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

Tuesday, December 2, 2014

Whole grains and half-witted notions

I was delighted to speak yesterday at the sold-out Whole Grains Council conference in Boston. I was also delighted to find myself in the company of a veritable who's who of dietary sense and science. Missing from the audience were ideologues and iconoclasts. Present were those people whose careers are not about defending a particular diet, but looking at all of the evidence, interpreting it, and sharing it. People like the lead dietitian at Eating Well and WebMD. People like the lead health writer at The Atlantic. Good company, indeed.

Whole grains are, and always have been, a mainstay in my diet and the diets of those I love most in the world. Nobody pays me to say that; nobody pays us to eat them!

I eat them because I love them (and this, no doubt, had something to do with my invitation yesterday); and because the evidence is decisive that they love me back, by promoting my health.

The odd part of this story is the need to make the case for whole grains in the first place, since they have had the support (as they still do) of the vast majority of nutrition authorities for decades (or maybe forever, since there were whole grains before there were nutrition authorities); have figured prominently in human diets since the literal dawn of civilization; and figure prominently today in the diverse diets of all of the healthiest, longest-lived populations on the planet.

But this is the age of half-witted nutritional nonsense, including nonsense about whole grains. This is the age of needing to defend what should be self-evident. Not long ago, I did an interview with the New York Times to make the case that, yes, despite the idea that fructose is toxic, it IS still okay to eat whole, fresh fruits. Geez! Compared to that, the need to argue that, yes, whole grains really are good for us, almost makes sense.

But it doesn't make much sense, and it sure does harm. The more we gyrate in place, re-arguing what we should already know, the less energy is left to do anything with it. If, for instance, despite the evidence that eating fresh fruit can actually defend against diabetes, we invoke arguments about fructose and throw our apples under the bus, what hope do we have for anything other than an unholy, mushy mess? We should use what we know, but we seem to have a far greater appetite for questioning reliable answers than answering meaningful questions. I suppose it provides a nice excuse for doing whatever the hell we want.

And that, I think, is the principal application of the so-called Paleo diet. My invitation to Boston yesterday was, in fact, to address the Paleo diet specifically, something I have done before, on more than one occasion.

Actually, I am far from a detractor. I fully endorse the relevance of evolution, natural selection, and adaptation to the dietary needs of all species, our own included. These, of course, are the basis for any argument in support of Paleo eating.

But after noting that fundamental relevance, things break down quickly. We don't know exactly what our Stone Age ancestors ate; we can only work out approximations. There were likely variations on the theme of Paleo eating, just as there are variations on the theme of healthful eating today. Our Stone Age ancestors probably ate a fair number of bugs, and nobody seems to want to talk much about that.

More importantly, the Paleo diet banner is generally flown over diets bearing just about no resemblance to true Stone Age diets, let alone Stone Age lifestyles. There was no Paleolithic bacon, for instance. There was no Paleolithic pastrami, or pepperoni, either. If you want a Stone Age diet, the animals you eat, need to have a Stone Age diet, too. That means venison, antelope, bison, and as a vague approximation, grass-fed cattle. It means game: wild animals of land and sea, living their native lives, and eating their native diets. Claiming that any other kind of meat is “Paleo” is, well, baloney.

Also routinely ignored is the assertion, common even to the apparently disparate voices in paleoanthropology from the hunter-gather to the gatherer-hunter end of the spectrum, that our native intake of fiber was very high, averaging something close to 100 grams per day. The average American gets something like 12 grams. Nobody addressed this better than the famous medical missionary, Denis Burkitt (after whom Burkitt's lymphoma is named): By global [and historical] standards, the entire population of the U.S. is constipated! Moving on.

If Paleo eating really is a good idea, how do you decide which parts of it are important? Is there a basis, for example, to conclude that eating meat is important, but getting that high fiber intake is unimportant? There is not. Pop culture has pulverized the valid concept of Paleo dieting, like those apples under the bus, into an unrecognizable mess. In my experience, the popularity of the concept resides almost entirely with an appetite for hamburgers and hotdogs, and the pleasant opportunity to pretend there is a halo over those choices.

No one knows that Paleo eating is best for health. To know for sure, we would need a randomized trial of thousands upon thousands of neonates, assigned to all of the competing dietary patterns, then followed for about 100 years to see which group lives the longest and best on average. I trust you are not surprised to find that study has not been done, nor is it likely any time soon.

In the interim, though, we do have the real-world evidence of Blue Zone populations about diet, lifestyle, and health across just such a span. As noted, these longest-lived, healthiest populations on the planet all consume whole grains routinely.

There is evidence that whole grains can be the best solution to the very dietary problems associated with refined grains. In at least one study comparing different ways to achieve a low glycemic load, a mostly plant-based approach including whole grains outperformed a meat-based approach across a wide array of bio-markers.

The other argument against grains is, of course, the widespread concern about gluten. That concern, however, is far more widespread than actual gluten sensitivity, prevalent though the latter may be. This is an easy one: If you are gluten intolerant, don't eat gluten. That's right up there with: If you are allergic to peanuts, don't eat them. But in neither case does it say anything about what the sensitivity-free majority should do. The food industry has exploited the popularity of gluten-free eating, just as they have exploited every dietary fashion trend before, and the result is abundant new opportunities to indulge in gluten-free junk food. On the off chance this isn't self-evident, there was no highly-processed, gluten-free junk food in the Stone Age.

I suspect members of the Paleo cabal have already reached their verdict, and have their clubs hoisted accordingly. But again, I am not here to throw Paleo dieting under the bus. If, however, you want to invoke that banner, then go all the way. That means the animals you eat in the name of Stone Age virtues need to have a Stone Age diet themselves. It means something close to 100 grams of fiber daily; many miles of daily walking; no tobacco or alcohol; sleep in accord with the cycles of light; and so on. And by the way, no technology, so stop reading this on a computer!

Even with all of that, we know nothing about the effects of Paleo living on the full, modern life span, because Stone Age life expectancy was a whole lot shorter.

The half-baked, half-witted approach to Paleo that prevails is another story altogether. A diet of modern meat from poorly-fed, ill-treated animals conjoined to the exclusion of whole grains that further reduces an already pitiful fiber intake is neither a formula for health, nor even a cogent concept. It has rather dire implications for the fate of the planet as well, since we are no longer scattered, roaming tribes; but a global horde of over 7 billion. It's not really Paleo; it's just a convenient excuse for baloney. Excluding whole grains from your diet does not make it Stone Age. Hunting antelope with a spear would be a good start.

Whole grains have figured prominently in human diets for roughly 15,000 years. They figure prominently in the diets of the healthiest populations alive today. And unlike the mostly extinct choices of our Stone Age ancestors, they are available to us today.

I eat accordingly. As for you, my case is just the grist. Mill it as you see fit.

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:

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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.

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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.

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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.

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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.

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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.

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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.

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The Blog of Paul Sufka
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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.

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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
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One of the most popular anonymous blogs written by an emergency room physician.

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