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Monday, June 22, 2015

Newton, nutrition, and the tweets of doom

For all his contributions to science, controversial and otherwise, in modern context Sir Isaac Newton is most indelibly associated with one rather succinct assertion of physical truth: For every action, there is an equal and opposite reaction.

Were the governance of this third law of thermodynamics limited to the domain of physics, as was Newton's apparent thinking on the subject, we would spare ourselves a great deal of grief. Unfortunately, the laws of thermodynamics are in turn, it seems, subject to the law of unintended consequences. So it is the hegemony of the third law has trespassed into the realms of human psychology and sociology, and public health is much the poorer for it.

I have been lamenting for years that not only have we managed to be serially wrong about nutrition, we have been wrong about how we went wrong. When, for instance, the salient guidance was to “cut fat,” it was wrong in some of the particulars. Not all dietary fat is created equal. Not even all saturated fat is created equal. But any deficiencies in the admonition were greatly subordinate to its willful exploitation for profit.

What do I mean? When those in the vanguard of the movement first suggested reducing dietary fat intake, there was really only one way to get there from here: Eat more vegetables, fruits, beans, lentils, and whole grains. Since those foods are salient, if not overtly predominant, in diverse diets around the world associated with the greatest longevity and vitality, this could only have done us good. But we never had a moment to renounce mounds of salami to make room for more spinach, or to get a bit more of our protein from pinto beans and a bit less from pepperoni. Before ever we paused to consider such judicious opportunities, Snackwells had been invented, and the era of low-fat junk food began.

No nutrition expert ever said: Eat fat-free junk food, and all will be well. But that's what we did. And these days, we act as if that is somehow a failing of epidemiology, rather than assigning blame where it belongs: those elements of supply willing to subvert public health messaging for profit, and those elements of demand willing to believe that what seemed too good to be true was true nonetheless. Eating cookies will make me healthy? Bring ‘em on!

Regrettable as that digression was, it might have been worth it had we learned anything from it; but we did not. Or, rather, we seem incapable of learning from the follies of nutritional history, because our responses are surprisingly constrained by the stipulations of Newton.

The logical, and genuinely salutary reaction to the boondoggle of lipstick on low-fat pigs was to conclude that we should not fixate on any one nutrient, but rather think in terms of wholesome foods in sensible combinations. After all, if we eat truly wholesome foods in genuinely sensible combinations, there is no way to get it wrong. But alas, that kind of thinking would not have been equal and opposite, and that's how we roll.

What was equal and opposite to “just cut fat”? Obviously, “just cut carbs.” We never worried much about some potentially vexing details, such as: ALL plant foods are carbohydrate sources. Equal and opposite is a clear and compelling mandate, and if it means we lump together lentils and lollipops like so much baby and bathwater, well then, so be it.

Leaving aside whether or not cutting carbs was a better or worse idea than cutting fat, we can at least give Robert Atkins his due: When he proposed it, he presumably did not have low-carb brownies in mind. But Big Food did to Atkins exactly what it did to Keys, turning his message into an opportunity to invent a whole new inventory of highly profitable junk foods.

And again, we failed to learn from history, perhaps because we are mere pawns to the tyrannies of physics. Perhaps we are incapable of a reaction other than equal and opposite. If just cut carbs did not make us all lean and vital, let's just cut fructose. Or gluten. Or GMOs. Or grains. Or … well, we'll think of something.

Not long ago, I was beginning to grow hopeful that we had run out of ways to eat badly and might actually have to consider eating well. Eating well is not about fat or carbs, it is about wholesome foods in sensible combinations. Get the dietary pattern right, and the nutrients reliably sort themselves out. Fixate on any given nutrient, whatever the arguments for its primacy, and history dishes out nothing but precautionary tales. I had begun to hope we were out of ways to miss the forest through the trees.

But now, I am sadly less sure. The Internet greets me each day with a new barrage of angry tweets. Ideology routinely trumps epidemiology. Far from achieving separation of church and plate, the divergent convictions about diet and health grow ever more zealous, ever more vitriolic, and ever more fanatically sure. The prevailing reaction of each to all others is entirely of the equal and opposite variety.

Science, however, advances incrementally. Rarely is there cause to throw all we thought we knew yesterday under the bus and start anew. Progress is far more probable when we consider the provocations of good, new questions in the context of established answers.

Is it a good idea to cut dietary fat? We now know the question to be bad, and bad questions invite no good answers. A diet will certainly not be improved if it cuts out nuts, seeds, avocado and fish and replaces any of these with Snackwells. Is it a good idea to cut carbs? The question is equally silly. Fewer carbs could mean less refined starch and added sugar, or the renunciation of fruits and beans. Is it a good idea to vilify fructose? Not if it gives Big Food recourse to a halo for their lateral moves.

As for those tweets, they can be painful. Many are ad hominem attacks, and each of them reverberates in its own insular echo chamber. Some are so absurd that people who actually know me and my values don't know whether to laugh or cry. I generally do neither, recognizing that the unintended consequence of our New Age connections is to give every fringe and faction the same megaphone. Those propounding despicable racial slurs against the duly elected President of the United States are, presumably, a population rounding error and a lamentable, lunatic fringe, but in the Twitterverse, they are regrettably audible just the same.

That, then, is the modern challenge to public health nutrition. If every equally misguided and oppositely directed reaction to every prior, wayward action echoes endlessly in cyberspace, do we ever navigate past the din and the discord and advance beyond the follies of history? Or will we have constrained the human mind to the confinement of 140 characters, subjugated human will to the dictates of physics, and exaggerated the purview of Sir Isaac, as we tweet, and retweet, the redundancies of our doom?

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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