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

Wednesday, March 18, 2015

We're fat and sick and the broccoli did it!

The ink hadn't yet dried on the report of the 2015 Dietary Guidelines Advisory Committee before the assaults began. I guess in this day and age, that's not much of a big, fat surprise.

Despite all the over-heated rhetoric I've seen about not trusting this report because the “government” can't be trusted, this report is not from the government. While we may, indeed, need to worry about what the political authorities will do with the recommendations of this advisory group, as historically cautioned by Marion Nestle, this advisory group is a multidisciplinary assembly of top-tier public health scientists. They don't work for the government. The government does convene them, but they work for us. It is, in fact, the very group Dr. Nestle herself once chaired.

In other words, the very best way to prevent government lobbyists from adulterating this report is by supporting the evidence-based consensus of the scientists themselves. The more we all bicker, pretend that know better, or malign this effort as biased, misguided or morally bankrupt, the more we play into the hands of lobbyists only too happy to say: “You certainly can't trust those guys, so listen to me … “

Predictably, most of the griping under way is by entities with obvious interests at stake. No surprise, really, that the makers of bacon-cheeseburger-muffins would rail against advice to eat more vegetables and less sugar, refined flour, and meat.

That someone with book sales at stake might inveigh against the collective judgment of the diverse members of the Dietary Guidelines Advisory Committee is also not much of a big, fat surprise. That the person in question might misconstrue her own, strong opinion for genuine expertise despite lack of relevant training is no big, fat surprise either. Our culture indulges in this routinely, having already killed off expertise, and now indulging in routine abuse of its rotting corpse. We are routinely told what research studies mean by people who not only were never trained to do research, but weren't trained to interpret it, either. Whether or not they even bother to read it is anybody's guess most of the time.

But since it's how we roll, it's no big surprise that someone untrained in research methods would tell us all what the research really means and why the scientists on this committee, all trained to do research and interpret it, are just a bunch of hacks.

But that the New York Times would allocate its imprimatur and rarefied real estate to an infomercial masquerading as an Op-Ed is, well, a genuinely big, genuinely fat, and lamentably disappointing surprise. That journalistic standards are complicit in the death of expertise is a sad surprise. Oh, well.

There is another actual surprise in the mix as well. The author in question, who has used social media before not only to tell me truths I am apparently too stupid to recognize despite my nine years of post-graduate training in relevant subjects; but also to impugn my character, my research funding, and maybe even my ancestors, engaged me recently in such an exchange to tell me: the broccoli did it!

The contention, via sequential tweets, was that advice to eat more vegetables and fruits must be wrong, because we have eaten more vegetables and fruits and only gotten fatter (and, I might add, sicker). The evidence presented was a table of per capita availability of vegetables in the U.S. between 1970 and 2005. The conclusion? We are fatter and sicker, and have more vegetables now than years ago, so: the broccoli did it! Okay, that last part is mine, but it's a close approximation of the indictment intended.

Does this make even a snippet of sense? Of course not.

Since 1970, per capita availability of the following have also gone up: Internet access; smartphones; Acai berries; solar panels; noise-canceling headphones; hybrid cars; DVDs; music downloads; and fitness apps. So, maybe the solar panels did it!

But let's not rush to judgment. Also up per capita are: reality TV show episodes; winners of American Idol; Geico commercials; and Uggs. Maybe the Uggs?

Oh, and by the way: over that same time frame, per capita meat consumption (not just availability) in the U.S. reportedly increased 50 percent. In, from what I believe to be the very report cited at me on Twitter, we get these statistics for the period between 1970 and 2005: total meat available per capita increased 13 percent; total cheese availability increased 106 percent; and total added fats and oils increased 63 percent. Then, of course, we have the rather famous study by Dr. Robert Lustig, pointing out the marked, global rise in per capita availability of added sugar (by whatever name), and the obesity and diabetes that follow predictably in its wake.

But damn the distractions! The broccoli did it.

True, we produce more vegetables than we did 45 years ago. But are we eating more produce?

In absolute terms, probably a bit. But as a percent of calories? Not at all.

You see, our calorie intake has gone up, and not from broccoli, but from the usual suspects: junk food, fast food, the stuff Michael Moss tells us is willfully engineered to be addictive. Some of it is meat and cheese, much of it is refined starch and added sugar (who ever came up with the idea that only one of these at a time could be a bad actor?). But it sure isn't unadorned vegetables.

Why do we eat more now than in 1970? Well, for starters because we can; tens of thousands of new, hyper-palatable, hyper-processed, and perhaps willfully addictive foods have been introduced into the food supply since 1970. Back then, the typical U.S. supermarket had about 15,000 items; they often now have 50,000 or more. If you can think of 35,000 new vegetables invented since 1970, I would love to see that list.

And, by the way, the now famous notion that we decreased our intake of dietary fat, or even saturated fat, is mostly belied by national trend data. We actually kept our total fat intake, and saturated fat intake, nearly constant, but diluted it down as a percent of total calories by eating more low-fat junk food. The idea that cutting saturated fat doesn't foster cardiovascular health is based on the antics of a population that never cut their saturated fat intake in the first place. Oops.

We got fatter because we ate more calories. But then, we also began eating more calories because we were fatter. Why does this make sense? For the same reason that a lean horse needs more daily calories to maintain its weight than a comparably lean rabbit. The bigger the animal, the more it needs to eat just to maintain its body mass, whether lean or obese. We are bigger animals than we were in the 1970s.

So, yes, perhaps we eat a little more produce, although availability of produce doesn't guarantee that. We also export some, and waste a lot. But our intake of produce as a percent of our total diet? Hasn't moved up in decades! Study, after study, after study attests to that, as they attest to the lamentable level of produce intake in the U.S. as compared to countries that tend to have less obesity and better health.

So did the broccoli do it? Not so much. The case against the solar panels and Uggs is still in court. Moving on.

The evidence is, in fact, overwhelming, from every conceivable kind of study, ranging from rigorously controlled intervention trials in Americans with heart disease, Europeans with heart disease, diabetics, cancer patients, and more; t oobservational epidemiology at the level of entire populations over decades, that the Dietary Guidelines Advisory Committee got it right.

Well, there's a big, fat surprise: a multidisciplinary panel of highly trained, public health experts commissioned to develop dietary guidance for an entire population in one of the most watched fishbowls in American public policy was more right than someone saying, in essence, “buy my book.” A real shocker.

Call me old fashioned, but I think when someone says “the data show,” they are obliged to show actual data, and ideally, more than the data they cherry-picked.

The committee did that. They followed the evidence where it lead, and clearly put epidemiology ahead of ideology, unlike those now lining up to take them down. For instance, the committee opted to put a whole section in their report on sustainability. Much as that argues for plant-based eating, they also chose to remove guidance against dietary cholesterol. This appears to be at odds with the gist of the report, but that's the beauty of it. The committee members looked at a vast array of evidence, and did the hard work of research: considering conclusions they didn't necessary hold at the start. The result is a report that reliably leans with the weight of current evidence, the very thing the committee was tasked to produce.

Folks, we are pervasively, persistently, and unnecessarily fat and sick. If we want to fix it, we may need to get sick and tired instead.

We need to get sick and tired of pseudo-expertise; of iconoclasts only showing the citations that support the position they held at the beginning, a dangerous variety of legerdemain for public health. We need to get especially sick and tired of iconoclasts who aren't even that, but rather copycats, reheating decade-old revelations of the “been there, done that” variety. We need to get sick and tired of exploring the innumerable ways there are to eat badly, so we might actually try eating well.

The broccoli didn't do it. We are fat and sick for rather obvious reasons. If we've had enough of that, it's time to act accordingly, by getting sick and tired of business as usual.

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.

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.

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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