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Monday, June 23, 2014

You can chew it. You can swallow it. But is it food?

There is, of course, stuff we can chew and swallow that isn’t food. Play-Doh comes to mind. As does Silly Putty.

My thoughts turned to those substances, among others, when my friends at Time magazine asked me to opine on the suggestion that “junk” foods should carry warning labels. My first inclination was: No, that’s too much. But then it dawned on me: Is anything that is a legitimate candidate for a warning label a “food” in the first place?

I looked up the definition of food, and the first one I found was: “any nutritious substance that people or animals eat or drink, or that plants absorb, in order to maintain life and growth.” That in turn implies that non-nutritious substances that, say, gum up our coronary arteries, pad our adipocytes, or rot our teeth might not qualify.

So, in some ways, a warning label on a food would be like a warning label on a computer that says: “Not To Be Used For Computing.” So how can it be a computer? Or a label on a car indicating it is “Not Suitable For Transportation.” Well, then, is it a car? You see where I’m going.

The suggestion about warning labels came at the World Health Organization’s 67 World Health Assembly, now ongoing in Geneva. The case was made that junk food is even more damaging to public health today than tobacco, and that warning labels should be posted accordingly on the implicated foods.

The argument that junk food (whatever, exactly, that is) does more damage globally than tobacco is far more defensible than it may at first seem. As far back as 1993, we knew that the combination of eating badly and lack of physical activity was just behind tobacco on the list of leading causes of premature death (and chronic disease) in the United States. When the analysis that produced that original list was repeated a decade later, that gap had narrowed, due both to less smoking, and ongoing neglect of both feet and forks, with worsening epidemics of obesity and diabetes to show for it.

Related studies have been published with regularity ever since, showing again and again and again, in populations around the globe, that eating badly and inactivity are exacting an enormous toll. Both have now been implicated among the leading causes of premature death and chronic disease worldwide. So that case can be closed.

What, then, of warning labels?

Well, the libertarians among us, and that portion of libertarian in all of us, are likely inclined to balk. In fact, the balking began before ever the talking on the subject had concluded. The basic gist here is: don’t tell me what to eat! And, of course, resistance to intrusions by Big Brother inevitably invite slippery-slope paranoia: If the government can tell me what food I shouldn’t really eat, what’s to stop them from telling me what food I must eat? The next thing you know, breakfast is prescribed by the Feds and administered by military police.

I understand the objections. But I don’t think they hold up. And in fact, I want to make the case that a skull and crossbones on a package of “toaster pastries” or multicolored marshmallows masquerading as part of a complete breakfast (what part, I’ve always wondered?); or a day’s supply of sugar dissolved in caramel-colored liquid; or something that once resembled animal flesh that has now been processed into a concoction of meat, sugar, salt and carcinogens, does not go nearly far enough.

After all, we are talking about food. And food should be … well, food.

Tobacco is tobacco, there is no way around that. None of us has to smoke, and those of us who do are exposed to the intrinsic harms of tobacco. We deserve to know what those are, and how significant. This is really no different than providing just such information about pharmaceuticals. I doubt even the libertarians object to disclosures about the potential side effects of Big Pharma’s offerings. In fact, I suspect the libertarians may feel particularly entitled to just such information.

Tobacco and alcohol are the same. They are drugs, albeit drugs used recreationally. They come with intrinsic dangers, and the consumer has a right to know about them.

One might argue to extend just such thinking to “junk” food, and thus counter the libertarian argument. Indeed, I think that could be done: being told what’s what is not being told what do to! We can be told what is in our food without being told what food to put in our mouths.

But as noted, I don’t think the “unless you want to die slowly and painfully, don’t eat this food!” label goes far enough. Because unlike tobacco or alcohol, or drugs used to treat disease, food is supposed to be good for us, not bad. It is supposed to be sustenance, not sabotage.

We are, truly, what we eat, using the nutrient components of food to reconstruct ourselves from our molecules on up every day. Consider, in particular, that food is the one, only, literal construction material for the growing body of a child you love. How we ever got the notion that “junk” food, out of which we are growing our children, was cute, or innocent, I have no idea.

You can’t smoke tobacco and avoid tobacco. You can’t drink alcohol and avoid alcohol. But you can eat food and avoid junk. There is, in fact, an impressive range of overall nutritional quality in almost every food category, so we could abandon junk food altogether, and quickly learn not to miss it.

In my opinion, that’s what we should do. Despite thinking at first that warning labels might go too far, I wound up realizing they wouldn’t go nearly far enough. Junk should never have been glorified as a food group in the first place. So sure, let’s apply some objective method to determine what foods warrant a scarlet “J,” but then, let’s eradicate them, because they aren’t food. We can sell them for something else, like spackling, for instance. But food ought to be food, not junk. It’s silly to have “don’t buy this food” labels on food we keep selling as... food. If it warrants the warning, it really doesn’t qualify. There are alternative products that do in every case.

Which might, I suppose, put me at odds with the libertarians. What else is new.

But frankly, even they should object to the false advertising involved in marketing junk as food. Besides, they can still smoke and drink.

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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