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Monday, March 10, 2014

Baloney, bushes and the bird in hand

It dawned on me recently, pretty much out of the blue, that I might be going about this whole thing all wrong. My epiphany was, I believe, precipitated by some rather tedious fact-gathering for a medical publisher in the service of refuting some of the latest fad diet nonsense to capture the public imagination.

I have been refuting fad diet nonsense for going on 20 years, and it is getting tedious. It’s getting tedious in particular, because I had hoped we would have run out of fad diets by now, but we never do. There is an endless parade of them, and there’s just 1 of me, so they are wearing me down.

Don’t get me wrong: I don’t have misgivings about the job. First, they really are fad diets, as evidenced by the fact that each one comes and goes to be replaced by the next. If any of them was the real deal, why on earth would we need the next one, and the next, and the next? And, as a preventive medicine physician whose daily obligations, sacred oaths, and vocation are all tethered to using the best available information to add years to life and life to years, I would be abdicating dishonorably if I didn’t highlight fad diet nonsense wherever it presents itself, whether people want to listen or not.

But the fad diets never stop, and the miles and years were taking a toll on me yesterday when I had my epiphany. They were taking a toll as I pulled together peer-reviewed citations to affirm that what everyone with sense knew was nonsense until quite recently was still nonsense despite a best-selling book that claims otherwise, and does so convincingly by citing the literature very selectively and leaving out all of the very references it was my job to pull together.

My epiphany was about birds, bushes and baloney. I have been berating the constant manufacture of beguiling and lucrative baloney by an assembly line that involves fad diet authors, publishers, the media, and a public seemingly incurably prone to the gullibility of desperation. Take ordinarily level-headed people and offer them magical weight-loss promises and/or it’s-just-this-one-thing-that-noboby-but-me-knows-and-is-willing-to-tell-you conspiracy theories about diet, and their eyes glaze over, they start walking like zombies, and reach irresistibly for their credit cards.

I’ve been battling the baloney, and my epiphany was: Maybe I should just brandish the bird in hand.

More than 20 years ago, in 1993 when McGinnis and Foege’s seminal paper, “Actual Causes of Death in the United States,” was published in JAMA, we already knew how to prevent virtually all of the premature deaths in the United States by modifying factors we know how to modify. And for our purposes, we already knew how to prevent 80% of all premature deaths and the chronic diseases propagating them by modifying just 3 things: what we do each day with our feet (physical activity), forks (dietary pattern), and fingers (not smoking).

It’s the middle one of those 3, forks, that served me yesterday’s epiphany. In case it’s not clear, I’ll spoon-feed it: we already knew! In 1993, we already knew enough about the fundamentals of healthful eating to prevent 80% of all premature death and chronic disease, namely: heart disease, cancer, stroke, diabetes, dementia, and so on. We already knew!

But how could we possibly already have known? The paper was written before the publication of the #1 New York Times best-selling Dr. Atkins’ New Diet Revolution, which came out in 1992, but really took off in 1999. That was before the #1 New York Times best-seller Sugar Busters, was published in 1998. It was before the #1 best-selling The Zone was published in 1995. It was before the fat flushes, cleanses, grapefruit diets, coconut diets that have followed. It was before best-selling arguments were made that we all need HCG injections, we all need to stop eating fruit and carrots, that fructose is public enemy #1, that wheat is, that grains are.

We already knew!

And we truly did know, as has been demonstrated abundantly and robustly in the fullness of time. Erudite though doctors McGinnis and Foege may be (and, indeed, they are), 1 paper does not a decisive argument make. But their paper was merely the first beat in a repetitive percussion of publications now spanning decades, telling us over, and over, and over again of the power of that very short list of lifestyle factors, including the well-known fundamentals of simply sensible eating, to all but eliminate obesity and eradicate fully 80% of chronic disease and premature death. Those same findings have been replicated by researchers at the CDC, researchers in Potsdam Germany, researchers in the U.K., and again, and again, and again by investigators at universities throughout the U.S. and world.

And when those same, long-known fundamentals of eating well have been put to the test, they have been shown—repeatedly—to alter even gene expression in a way that favors health and forestalls chronic disease, including cancer.

I have written about this short list of factors, and our mostly latent capacity to improve our lives and the lives of those we love by slashing risk for all chronic disease—losing weight, finding health, adding years to life and life to years—many times. In fact, my most recent book, Disease Proof, is all about that promise and the skill set I rely on, and you can use, to get there from here.

So what, then, is the epiphany?

Rather than fight the fad diet authors and the public’s endless, if promiscuous and fickle love for them, what if we just say—maybe they are all right! Maybe everything we ever heard about every diet in the past 20 years is true. Maybe it IS all about balancing macronutrients just so, all about cutting carbs, all about not counting calories, all about cutting fat, all about the glycemic index, all about fructose, all about wheat; it’s all about meat, all about grains, all about grapefruit, cabbage soup, pH, or coconut. Let’s give everyone the benefit of any doubt (if there really is any doubt), and just assume: They are all right!

Here’s the thing: All of this wonderfully empowering information about diet came along AFTER we already knew how to prevent 80% of all chronic disease and obesity with a short list of lifestyle factors, including diet. Stated differently, we already knew enough about diet and health in 1993 to use diet to prevent almost all obesity, chronic disease, and premature death.

So, even if every beguiling diet to come along since has been absolutely, spot-on right (challenging, since most of them refute what all the others contend, but we’ll look past that for now)—all they could possibly do is help us wrestle under control the remaining 20%. All this my-diet-can-beat-your-diet fussing is about the residual 20% of modern epidemiologic misery left behind after we’ve already eliminated 80%. It has to be, because in 1993, WE ALREADY KNEW how to eliminate 80%.

And so we come to it: We already knew, but did not do. We have not eliminated 80% of chronic disease, or all but eradicated obesity. Knowledge isn’t power if you don’t apply it. We have not applied it. Instead, diverted and distracted and dizzy from an endless parade of competing theories, we have largely ignored and neglected the opportunity to get 80% of the prize, while caught up in the competition for the residual 20 percent. Beguiled by the beauty pageant, we have squandered years of life and life in years, and not just our own, our children’s and grandchildren’s as well.

In case you are wondering what we knew about diet back in 1993 capable of all this, it’s the obvious. Genius is the capacity to see the obvious that everyone overlooks, and Michael Pollan’s pithy summary, “eat food, not too much, mostly plants,” is genius. It’s also quite correct, and the formula for an 80% reduction in chronic disease.

I know, because it’s my job to know. Over the 20-year span of fighting this fight, I have written 3 editions of a nutrition textbook widely used in medical education, the third edition of which is just now in production. I know, because I have been asked more than once to review this literature dispassionately and reach an evidence-based conclusion about what makes for healthful eating, and subject my efforts to the gauntlet of peer-reviewed publication. My latest effort in this area is a paper entitled “Can We Say What Diet is Best for Health?” due out in the Annual Review in Public Health in March. I know, because I have not been interested in selling any particular diet, but I have been eager to know and share the truth.

The truth is we are not now, and were not in 1993, clueless about the basic care and feeding of Homo sapiens. We knew then, as we know now, the basic theme of healthful eating, even as our knowledge, and ignorance, allow for variations on that theme. What we have known all this time is that a diet of mostly real foods, mostly direct from nature, mostly plants, would do the trick. By placing an emphasis on wholesome foods, vegetables, fruits, beans, lentils, nuts, seeds, whole grains, water, with or without eggs, dairy, meat, fish, poultry, and seafood, we would be getting lots of good stuff, and little bad. By getting the pattern just basically right, carbs and fats and sugar and calories and glycemic index and pH would just tend to take care of themselves.

We are not clueless about the basic care and feeding of Homo sapiens. We have known the fundamentals since long before 1993, and we’ve had compelling evidence of their effects since then at least. We know the basic theme of healthful eating, even if that leaves us abundant opportunity to parse the variations on that theme.

And what we have known about diet for decades is enough for diet to do exactly what we wish, in our fervent imaginings, food would do: make us look good, make us feel well, help us live long, make us vital, give us pleasure, and let us share those blessings with those we love.

I have been fighting fad diet baloney for 20 years or so. I have been doing so because it’s my job. But it suddenly dawned on me yesterday, they could all be right, and it still wouldn’t matter. Every diet book to come along in the past 20 years has been beating the bushes for some portion of the residual gains to be had after we put to use what we already knew in 1993. If they are all right, they can collectively deliver only a small fraction of the prize to which we have had access, and which we have been mostly squandering, for decades.

They can all be right, and it still doesn’t matter. Whether they are peddling baloney, or beating the bushes, it just doesn’t matter, because we had the bird in hand all along. You know what they say about the bird in hand. Why ever would we neglect it?

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 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.

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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