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Wednesday, July 23, 2014

Fat: ending the war that nobody started

Given the timing, it is more than a little ironic that the current Time magazine cover story is about an alleged war that has been raging for a long time; about questionable motives and dubious intelligence; about the failure to find what we went after in the first place; and about a whole lot of questions and chaos in the aftermath—yet is has nothing to do with Iraq. As noted, truly ironic.

The current Time magazine cover story refers to ending the war on dietary fat. And overall, writer Bryan Walsh does a good job of war reporting, addressing all fronts of this now decades-long conflict in the span of just a few pages.

As you might expect, though—I am left with some concerns. When it comes to diet, we seem more prone to the crude influence of inertia than a block of flotsam floating through space—and all but immune to the subtleties of actual thinking. Since the current momentum is aimed at a condemnation of the so-called ‘war’ against fat, this article may simply feed into it—and encourage people to feed themselves ever more baloney (and related deli meats). This despite the ongoing parade of studies highlighting the hazards of doing just that.

I also worry that the majority of readers won’t get past the title and cover image, since the majority of readers never do. Most, I suspect, will simply decide on the basis of the buttery cover that the article means just what they want it to mean—and pass the pork chops accordingly.

Whether or not a product of good reporting, that’s bad news. We in the media are overdue to embrace the anti-intellectual realities of this sound bite, Tweet-driven world of ours and acknowledge that titles and cover images matter, as they are all many will ever see. For many—the title or headline is the punch line, not the introduction. Calling all editors: Please choose accordingly from now on!

No, folks. You should not start eating more baloney, nor meat in general, nor butter, nor cheese. We’ll get back to that war in a moment, but for now, here are four important considerations for you:

1) We have been eating fewer vegetables. This is an easily overlooked tidbit in Mr. Walsh’s article—it shows up in the third column of the second row of a figure about where our calorie intake went down. The figure tells us that our intake of calories from vegetables has gone down 3% since the 1970s. Since vegetables don’t have many calories—one of their many virtues—that means our intake of vegetables has gone down rather a lot. That advice to eat less meat, butter and cheese could result in reduced vegetable intake is pretty incredible. If we extend the war analogy, it would be right up there with looking around at the aftermath of the bombardment—and then realizing we had landed the troops in the wrong country altogether. Oops. Sorry, everybody!

2) We increased our calorie intake. This may not have been as diametrically opposed to the intended guidance as reducing vegetable intake—but it’s pretty darn close. Mr. Walsh devotes most of his verbiage to the particular, and competing sources of calories, but he does tell us this one line in 1 little paragraph somewhere in the middle of his piece: “The idea here was in part to cut calories, but Americans actually ended up eating more: 2,586 calories a day in 2010 compared with 2,109 a day in 1970.” We were too fat, and too often sick when the ‘war’ against dietary fat began—and that in fact is why it began, partly in an effort to help curtail our intake of excess calories, driving the obesity epidemic—and the attendant epidemics of related chronic diseases that persist to this day. Calorie intake was supposed to go down, not up. We ate more instead of less, and got fatter instead of thinner. And so again: Oops!

3) We are not clueless about the basic care and feeding of Homo sapiens. I won’t belabor that here, but will note that a recent review of relevant literature lead me to no particular epiphanies about fat, or carbohydrate, or protein; but to the conclusion that the basic theme of healthful eating is very clear to anyone willing to see it. Unfortunately, those hungering for scapegoats or silver bullets are not willing to see it—or swallow it.

4) In an entirely unrelated review of the literature on diet and diabetes, Dr. Frank Hu and colleagues reached a virtually identical conclusion to mine in #3.

But let’s get back to the war. There clearly isn’t a war against all dietary fat, and hasn’t been one for a very long time if ever. Anyone not living under a rock on another planet knows that the ‘Mediterranean diet‘ is one of the healthiest options we’ve got, and it’s awash in olive oil. Anyone not lost at sea without radio contact knows that fish oil is good for us.

But while no one ever really declared a war against dietary fat in the first place, somehow, that distorted perspective took hold. The whole thing resembles nothing so much as a game of ‘telephone,’ in which an initially intelligible message is passed through a series of whispered repetitions, until utter gibberish emerges.

An effort by scientists—whether inspired or misguided—to shift our dietary pattern away from certain foods and toward others was co-opted by food industry opportunists, and shifted toward a different, and newly invented set of foods. Then, we the people, happily eating Snackwells, did the rest—with some help from the usual suspects: media, marketers and faddists. The war we are now being encouraged to end was more of a charade than the one in the movie Wag the Dog.

But even if a war against dietary fat had ever really existed as anything more than gibberish, it would still be long over by now. Recent battles have been far more surgical in nature, although perhaps still not quite enough so. We appropriately went after trans fat. But we have tended to refer to all polyunsaturated fats as “good,” while neglecting the rather extreme and well-documented imbalance in the pro-inflammatory omega-6s and the anti-inflammatory omega-3s (an oversimplification, but useful just the same) in modern diets. We have maligned saturated fat as a class, and only late in the game are coming to realize that not all saturated fatty acids are created equal. We are still a bit stuck with the need to make them all good in order to acknowledge that they aren’t all bad. Modern nutrition seems more a product of Newton’s third law of motion than anything resembling evidence-based sense.

We have certainly had, and continue to have, baby and bathwater issues. Or, to continue the military metaphor—we have at times failed to recognize the enemy disguised as a friend, and at times have perpetrated the inadvertent harms of “friendly fire.”

Mr. Walsh is rather harsh in his characterizations of Ancel Keys, the epidemiologist who was among the first to look for explanations in cultural and dietary variations for the high and rising rate of heart disease in the U.S. But wherever you land with regard to Dr. Keys, it’s important to pause and note this: heart disease rates were high and rising when Keys started this work, and that’s why the work was started. Attempts to blame Keys and his disciples for what ails us run afoul of the fairly standard requirement that cause should precede effect.

The original advice about cutting fat—from Keys and others—was advice to eat fewer of the fat-rich foods that predominated in the then typical American diet—namely meat, butter and cheese—and replace them with more of the then-available foods naturally low in fat. Those foods were vegetables, fruits, beans and legumes, and whole grains. Had that swap ever been made, there would have been no war to wage, no war to end, and many fewer casualties along the way of chronic disease, premature death and obesity.

The intended guidance was never applied. Big Food took over the field, and completely recast the terms of engagement. Rather than eating less steak and more spinach, we passed the Snackwells. As noted, when the advice about dietary fat was first issued, Snackwells had not yet been invented.

That invention inevitably became the mother to new nutritional necessities; suddenly, we all needed low-fat snack foods. That would have been bad enough—but things got worse. Foods like Snackwells came along with propaganda: this is what was meant by ‘cut fat’ in the first place. Of course, it was not.

The ‘eat low-fat junk’ phenomenon was never the product of scientific guidance. It was the result of epidemiology drowned out by economics, public health subordinated by propaganda. Madison Avenue just made it up.

And we went along; of that, we are indeed guilty. Tempted though we may be to blame everybody else, to some extent when we meet the enemy here—it is us.

Our principal transgression was gullibility. It was as if we had all been told that it’s wrong to punch one another—with the intent, clearly, that we use our words to resolve our conflicts. But then the mallet salesmen came along to tell us that what had been intended was we use hammers instead of fists. And away we went, knocking one another over the head—wondering all along why the epidemiology of head trauma never improved. It is long past time for all that hammering to knock some sense into us all.

Only 1.5% of Americans meet daily recommendations for both vegetables and fruits to this day—despite decades of trying to change these deplorable statistics. We got advice to eat less meat and ate fewer vegetables. Looking at the trends in American eating from just a bit of altitude invites nothing so much as an incredulous shake of the head, and a roll of the eyes. We seem badly in need of a war against nincompoopery.

The evidence continues to accrue—with almost surprising frequency—that we should, indeed, eat less meat, butter and cheese (before we even factor in the environmental considerations, which frankly we should do). We just shouldn’t replace them with donuts, Snackwells and soda. Well … duh. Really.

So here we are—striving to end the war that no one really declared in the first place. Certainly no one ever recommended that we reduce our intake of fatty foods, but wind up eating fewer vegetables and more calories. Courtesy of no one’s advice, but a whole lot of agendas mostly involving money—that’s what we did. We have been living, and all too often dying, on a diet of unintended consequences ever since, and are still apparently disinclined to eat more vegetables, fruits, beans, lentils, nuts, seeds and whole grains. Alas.

And now we face the prospect of more unintended consequences, as we are told it’s time to end the war. The starchy, sugary, tasty low-fat junk foods we invented to exploit the ‘low fat’ guidance are still with us, and still tasty. So I envision a peace treaty with dietary fat that is silent on the matter of wholesome foods in sensible combinations ushering in a new era of dietary debauchery: this time, we will add back meat, butter, and cheese while failing to cut much starch or sugar. It is possible to eat even fewer vegetables and more total calories, and if history is any indication—that’s just what we’ll do. That will be tragic, because the evidence for what we really should be doing is strong and clear and consistent and compelling. But it’s devoid of conspiracy theory intrigue, lacking in scapegoats, and bereft of silver bullets. It’s a non-starter in other words.

Which leads us back to where this began, the start of a war no one ever really declared, that it is now time to end.

Okay, but do have a look out at the world—Iraq in particular—and consider that how a war is ended can be at least as calamitous as how it is begun. I told you it was ironic.

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.

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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