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

Thursday, December 5, 2013

Grains of truth

To the best of my knowledge, the ardent vegans have not yet marched off, lances burnished in the morning light, on a holy crusade against the New-Age anti-grain crowd. To my knowledge, the wheat detractors have not yet declared jihad against those meat detractors. And thank goodness, the most fervent disciples of the low-carb cult have not yet executed anyone for heresy, although the comments some have directed at me suggest they might wish they could.

But while none of the nutrition militias have yet resorted to anything like car bombs, the mutually exclusive disparagements I encounter ever more frequently seem infused with just that sort of toxic passion. While the idea of violence in defense of what constitutes the most blessed composition of breakfast may seem far-fetched, I am not so sure in a world that uses violence routinely in the name of God, and has done so to protect the environment and defend animal rights. However wholesome the subject, inflamed passions run readily amok.

Since I first pleaded for a separation of church and plate, pointed out that an exclusive and extreme focus on any one aspect of diet invited unintended consequences, and asked rhetorically if we could handle a more holistic (and truer) version of the truth about health and food, passions have run higher, dialogue has all but disappeared, and the dogs of war seem ominously restless.

As already noted, I am routinely baited and berated by the faithful followers of any given church of food. The low-carb crowd has long denigrated me for my failure to acknowledge that one of only three macronutrient classes, the main fuel source for all omnivores, and the home to everything from lentils to lollipops isn’t public health enemy #1. I readily acknowledge that we eat way too much refined starch and added sugar, but that’s not enough for the true believers.

I have long been maligned with comparable ferocity by proponents of low-glycemic eating for my failure to concede that carrots are not the root vegetable of all evil. Of course, I fully acknowledge the value of low glycemic eating, and count both Dr. David Jenkins (the inventor of the Glycemic Index), and Dr. David Ludwig (one of the more influential researchers on the topic) among my close friends and colleagues. But even so, I don’t think we have carrots to blame for epidemic obesity and diabetes, and apparently that, to the truly devoted members of this faction, is blasphemy.

I have long emphasized the relevance of adaptation to the dietary requirements of every species, and thus, presumably our own. This lends support to approximations of our native diet, popularized under the “Paleo” rubric. But I have also noted that mammoth is hard to find these days, that our Paleolithic ancestors got lots of exercise and consumed an estimated 100 grams of fiber daily, and that even they ate “mostly” plants. So the Paleo crowd has long had their pointy sticks jabbing in my general direction, too.

Recently, the American College of Lifestyle Medicine, of which I am president-elect, held its annual meeting. One of the speakers described his treatment program for weight loss and health promotion, and emphasized that it featured an “all-you-can-eat,” cafeteria-style, “starch-based” diet. He went on to claim that all healthy human diets were starch based, and that virtually all ill health in the world had something to do with meat and dairy, which were thrown decisively under the bus. And finally, he invoked two million years of human evolutionary biology as the definitive rationale for a “starch-based” diet. We have, the argument went, always been starch eaters.

On the very remote chance you don’t see some problems here, let me point out mine. First, “starch” seems to me a very poor word choice, since French fries, Wonder Bread and Twinkies all qualify. If the speaker meant a diet based on whole grains and root vegetables, I think it would have been better to say so. We have done a lot of harm by speaking in terms of nutrient classes when we should have been talking about foods.

But the problems don’t end there, of course. Maybe root vegetables have long been a part of the human diet, but only a relatively small part. Grains only became a significant part of our diet some 12,000 years ago with the advent of agriculture, even if wild grains were occasionally eaten prior. I have never heard the professional anthropologists describe our native diet as “mostly starch.” Nor did it seem honest to me to invoke the span of our evolutionary history to justify starch intake, while rejecting meat. There are arguments against eating meat, but evolutionary biology isn’t one of them. Homo sapiens were omnivorous since before we were sapiens. Homo erectus hunted.

So this was, apparently, some form of vegan propaganda masquerading as expertise. I confronted it as such, because although I am a fan of vegan diets done well, I am not a fan of dogma or propaganda. I believe epidemiology should trump ideology. I was expecting some customary academic give and take, but what issued from the speaker was instead such a poignant antipathy, that I was afraid I was going to be beaten to death with a tuber.

So here we are. We have a faction long contending that animal protein is the devil in the details of our diets. We have another saying that wheat is making us fat, yet another contending that grains are making us stupid. In the context of mounting evidence that not all saturated fat is created equal, and that we can replace it (with sugar and starch and trans fat) and wind up worse off, a commentary in the British Medical Journal attempting to absolve it has prompted a predictable war of words, with competing armies facing one another under banners of saturated fat as unredeemed sinner, and misunderstood saint.

And let’s not even get into sugar as toxin, fructose as poison and whether calories count. Suffice to say those passions all run just as high.

Folks, is this really where we want to be? Haven’t disparate visions of God caused the world enough grief that we don’t want disparate visions of dinner to do the same? If any of the world’s religions is correct in all the details, then all of the others must be wrong, and countless people have both killed and died throughout history thinking it so. If any of the prevailing, mutually exclusive theories about diet is correct, then all the others must also be wrong. Should choosing a meal really require choosing a messiah?

Couldn’t the proponents of low-carb eating acknowledge that jelly beans were part of the problem, but pinto beans, not so much? The vegans have important arguments about the treatment of our planetary cohabitants, sustainable eating for a population of seven billion and planetary stewardship, but if anything, these get lost when they fail to allow for the fact that game and fish figure in the diets of some of the world’s longest-lived, most vital peoples. We could have been right about reducing saturated fat intake, and wrong about what we ate instead. We could agree that eating real food, close to nature, rich in nutrients, and mostly whether or not exclusively plants would be far better than the typical American diet, and would occupy ground common to the disparate theologies of food. We could, and if we did so, we might devote more of our energy to getting there from here, rather than berating one another for differing notions of exactly where “there” is. As we’ve spent literal decades doing just that, look around to see all the terrific progress we have to show for it.

Whether about wheat or meat, sugar or starch, calories or carbohydrates, this fat or that fat, we seem to have an insatiable appetite for mere grains of truth about diet and health, rather than the complete recipe. Planting such seeds, we are reaping just what we are sowing: more heat than light, unending opportunities for food industry abuses, stunning lack of public health progress and the very kind of trees that make the forest impossible to see.

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:

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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