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Monday, November 26, 2012

Raw food diet hype is overheated

Raw food diets have emerged as a pop culture preoccupation. They seem to have considerable traction in the public psyche, as evidenced by the volume of websites they populate, and the coverage they command in print.

It is doubtful they have comparable traction at the dinner table, of course. We have enough trouble getting people to eat a reasonable amount of reasonable foods, and to renounce ingestibles that glow in the dark. In this context, it seems a bit far-fetched that we would shift, en masse, to a strict diet of raw, unprocessed foods.

But our appetites for the concept, and the claims made in its defense, seem insatiable. So let's chew on it.

In pure form, raw food eating is exactly as advertised: No foods are cooked. The diet is based overwhelmingly, if not exclusively, on plant foods. If it does include animal foods, they are consumed raw. If milk is consumed, it is consumed raw, which is to say, unpasteurized. Some versions are strictly vegan, and ban all animal products.

There are, to be sure, potential benefits of such a diet, or of many aspects of it. By placing an emphasis on plant foods, the diet is a rich source of the foods that are in turn the richest sources of valuable nutrients. The diet renounces most processed foods, and thus eliminates trans fat, and provides generally very low levels of saturated fat, sodium, and sugar, while providing nutrient-dense foods, rich in fiber. And because food choice is subject to rather strict constraints, calories are caged, making raw food diets an effective answer to the prevailing problems of weight control.

Many foods are, indeed, most nutritious when raw. Heat can destroy many nutrients, notably some water-soluble vitamins, many antioxidants, and unsaturated fats, including omega-3s. The beneficial effects of dietary fibers, both insoluble and soluble, may be altered, and at times reduced, by cooking.

And there are potential harms of cooking that raw foods sidestep. Cooking meat can lead to charring, which generates carcinogenic compounds known as heterocyclic amines. Cooking of carbohydrates can produce acrylamide, another potential carcinogen.

There is, however, a great leap of faith from some benefit in eating some foods raw some of the time, to raw is always and dramatically better.

There are claims, for instance, that raw food is better because cooking destroys enzymes in plants. Perhaps so, but so does digestion. Very few enzymes survive the hydrochloric acid they encounter in the stomach. Meaningful health effects of swallowing an enzyme that doesn't survive to see the duodenum are dubious at best.

Raw food advocacy ignores the fact that some foods are more nutritious when cooked. The nutrient lycopene makes tomatoes red. It is a potent carotenoid antioxidant, long thought to reduce prostate cancer risk, although that effect per se is in doubt. Lycopene is fat-soluble, and much more "bioavailable", that is to say, available for absorption and making contributions to our health, when tomatoes are heated in combination with an oil. Tomato sauces with olive oil are ideal, and raise blood lycopene levels far more effectively than eating raw tomatoes.

Eggs are a good source of biotin, a nutrient important in many ways, its contributions to healthy hair, skin, and bones noteworthy among them. Raw eggs contain a protein called avidin, which binds and inactivates biotin. Cooking denatures avidin, a term used when the shape of a protein is changed. Denatured avidin does not bind biotin, so cooked eggs are a good source of bioavailable biotin.

Even more important than the nutrients that cooking can "add" to food are the things it can take away, namely pathogenic bacteria. Cooking is the best and final defense against salmonella, E. coli, and other microscopic nasties that can hitch a ride on our foods. Raw milk has captured the modern imagination, but pasteurization took hold for good reason. Milk can be contaminated by bacteria, from the cows, the farmers, or farm equipment, and it makes a great growth medium. Pasteurization protects us from the attendant consequences, which were once fairly common.

And finally, there are some truly excellent foods that can't be eaten raw; beans and lentils come to mind. These are nutrition powerhouses, inexpensive, and rich enough in high-quality protein to make a good meat alternative. But they are all but indigestible unless cooked.

Some variations on the theme of raw food eating accommodate this concern, by allowing for cooking at low temperatures. But food cooked low and slow is not really raw, it's slow-cooked, and should call itself that. Cooking is always a product of heat intensity times duration, so when raw food expands to encompass slow cooking, the topic devolves to a debate about cooking methods.

Lastly, there is the notion that cooking is a form of food processing and thus "unnatural." Perhaps. But cooking, and freezing, have figured in humans' interactions with foods since long before the dawn of agriculture. So if cooking is "unnatural," everything about agriculture is even more so. To make it just as blunt as a stone hammer: We cooked meat long before we ever grew potatoes.

What we are left with, then, is a whole lot of hype that runs well ahead of any legitimate science.

All too often, opinions about nutrition are disseminated with religious zeal, as if gospel. I have argued before for the separation of church and plate, and reaffirm my own commitment to it here. I have my own opinions about nutrition. But when they are just opinions, I am careful to treat them as such.

At its best, nutrition is science. That doesn't make it perfect. Our scientific understanding is not perfect in any field, and nutrition is far from an exception. But all opinions about a science must at least run the gauntlet of what we do know. Those that cannot do so and survive are hearsay.

We tend to honor this implicitly in almost every science but nutrition. Unsubstantiated opinions about how to build a suspension bridge, perform neurosurgery, or accelerate atoms are of no particular interest. We recognize in these disciplines that expertise matters, and we differentiate the insights of those with such expertise, generally born of years of study, from the random inclinations of the rest of us riff-raff.

Somehow, though, we make an exception for nutrition. Perhaps the fact that everyone eats invites us to view everyone as comparably expert in the far-reaching implications of what we eat on physiology, pathophysiology, cell biology, and biochemistry. But of course, that just ain't so.

Cyberspace may be the perfect crock pot for haphazard food for thought. Everyone with an Internet connection gets to dish. And so while raw food advocacy has been around for 200 years, it has taken on a whole new prominence only rather recently.

The result of acting as if all food-related opinions are created equal is a whole lot of food for thought unsuitable for human consumption. Ingesting such opinions nonetheless leads to a state I am inclined to label "cognitive indigestion", a condition of unfounded convictions, misplaced trust, and/or perennial confusion.

Many foods can be eaten raw, and many foods are the better for it. An emphasis on eating mostly plants direct from nature is irrefutably good, be they raw or cooked. But as is true of so much in the realm where opinions about nutrition masquerade as gospel, the case for raw food eating is oversold, the rhetoric is overheated, and the claims of universal benefits, substantially overcooked.

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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Blog log

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.

Auscultation
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 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.

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.

DrDialogue
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.

FutureDocs
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.

KevinMD
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).

Prescriptions
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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