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

Friday, April 13, 2012

Separation of church and plate

A proud American, I think the separation of church and state long honored by a nation literally founded by those fleeing state-sanctioned religious persecution in Europe, and dedicated to tolerance, is a very good idea. But I'll leave that fight to others and move on to matters of church, and plate.

The separation of church and plate also appears to be in peril. I write to defend it, hoping no blood-spilling will be involved.

Religion and food have always commingled, of course. It's the mingling of religious fervor and opinions about nutrition that is a new, growing and ominous trend.

Food is the centerpiece of virtually all important social interactions, many of which are religious in nature. Think of any major religious holiday and not just food, but particular foods, are apt to spring readily to mind.

Food and religion meet in the area of cultural imperatives, where religion has much to say about what we should and shouldn't eat. Well-known examples include keeping kosher or Halal, and the vegetarianism of Seventh-day Adventists and some Hindus. Some of this doubtless originated in good sense and observational research. It is likely that some of the foods banned by devout Jews, Muslims and other groups were seen to cause illness. While I often argue for epidemiology over ideology, religious dietary practices are apt to represent the time-honored confluence of the two.

Almost every major religion has something to say about food, and none of this is cause for concern. What is of concern--and a threat to public health progress, in my opinion--is the evolving tendency to apply religious fervor to principles of nutrition in general. Fixed and mutually exclusive views of how to eat "right" seem to be proliferating, and fostering nutrition fundamentalism as pernicious and toxic as intolerant religious fundamentalism can be.

There are many dietary denominations, and new ones all the time. Each seems to show ardent disdain and utter intolerance for all others.

One such denomination is the "foodie elite." This group rallies around the proclamations of Michael Pollan as if he were the Messiah, and argues for perfect dietary propriety as if it were a measure of human worth. If you dare to eat a chip, you apparently chip away at your character and any hope for redemption.

But in the real world, people--even decent people, even healthy people--occasionally eat a chip. More importantly, most people--even decent and healthy people--eat SOME foods that come in bags, boxes, bottles, jars or cans. The foodie elite denigrate this, along with any effort to help people make better choices among the thousands and thousands of such options.

But what exactly are the "real" foods for which they advocate?

As compared to raw meat, cooked meat is processed--so is it off the reservation? Bread--any bread--is a processed food. So is oatmeal. So the definition of "real" food is on a slippery slope, inhospitable to religious fervor and sanctimony.

As for foods in packages of any kind--pure almond butter in a jar is hard to indict. Ditto raisins in a box. And I'm not sure the use of pure tomato paste in a can should qualify as a food felony, let alone a sin.

Clearly organic, locally-grown kale is a good choice, but what about dried lentils in a bag? Even if the definition of real food were clearly established, there would be foods on both sides of the line in packages adorned with ingredient lists and nutrition facts.

No matter what our aspirations may be, the typical American diet is overwhelmingly dominated by foods in a package of some kind. This can be bad, but it isn't always.

Religious fervor about food doesn't allow for conditional truths. In the world of absolute truths, there is no place for helping people make better choices among foods available in a supermarket, because the truly enlightened would avoid the supermarket altogether and only buy organic, locally-grown produce at their farmers' market on their way to heaven.

Another denomination with comparable conviction and diametrically opposed views is the church of latter day anti-food-police. The gospel of this group is perhaps best captured by "Keep your cause off my kid's cupcakes."

In essence, this group opposes any suggestion that food choices--especially, but not exclusively in schools--should factor in considerations of health. There is religious opposition to the notion that every classroom occasion needn't be celebrated with a large tray of cupcakes; or for taking toys out of Happy Meals.

The scripture and verse this group cites goes something like: We ate cupcakes in school when I was a kid. We should let kids be kids, and you food police should butt out and mind your own business.

But letting kids get adult onset diabetes is NOT letting kids be kids. It is an established fact of epidemiology that Type 2 diabetes, formerly called "adult onset," is now widespread among kids, largely because of what and how much they eat, and the physical activity they no longer get. Let us, indeed, let kids be kids, which should certainly include avoiding nasty chronic diseases formerly limited to mid-life and beyond.

Cultural norms have to change to keep pace with environmental change, or they become very silly very fast. Imagine if you grew up in southern California, and your family lived there for generations. It might well be that you, and all members of your family, went to school every day wearing shorts and a T-shirt. If you relocate to North Dakota, do you think this "tradition" will be kind to your kid on a typical day in January? Change in the food environment is no less a justification for modifying our behavior.

Yet another denomination is the "my way or the highway to hell" vegans. Veganism, well-practiced, is undeniably among the best diet options for human health and the health of the planet. But there is no basis in data for the argument that veganism is the only healthful way to eat. Homo sapiens have been omnivorous since before we were sapiens.

Opposing the vegans with comparable zeal are the low-carb acolytes, and the disciples of meat. Members of these groups, some of whom view the Paleolithic diet as sacrosanct, others of whom still seem to worship at the altar of Robert Atkins, dismiss and demean all arguments, and all evidence, for eating more plants (except for the branch that acknowledges the merits of the "eco-Atkins" approach). Once you decide something is heresy, there is no point in even listening.

As with the disagreements among actual religions about what is true, the disagreements among food denominations come in almost limitless flavors. There are those who impugn sugar--or even specific varieties of sugar--with religious fervor, and others who do likewise with sugar substitutes. Some argue for the myriad benefits of dairy--and some who only see the glass of milk, any kind of milk, as half-empty. I encounter the competing disparagements almost daily.

Some who have absolute conviction regarding what is true about food have legitimate expertise; others simply have opinions. In our culture, anyone who has ever lost weight, cooked or eaten has the necessary credentials to establish a new church of nutrition. If we were comparably benighted in other areas, anyone who ever rode in a plane would qualify to open a school of aviation.

It's true that nutrition experts don't know all there is to know, any more than astrophysicists know all there is to know about the universe. But in both cases, those who devote their lives and careers to the topic do, indeed, know more than the average citizen who simply happens to have an opinion. It may be hard to swallow, but fixed opinions about nutrition are not commensurate with expertise.

Among those with expertise and rigidly fixed opinions, I think they are making their perception of perfect an enemy of the common good.

We have excellent evidence to support a general theme of healthful eating, but that evidence allows for variation on the theme. It would be great if more of our food came directly from field to plate, but we have evidence that better choices can be made among packaged foods, and that making those better choices can help promote better health. For those not inclined to approach nutrition as a religion, this is a good thing, leaving the latitude necessary for people to make the choices they prefer, and love food that loves them back.

But for now, the holy wars of health and nutrition hold sway. The fervent vegans consider the carnivores unenlightened brutes. The omnivores consider the vegans malnourished loonies. The foodie elite argue for pure foods, while many in the real world are traipsing across food deserts, with the promised land nowhere in sight.

The religious overlay that nutrition has taken on is neither holy nor wholesome. It precludes us from breaking bread together. It forestalls the public health progress that could occur if we could all find a seat at a common table.

So here's to the separation of church and plate. Can I get an amen? If not, I'll settle for some holy guacamole.

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:

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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.

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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.

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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.

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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.

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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.

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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.

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The Blog of Paul Sufka
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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.

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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.

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