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

Monday, June 1, 2015

Dietary guidelines for which Americans?

We received the report of the 2015 Dietary Guidelines Advisory Committee some weeks ago. Some months from now, that science-based report, politics, and a whole lot of pestering will come together, and we will get the actual Dietary Guidelines for Americans 2015.

That's how it works, which I presume most people in this country at least already know. We have Marion Nestle to thank for first shining a spotlight on the potential dilutions, distortions, and adulterations of science-based guidance by political considerations. Independent, diverse scientists are convened to review the relevant literature and update what they think dietary guidance should be. The Department of Health and Human Services and the USDA have the final word on what the dietary guidelines are.

That explains the politics; what of the pestering?

Ever since the politically-modified beans of this process were first spilled, it has all become increasingly transparent, and public. The Secretaries of Health and Agriculture, when they announce the release of the official guidelines, tend to acknowledge openly that they start with the work of scientists, but end with the determinations of federal policy makers, subject to the usual influences. There is also this period in which we now find ourselves, with guidance in hand but guidelines yet pending, in which the work of the scientists is on display (an open casket comes to mind), and public commentary is invited.

In a land where Citizens United is the law, it should come as no surprise that the “public” inclined to comment is not just loving parents and grandparents, weighing in to defend the purity of public health science on behalf of their family's health. Much of the public commentary is from large, well-organized, special interests, with various means at their disposal to pester more influentially than the mere submission of a comment through an online portal.

Comments, of course, are diverse, and often conflicting, as one would expect given the varied constituencies prone to opine. At last check, I believe the tally of comments was roughly 6,000; and frankly, I was surprised not to find more.

Among the more noteworthy of feedback to date is the already well-publicized position of the meat industry. Apparently the makers of, among other things, sausage, don't like how this particular sausage is being made.

To be clear, the DGAC did not advise against eating meat; they simply advised eating less meat, more plants in general, for two reasons. The first is their conclusion that the weight of evidence regarding diet and human health favors mostly plant-based diets quite decisively. I have reviewed the literature as well, and reached the same conclusion.

Arguing with a group of well-trained, unconflicted, multidisciplinary scientists about what the science says is certainly possible, but something of an uphill battle for an obviously conflicted, less qualified special interest. So instead, the focus has been on the second reason for this recommendation: sustainability. This DGAC, in a departure from prior efforts, decided to include in their report the relevance of dietary pattern to the real-world sustainability of the sources of food populating that pattern. Vested interests with profits at stake are claiming this is overreaching. My inclination is to say any of the following: Amen! Bravo! Duh? Or, what took you so long?

Food is fuel for the human machine, and thinking more generically about fuel may inform this debate. We are all careful to put the “right” fuel in our cars, be it regular, premium, diesel, or other. The fuel to which an engine, be it mechanical or biological, is suited is the fuel on which it will run best.

As for quantity, we tend to be unconcerned when making short trips with a full gas tank. But how much fuel becomes a salient concern either when the trip is long, or the gas gauge is nearing the red line.

Prior DGAC reports were relatively silent on the issue of sustainability for the same, flagrant reason: there seemed to be plenty of fuel in the tank. With climate change, water shortages, crop failures, and global population growth all fixtures of life in 2015, we can readily see, perhaps for the first time, the potential to run out of fuel for us all. To ignore that in the fueling of a population is as illogical, shortsighted, and cavalier as it would be in fueling a vehicle with a long way to go.

One important difference is that vehicles are fueled through distance; people are fueled over time. Shortages in food induced by wanton disregard or willful neglect will be a problem not for progress along the interstate, but prospects across generations.

In other words, when we use the term “sustainability,” the question implied is: will our kids and grandkids be able to do as we do? We might note in passing that the diets around the world associated with the longest lives and best health are just such, traditional diets: practiced generation after generation.

Ever shortsighted, and generally impervious to the wisdom of looking many generations ahead, when the answer was an easy yes, it was business as usual. The answer is no longer an easy yes, and that changes things. As I've noted before, the elimination of sustainability as a relevant consideration in dietary guidelines when we can clearly see the threat of shortages looming, is a willingness to eat our children's food, and leave them to go hungry. I trust I may rely on my fellow parents to renounce that proposition.

At this point, the lid is off the box, and we know sustainability is a concern. We only have two choices: honor that concern, or dismiss it, and knowingly eat at the expense of those to follow us. If the latter, then these cannot be dietary guidelines for “Americans,” but rather dietary guidelines for some Americans at the expense of their children, and grandchildren.

So forget about sustainability, and let's just address the parent question: The dietary guidelines are for which Americans, exactly?

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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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.

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.

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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.

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.

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Kevin Pho, MD, ACP Member, offers one of the Web's definitive sites for influential health commentary.

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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.

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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.

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

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