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Thursday, April 23, 2015

Dietitians, food and truth: winds of change?

In what became a notorious move before ever the ink had time to dry on the hermetic plastic wrappers, the Academy of Nutrition and Dietetics, until recently, the American Dietetic Association, conferred its “Kids Eat Right“ seal of approval on Kraft American Cheese Singles. Blessed, indeed, are the cheese makers! But even they aren't entirely sure this stuff qualifies entirely as cheese, its somewhat dubious pedigree having been parsed for public consideration before now.

I can leave the specific merits and demerits of cheese and cheesy derivatives of it, and for that matter the particular uses and abuses of the “Kids Eat Right” seal to others, as the ink involved here has migrated from the Kraft wrappers to many columns and blogs. I am thus unburdened of that to focus on dietitians, food, and truth.

In principle, the Academy of Nutrition and Dietetics represents the interests of its roughly 75,000 dietitian members. But like all institutions, this one has developed a preferential interest in itself, which leads inevitably to an interest in money. Money tends to flow most readily to an organization advising the public on food choice from the entities most interested in the public choosing their foods. This makes for somewhat unsavory liaisons, and the history of the Academy has been sullied by just such trysts.

While the Academy will need to officiate, or prevaricate, its own way out of this mess of its own devising, the dietitian members are not so constrained. Members though they may be, they speak for themselves, and all the good ones, on behalf of truly good nutrition and public health. So they have done what needed to be done: they have mutinied.

The mutiny here takes the form of a petition, labeled “Repeal The Seal,” and which had 7,336 signatures when I arrived, and 7,337 when I left. That's less than 10% of the Academy membership thus far, but the petition was just launched, and it is nearly 10% of the entire membership. I suspect it has the Academy's attention, and Kraft's, along with every other would-be suitor for that seal.

So, first and foremost, I applaud my many dietitian friends and colleagues who have made the public's right to true food, and the unadulterated truth about food, their rallying cry. I encourage the many thousands more on the sidelines to get in this game, stand up, and be counted.

But then we need to look past this incident to the greater problem underlying it. We do not allow Toyota, or Ford, to determine who wins “car of the year.” Such designations are courtesy of those famously independent third parties, such as Motor Trend in this case. We do not permit appliance makers to manufacture their own metric for energy efficiency; they are all scored on the same, government-sanctioned scale. And while vacuum makers may all choose to accentuate the particular way their product sucks, the savvy shopper is generally more interested in the judgment of Consumer Reports, which doesn't sell a vacuum.

In nutrition, though, we have long allowed foxes to guard the hen house. The easy access of Kraft to an apparent endorsement by the Academy of Nutrition and Dietetics is only the latest example, and by no means the worst. Remember “Smart Choices“? Confronted by various efforts, including one I directed, to provide reliable, at-a-glance guidance to better nutrition, Big Food developed its own, and for a while, it seemed as if everyone would be okay with that.

The program, which declared Froot Loops a “smart choice” didn't last long, because it garnered the well-deserved ire of some state attorneys general, notably ours here in Connecticut; and some members of Congress, notably our own, much-loved Rosa DeLauro. But until all that, there was no reflexive, public outrage that the makers and marketers of multicolored marshmallows as part of a complete breakfast would be the ones to tell us what constituted a “smart” choice.

Why not? Would anyone take it seriously if the toothpaste-of-the-year award were conferred upon Crest, by Crest?

This has to stop. Food is right at the top of a short list of factors that most potently determine nothing less than our medical destinies, factors that account for roughly 80 percent of all chronic disease and premature deaths. Factors that could be leveraged to add years to life, and life to years. If we were inclined to sublet any given hen house to the oversight of foxes, we could scarcely have made a worse choice.

These, then, are the critical considerations that must reverberate for for us all when the #RepealTheSeal campaign has run its course, as it will:

1. We are not clueless about the basic (care and) feeding of Homo sapiens! We know the truth about good nutrition. Hyperbolic headlines, and competing fad diets create cover for the manipulations of Big Food, because they suggest there are no actual “experts,” and that if there are, no two agree. This is false.

True experts may disagree about details, but overwhelmingly agree about the fundamentals. The former makes for titillating and ever-changing media commentary, and marketing opportunity; the latter is vastly more important and substantially ignored. The True Health Coalition is a new initiative of mine, dedicated to fixing this very problem; please visit here, and join us.

2. Nutrition deserves respect. If we would all roll our eyes at Charmin as judge and jury for the toilet-paper-of-the-year award, it's hard to fathom our tolerance for just such conflicted nutrition guidance. Junk and food never belonged together as descriptors of the same substances, and junk guidance has no place in the mix, either.

3. In unity there is strength. The dietitians are demonstrating the importance of unity with their petition, but it can't be a flash-in-the-pan. There is a tendency to prioritize personal concerns in a way that sacrifices shared, evidence-based truths. We can all choose preoccupations born of private conviction, but we must also stand together in defense of those shared, evidence-based truths. To do otherwise makes us all cooks of a rather unsavory stew.

4. There is a better alternative to nannies, than ninnies. There is a strong anti-nanny-state contingent in our culture. To some extent, this reflects real conviction about personal liberties. To some extent, it is confabulated nonsense, such as when an organization called “New Yorkers Against Unfair Taxes” rallied against a proposed penny-per-ounce tax on sugar-sweetened beverages. That provocatively named organization was founded entirely and exclusively by the beverage industry, and represented no interest other than their own. Be that as it may, we can all agree that we don't want government regulations determining what we can or can't have for breakfast; but also don't want marketing by the makers of stuff like Fluffernutter masquerading as nutrition guidance. There is something in between the nanny state, and the land of exploited ninnies. I would hope we might all find common ground, and common cause, there.

5. It's bigger than dietitians. I mean no offense, here; it's bigger than physicians, too, and all health care professionals put together. In those places around the world where people eat the best, it's not because their clinicians get it right and provide terrific guidance; it's because their culture gets it right, and no guidance is necessary. The Blue Zone populations live, and thrive, in places where all available food is true food, and there is no predatory, profit-driven nonsense to compete with the truth about food. We ought to have what they're having.

Truth and food go together and belong on the same menu; junk and food do not, and never did. The truth about food should issue from those devoted to public health, not be manufactured by those apt to profit at its expense.

The dietitians have mutinied, but that simply means they have, rightly, taken over the ship in this instance. There is more to be done. The wind that fills those sails is bigger than any one group; it derives from our culture. Culture is a medium of our collective devising, subject to our priorities, and control. We decide which way this wind blows. Maybe the time has come for smart choices, after all.

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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