just about the converse for every other diet on the site!), is sensibly aligned with healthful eating and provides the structural support many people need.

I believe, however, we can do even better by building skill power systematically and comprehensively to facilitate lifelong health and weight control, while addressing the needs of all family members at once. A program I have helped develop, Weigh Forward, is an example. I also see opportunities for customizing variations on the theme of weight control based on genetic testing, especially for those who find they are unusually weight loss resistant, an idea that is just now ripening into real utility.

As we size up best diets at the start of a new year, we can celebrate the winners, but note that too many of us are still losing. A majority of adults in the U.S. are overweight or obese, as our far too many of our kids. Our best efforts to date are not good enough.

What would truly be best is modifying the world so that eating well and being active simply prevailed. While waiting for that change, or better, while working for it, the best diet is bounded by considerations of not just losing weight, but finding health; not just you, but your family; not just now, but lifelong. Within the bounds of that theme, there is plenty of latitude for you to be the boss, and choose the best way forward for yourself and your family. Out of those bounds is a whole world of hucksterism and potential hurt. So I, and 21 other judges, encourage you to play inside the lines.

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.

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Members of the American College of Physicians contribute posts from their own sites to ACP Internistand ACP Hospitalist. Contributors include:

Albert Fuchs, MD
Albert Fuchs, MD, FACP, graduated from the University of California, Los Angeles School of Medicine, where he also did his internal medicine training. Certified by the American Board of Internal Medicine, Dr. Fuchs spent three years as a full-time faculty member at UCLA School of Medicine before opening his private practice in Beverly Hills in 2000.

And Thus, It Begins
Amanda Xi, ACP Medical Student Member, is a first-year medical student at the OUWB School of Medicine, charter class of 2015, in Rochester, Mich., from which she which chronicles her journey through medical training from day 1 of medical school.

Ira S. Nash, MD, FACP, is the senior vice president and executive director of the North Shore-LIJ Medical Group, and a professor of Cardiology and Population Health at Hofstra North Shore-LIJ School of Medicine. He is Board Certified in Internal Medicine and Cardiovascular Diseases and was in the private practice of cardiology before joining the full-time faculty of Massachusetts General Hospital.

Zackary Berger
Zackary Berger, MD, ACP Member, is a primary care doctor and general internist in the Division of General Internal Medicine at Johns Hopkins. His research interests include doctor-patient communication, bioethics, and systematic reviews.

Controversies in Hospital Infection Prevention
Run by three ACP Fellows, this blog ponders vexing issues in infection prevention and control, inside and outside the hospital. Daniel J Diekema, MD, FACP, practices infectious diseases, clinical microbiology, and hospital epidemiology in Iowa City, Iowa, splitting time between seeing patients with infectious diseases, diagnosing infections in the microbiology laboratory, and trying to prevent infections in the hospital. Michael B. Edmond, MD, FACP, is a hospital epidemiologist in Iowa City, IA, with a focus on understanding why infections occur in the hospital and ways to prevent these infections, and sees patients in the inpatient and outpatient settings. Eli N. Perencevich, MD, ACP Member, is an infectious disease physician and epidemiologist in Iowa City, Iowa, who studies methods to halt the spread of resistant bacteria in our hospitals (including novel ways to get everyone to wash their hands).

db's Medical Rants
Robert M. Centor, MD, FACP, contributes short essays contemplating medicine and the health care system.

Suneel Dhand, MD, ACP Member
Suneel Dhand, MD, ACP Member, is a practicing physician in Massachusetts. He has published numerous articles in clinical medicine, covering a wide range of specialty areas including; pulmonology, cardiology, endocrinology, hematology, and infectious disease. He has also authored chapters in the prestigious "5-Minute Clinical Consult" medical textbook. His other clinical interests include quality improvement, hospital safety, hospital utilization, and the use of technology in health care.

Juliet K. Mavromatis, MD, FACP, provides a conversation about health topics for patients and health professionals.

Dr. Mintz' Blog
Matthew Mintz, MD, FACP, has practiced internal medicine for more than a decade and is an Associate Professor of Medicine at an academic medical center on the East Coast. His time is split between teaching medical students and residents, and caring for patients.

Everything Health
Toni Brayer, MD, FACP, blogs about the rapid changes in science, medicine, health and healing in the 21st century.

Vineet Arora, MD, FACP, is Associate Program Director for the Internal Medicine Residency and Assistant Dean of Scholarship & Discovery at the Pritzker School of Medicine for the University of Chicago. Her education and research focus is on resident duty hours, patient handoffs, medical professionalism, and quality of hospital care. She is also an academic hospitalist.

Glass Hospital
John H. Schumann, MD, FACP, provides transparency on the workings of medical practice and the complexities of hospital care, illuminates the emotional and cognitive aspects of caregiving and decision-making from the perspective of an active primary care physician, and offers behind-the-scenes portraits of hospital sanctums and the people who inhabit them.

Gut Check
Ryan Madanick, MD, ACP Member, is a gastroenterologist at the University of North Carolina School of Medicine, and the Program Director for the GI & Hepatology Fellowship Program. He specializes in diseases of the esophagus, with a strong interest in the diagnosis and treatment of patients who have difficult-to-manage esophageal problems such as refractory GERD, heartburn, and chest pain.

I'm dok
Mike Aref, MD, PhD, FACP, is an academic hospitalist with an interest in basic and clinical science and education, with interests in noninvasive monitoring and diagnostic testing using novel bedside imaging modalities, diagnostic reasoning, medical informatics, new medical education modalities, pre-code/code management, palliative care, patient-physician communication, quality improvement, and quantitative biomedical imaging.

Informatics Professor
William Hersh, MD, FACP, Professor and Chair, Department of Medical Informatics & Clinical Epidemiology, Oregon Health & Science University, posts his thoughts on various topics related to biomedical and health informatics.

David Katz, MD
David L. Katz, MD, MPH, FACP, 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.

Just Oncology
Richard Just, MD, ACP Member, has 36 years in clinical practice of hematology and medical oncology. His blog is a joint publication with Gregg Masters, MPH.

Kevin Pho, MD, ACP Member, offers one of the Web's definitive sites for influential health commentary.

MD Whistleblower
Michael Kirsch, MD, FACP, addresses the joys and challenges of medical practice, including controversies in the doctor-patient relationship, medical ethics and measuring medical quality. When he's not writing, he's performing colonoscopies.

Medical Lessons
Elaine Schattner, MD, FACP, shares her ideas on education, ethics in medicine, health care news and culture. Her views on medicine are informed by her past experiences in caring for patients, as a researcher in cancer immunology, and as a patient who's had breast cancer.

Mired in MedEd
Alexander M. Djuricich, MD, FACP, is the Associate Dean for Continuing Medical Education (CME), and a Program Director in Medicine-Pediatrics at the Indiana University School of Medicine in Indianapolis, where he blogs about medical education.

More Musings
Rob Lamberts, MD, ACP Member, a med-peds and general practice internist, returns with "volume 2" of his personal musings about medicine, life, armadillos and Sasquatch at More Musings (of a Distractible Kind).

David M. Sack, MD, FACP, practices general gastroenterology at a small community hospital in Connecticut. His blog is a series of musings on medicine, medical care, the health care system and medical ethics, in no particular order.

Reflections of a Grady Doctor
Kimberly Manning, MD, FACP, reflects on the personal side of being a doctor in a community hospital in Atlanta.

The Blog of Paul Sufka
Paul Sufka, MD, ACP Member, is a board certified rheumatologist in St. Paul, Minn. He was a chief resident in internal medicine with the University of Minnesota and then completed his fellowship training in rheumatology in June 2011 at the University of Minnesota Department of Rheumatology. His interests include the use of technology in medicine.

Technology in (Medical) Education
Neil Mehta, MBBS, MS, FACP, is interested in use of technology in education, social media and networking, practice management and evidence-based medicine tools, personal information and knowledge management.

Peter A. Lipson, MD
Peter A. Lipson, MD, ACP Member, is a practicing internist and teaching physician in Southeast Michigan. The blog, which has been around in various forms since 2007, offers musings on the intersection of science, medicine, and culture.

Why is American Health Care So Expensive?
Janice Boughton, MD, FACP, practiced internal medicine for 20 years before adopting a career in hospital and primary care medicine as a locum tenens physician. She lives in Idaho when not traveling.

World's Best Site
Daniel Ginsberg, MD, FACP, is an internal medicine physician who has avidly applied computers to medicine since 1986, when he first wrote medically oriented computer programs. He is in practice in Tacoma, Washington.

Other blogs of note:

American Journal of Medicine
Also known as the Green Journal, the American Journal of Medicine publishes original clinical articles of interest to physicians in internal medicine and its subspecialities, both in academia and community-based practice.

Clinical Correlations
A collaborative medical blog started by Neil Shapiro, MD, ACP Member, associate program director at New York University Medical Center's internal medicine residency program. Faculty, residents and students contribute case studies, mystery quizzes, news, commentary and more.

Interact MD
Michael Benjamin, MD, ACP member, doesn't accept industry money so he can create an independent, clinician-reviewed space on the Internet for physicians to report and comment on the medical news of the day.

PLoS Blog
The Public Library of Science's open access materials include a blog.

White Coat Rants
One of the most popular anonymous blogs written by an emergency room physician.

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