Thursday, October 4, 2012
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.
Contact ACP Internist
Send comments to ACP Internist staff at firstname.lastname@example.org.
- QD: News Every Day--Alternative medicine prevalent...
- Are organic foods healthier?
- QD: News Every Day--Patient education, lifestyle l...
- When medical protocols become a straightjacket
- Let the buyer beware
- Day 31: block 4 - renal and urinary
- QD: News Every Day--Ease into talks with potential...
- Evidence lacking that organic food is healthier
- QD: News Every Day--Women still on hormone replace...
- One more monitor
Members of the American College of Physicians contribute posts from their own sites to ACP Internistand ACP Hospitalist. Contributors include:
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.
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
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 Richmond, Va., 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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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
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)
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,
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
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.
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.
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.
The Public Library of Science's open access materials include a blog.
One of the most popular anonymous blogs written by an emergency room physician.