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

Monday, March 25, 2013

Better diet? Bigger picture!

A study just published online in the New England Journal of Medicine demonstrates a reduction in both chronic disease and premature death with adoption of a Mediterranean diet. This has some journalists opining that we now have evidence of a benefit we did not have before. Actually, that is untrue. We have long had evidence of the disease-fighting, death-defying potential of a well-practiced Mediterranean diet.

The new study has longtime proponents of the Mediterranean diet crowing as if this now proves it is the best diet going. That, too, is untrue. While an attempt was made in the new study to compare the Mediterranean diet to a healthful low-fat diet, participants in that group didn't really cut bad fats out of their diet. They mostly just kept eating a typical Western diet, which we already knew was bad. That the Mediterranean diet was better than the typical, prevailing diet of industrialized countries is yesterday's news. Those who want today's news to be that the Mediterranean diet has been proven superior to other truly good diets will need to wait until tomorrow, or longer. We had previously lacked any good head-to-head comparisons of "best diet" candidates, and we still do.

My colleagues who advocate for healthful low-fat eating have been quick to note that the comparison group in this trial was not it. But they may also go too far in defense of preconceived notions if they refuse to acknowledge that based on the evidence we have, a good interpretation of the Mediterranean diet is likely to be just as good as veganism for human health, if not necessarily as good for the planet and our fellow species.

What shakes out of all of this is the perennial tendency to find the patterns we are seeking, while missing the forest for the trees. Do we know what single dietary pattern is best for human health? We do not.

Do we know what fundamental theme of eating is best for human health? We certainly do -- as surely as we know that pandas should eat bamboo, and koalas should eat eucalyptus, and for many of the same reasons. Do we know how great the benefit of lifestyle as medicine could be? We do indeed, if only we could get the right medicine to go down. And no, more spoons full of sugar would not be helpful!

We have plenty of relevant science. We also have our common sense, although we tend not to apply it very commonly where diet is concerned. And we have, if we are willing to take in the view, an opportunity to see the (whole) elephant in the room.

Science, sense and elephense

(This poem was originally published in the online supplement to: Katz DL. 2011 Lenna Frances Cooper Memorial Lecture: The road to HEaLth is paved with good InVentions: of science, sense, and elephense. J Acad Nutr Diet. 2012 Feb;112(2):313-321. The audio link to the 2011 Lenna Frances Cooper Memorial Lecture is available here.)

Where the perils that threaten
prevail and surround-
it's not in small parts
that solutions are found.
There can be cause to love reduction
But I see the menace in its seduction.
In saying so,
I intend no provocation
Of this worthy congregation-
I just have this predilection
For review, and redirection.
And my fervor lies in finding means
to answer the right question;
Not in seeking foot of emperor
to practice genuflection!
So while I, too, profess compliance-
(In the company of giants)
With the tried and true of science-
I allow for some defiance:
Skiers race
An avalanche, a flight
That's make or break;
Would it count as
Defiance to say
There's no science
To indict a particular flake?
A river swells to
Cresting; its banks devolve
To mud. There's no science
To say that no science
Can say which sandbag
Stops the flood.
When with steadfast equanimity
We have parsed all plausibility
When to our telomeres we're diced
And from their bits, genomes respliced-
We may agree it is terrific
To be robustly scientific-
But lest we're muddled in denial
we must concede the best-run trial-
Though potentially inspired
Is still in tribulations mired.
For while to build a better sandbag,
we might design a RCT;
That we're wet and need a levee,
is on display for all to see.
We need science for microscopes
We need science for telescopes
But let's acknowledge, my friends
That the view decides the lens!
And while perceiving complications
may be something like reflex
A job may be hard instead of easy,
yet still be simple, not complex.
In this mad view, there's method,
whatever you may think-
For while it's true, I do see elephants-
they're only very rarely pink!
Through the trees to the forest,
we must all strive to perceive
When we do, we can't tarry-
We'll get no reprieve
We'll have miles to go, to get out
of the wood
And turn WHAT we all know,
into HOW to do good!
With utensils in hand
To carve up the beast...
We might pause to consider:
On what parts we feast?
Trees and forest;
View and lens-
Knowledge and power
Science and sense:
What road
We ought to choose
At the fork twixt
Win, or lose-
Could just come down
To views; and seeing
Past parts...
To whole elephense.
My friends, from the start
it was my intention
To make the case for good invention
for where there's a will
There's a way to be paved
So the health of our families
Can be righted, and saved.
And I'm confident
We can all escape our doom-
If we'd just see the elephant
Here in the room!

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.

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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