Life and death because of a diet of unintended consequences

The notion that Ancel Keys was wrong--profoundly wrong--when he was among the first to advocate forcefully for low-fat eating to prevent heart disease is evolving into New Age gospel.

The developing convictions are that Keys misrepresented or misunderstood the data he reviewed in his analysis of heart disease rates around the world. And his mistake about the importance and value of reducing dietary fat was propagated by many high-profile disciples, from Dr. William Castelli of the Framingham study, to names long since associated with low-fat dietary approaches: Pritikin, Esselstyn, Campbell, and Ornish, to name a few.

But here's the news flash. While it's true we now know that dietary fats are not all created equal--even dietary saturated fats are not all created equal--and that a "just cut fat" approach to diet risks tossing out both baby and bathwater, we don't really know that Keys or those who took up that same mantle were ever wrong. All we really know is that there are unintended consequences of badly bungling what we did with the dietary advice we were given.

We never--repeat, NEVER--did anything remotely like what Keys recommended, which was to shift our diets away from the higher-fat foods that predominated, including such items as hamburgers and hotdogs, butter and ice cream, to naturally low-fat foods, such as vegetables, fruits, beans, lentils and such.

What happens when this approach is taken? Many have addressed the question, but perhaps none more compellingly than my friend Dean Ornish. Dr. Ornish first showed, in dramatic fashion, that such a diet can shrink the plaque in coronary arteries. He went on to show it prevents heart attacks as effectively as the Mediterranean diet (although, I hasten to add, not more effectively). And he and colleagues have even shown recently that such a diet can modify gene expression in a manner associated with reduced risk of cancer occurrence, recurrence, or progression.

Keys was never really wrong. His message was certainly imperfect. Walnuts, almonds, wild salmon, and avocado are all high in dietary fat, and we now know these as "super foods." But if we had followed the actual advice being espoused--eat foods naturally lower in fat-- ur health as a nation would almost certainly have improved. Our weight as a nation would have declined.

So what went wrong? Unintended consequences. The food industry saw opportunity in the low-fat message, and reinvented the interpretation of the message to suit its profit-driven motives. The era of highly-processed, starchy, sugary, salty, low-fat foods was born.

But let's be clear: Dean Ornish NEVER said "Eat more Snackwell cookies to get healthy." Keys never once mentioned low-fat mayonnaise in any of his publications. I do not recall ever hearing "low-fat peanut butter rocks!" from Caldwell Esselstyn.

The message, though flawed, was reasonable, and an improvement over the prevailing diet at the time. The execution of the message was the debacle for all but the big food companies, which wound up counting money hand over fist.

Well, folks, this is a "fool me once, shame on you" scenario. But welcome to the age of fool me again, and again, again. And so, shame on us.

I never liked the Atkins diet, and still don't. There actually are very low-fat diets in the real world that are associated with excellent overall health and longevity. There are no such "low-carb" diets. People often invoke the Inuit, whose diet is low in carbohydrate and very high in fat, much of it omega-3. But the Inuit are not known for long lives, or especially good health. The Okinawans, on their low-fat native diet, are. The Seventh-Day Adventists, on their low-fat native diet, are.

Sometimes the Paleo diet is invoked to justify low-carb eating. But the Paleo diet was not low-carb, even if it was moderately high in protein. It was made up of foods direct from nature, and Atkins was never clear if when he said to eat more meat, he meant mammoth.

Everything from lentils to lollipops are "carbohydrate," so cutting carbs always seemed dietary hucksterism to me. But to give Atkins and other advocates their due, they NEVER said: "Eat more low-carb brownies, made principally from partially-hydrogenated oil." But that's just the sort of thing we did when the low-carb craze really got going, thanks in part to a New York Times Magazine cover story by Gary Taubes.

I never knew Robert Atkins personally, but I do know Gary Taubes. He's a smart guy, and I am quite convinced his intentions are good. If he erred in embracing the low-carb diet, it wasn't because he was pointing out the harms associated with an excess of starch and sugar. He was quite right about that. Rather, the mistake was in failing to learn from the follies of low-fat history.

The food industry fooled us once by turning "reduce dietary fat" into an entire inventory of Frankenfoods unimagined by Keys. Low-carb proponents had this history lesson, and so should have seen it coming. We wound up with a whole new inventory of highly processed, high-calorie, nutritionally moribund "low-carb" foods we may reliably believe Atkins never anticipated. Deja vu, all over again.

If this were just about history, there might be no need to care. It would be artificially sweetened, vitamin-fortified, New Age water under the bridge. But it's not just about history. A diet of unintended consequences remains a clear and present danger.

Dr. Robert Lustig is arguing forcefully for the harmful, indeed poisonous, effects of fructose in our food. I have not heard him say "eat more artificially sweetened muffins," but you can bet that's just what the Muffin Man is hearing.

Dr. David Jenkins has pointed out the hazards of foods with a high glycemic index. I don't ever recall him suggesting we should eat more pastrami and fewer carrots, but some diets based on the "GI" have pretty much done exactly that.

More recently, Dr. Jenkins and colleagues suggested that eggs were as bad for heart health as tobacco. Leaving aside the very profound limitations of that study, and my disagreement with the authors about its implications and the health effects of dietary cholesterol, we can all agree the study did NOT say: "Stop eating eggs, but keep the bacon and add donuts." Since America runs on Dunkin', that response may be anticipated. Unless Dr. Lustig's advice is incorporated, in which case the donuts will be fructose-free.

We have abundant evidence that the "go organic" message can be corrupted; it never meant more nutritious. We know that the good intentions of the "locavore" movement can run off the rails. A locally-grown tomato in Minnesota in February could have a larger carbon footprint than one sent there from Japan!

Michael Pollan and overall nutritional quality. We need to be more pragmatic, and less dogmatic. And we need guidance that extends to the full range of food choices people actually make every day.

In attempting to improve the American diet and health, I am in excellent company. My intentions and intelligence are not better than those of my colleagues. But I do seem more inclined to focus on the big picture, or maybe I'm just more cynical. I believe, given the least opportunity to do so, our society will certainly replicate the profitable follies of our nutritional history.

I may seem in this rant to be quite critical of the food industry. But actually, that's not so. The business of business is business. And if devising dietary concoctions that address the concern du jour keeps the customer satisfied and boosts profit, it's rather hard to see why companies in a capitalist society would do otherwise. The fault lies not with the rising stars of Wall Street, but with ourselves for serving up such one-nutrient-at-a-time invitations to dietary debacles in the first place.

Our collective problem is not want of intelligence, nor good intentions, nor even good messages. It is our failure to learn from the follies of history, and anticipate the enthusiasm with which industry elements will replicate them. I can't help but think that in boardrooms around the country, hands are being rubbed together in glee each time we come out with the next "one" thing wrong with our food supply. Because each is another gift-wrapped opportunity for a marketing bonanza, and mountains of cash.

It's past time to learn how our good intentions can be corrupted. It's past time for us to digest the follies of our recent nutritional history. And it's past time for us to chew on the law of unintended consequences and design our strategies with those consequences already in mind.

We have been living and dying for decades on a diet of unintended consequences. We seem disinclined to digest the lessons of history and avoid perpetuating this pattern. It will be a real shame if it goes on like this because people will get sick, and die, unnecessarily as a result. And since we have already been fooled more than once, this time around, the shame will be ours.

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.

Labels: David Katz, diet, guest post, Nutrition, weight loss

posted by David L. Katz, MD at 9:00 AM