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

Wednesday, March 11, 2015

Diet, dog and dogma

The release of the 2015 Dietary Guidelines Advisory Committee report does not officially give us new dietary guidelines for Americans just yet. Famously, there is a political element to this process. The scientists making up the advisory committee do just that: they advise. What actually emerges as guidance is determined by the federal agencies in charge, the U.S> Department of Agriculture and the Department of Health and Human Services.

Over the years, though, as the involvement of politics in our official dietary guidance has become ever more transparent, thanks at least partly to the efforts of Marion Nestle after chairing 1 such advisory committee, they have also tended to become a bit less heavy-handed. When the report of the scientists is circulated on the Internet, as it now is, the alterations made by politicians are visible to everyone who cares. That makes any serious adulteration of the scientists' recommendations something of an embarrassment, and rather a liability.

That doesn't mean there won't be any changes. Before the committee report is translated into official guidelines, there is a period of public comment, which is a banner that flies over a host of agendas. Some of the commentary will be from public health advocates, but much will be from industry. What exact dietary guidelines will emerge from this gauntlet remains to be seen.

But given that, I like what I see so far. I think the advisory committee has done a stellar job.

Their report runs to 572 pages, so I confess I have by no means read every word yet. But I have been through it enough to get the gist, and the gist is: wholesome foods, in sensible combinations. Amen to that!

Specifically, the report uses this language: “The overall body of evidence examined by the 2015 DGAC identifies that a healthy dietary pattern is higher in vegetables, fruits, whole grains, low- or non-fat dairy, seafood, legumes, and nuts; moderate in alcohol (among adults); lower in red and processed meats; and low in sugar-sweetened foods and drinks and refined grains. Additional strong evidence shows that it is not necessary to eliminate food groups or conform to a single dietary pattern to achieve healthy dietary patterns. Rather, individuals can combine foods in a variety of flexible ways to achieve healthy dietary patterns, and these strategies should be tailored to meet the individual's health needs, dietary preferences and cultural traditions. Current research also strongly demonstrates that regular physical activity promotes health and reduces chronic disease risk.”

This is really good stuff. The consensus of the scientists on the committee is, basically, that the theme of healthful eating is clear, but that there is no single variant on that theme that is the obvious choice for all. I like that conclusion both because it is true, and because it leaves people the latitude required to wind up loving the food that loves them back, as my own family does.

The emphasis on plant foods is based both on the body of evidence related to human health, and quite appropriately, on considerations of sustainability. As I addressed inmy prior column, whatever the potential merits of a meaty, Paleo diet, they are impractical for a huge population of humanity on a shrinking planet. The Dietary Guidelines for Americans now serve an audience of over 300 million people, and that must figure in the recipe. There is no healthy diet for healthy people on a seriously unhealthy planet. A section in the advisory committee's report devoted to sustainability is a very welcome addition.

In the fullness of its many pages, the advisory committee report does of course get into the nutrient particulars. The news was leaked in advance of the report release that the current committee has dropped the recommendation for restricting dietary cholesterol intake. That is indeed true, and as I have noted in a prior column, justified in my opinion.

There has been much debate lately about appropriate thresholds for dietary sodium, and the committee was clearly attentive to it. Their conclusion, again appropriate in my opinion, is that most Americans still get more sodium than is good for us, and efforts to reduce prevailing intake should continue. Since roughly 80 percent of the sodium in the typical American diet comes from processed foods, rather than the family salt shaker, a shift to less processed, and more home-prepared foods in general, rather than a fixation on sodium per se, is the right strategy.

Given all the recent noise regarding saturated fat, to which the committee members were most certainly not deaf, one might have expected some change in direction on the topic. There was none, and I again think the committee got it right. Despite the hype, no studies have shown health benefits of increasing saturated fat intake; they have, at best, indicated that when we replace an excess of saturated fat with an excess of sugar and refined starch, we are going sideways. In contrast, intervention trials with both Mediterranean and plant-based diets low in saturated fat have been shown to slash rates of heart disease. The committee thus retained saturated fat as a nutrient of concern, suggesting we limit our consumption. Again, however, the right response is about foods, not nutrients. There is no health benefit in reducing saturated fat by eating Snackwell cookies. There is for most of us a decisive health benefit if we eat less baloney, more broccoli and more blueberries.

The multidisciplinary committee was charged with looking at dietary components from the proverbial soup to nuts, and did just that. Unlike the seemingly competing factions in our culture at present, they felt no obligation to choose one nutrient focus over another. The recommendations rightly recognize the harms of excess sugar and refined starch, while also noting the liabilities of excessive intake of meat, processed meat especially. The recommendations also rightly ignored the distorted arguments and evidence-shopping that have landed books advising against wheat and grains on best-seller lists, but which are belied by the weight of evidence viewed without such bias. To my knowledge, the word “gluten” does not appear in the report.

Finally, there is a certain emphasis in the report on family. Personally, I would have liked that to be even greater, but it's pretty good. The committee clearly recognized the importance of shared, family dietary practices, and the potential advantages of family meals. A cultural emphasis on families eating well together will speed the dawn of the day that “dieting” dies, and good riddance to it. In the Blue Zones, they don't diet, they live it. They eat well, in traditional patterns, and live longer and better than the rest of us as a result.

The work of the 2015 Dietary Guidelines Advisory Committee is, in a word, excellent.

We likely still have a long way to go reorienting our culture to a renunciation of quick-fix diets, and an embrace of the tried-and-true fundamentals of healthful eating. In an age of polarized opinions, magnified in the echo chambers of cyberspace, there are a lot of competing dogmas to overcome. Getting past that, and coming together, is an important mission, but perhaps a topic for another day. For today, we at least now have recommendations, and the promise of official guidelines, that emphasize wholesome foods in sensible combinations, rather than isolated nutrients, which for far too long have unbalanced our diets, like a tail that wags the dog.

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.

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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.

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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.

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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.

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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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