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Monday, July 20, 2015

Big, fat transgression

Trans fat is going, if not yet gone, and good riddance to it. The word on the street is that the FDA is acting to “ban“ partially hydrogenated oils from the food supply. The slightly more banal reality is that the agency is finalizing an action, begun two years ago, to formalize the position that trans fat is no longer “generally recognized as safe.” Whereas a ban would be an active prohibition, this is a more passive removal of blanket allowance. Companies might, in fact, still be able to make select use of these oils, but would now have to petition for FDA permission to do so.

But even if the FDA action is more about not saying yes than it is about saying no, it will do. Tans fat will go, altogether or nearly so. The action is welcome.

I have been asked if it will matter much, and the honest answer is no. While the agency has clearly done the right thing, and it is important in principle, the effect in practice is much reduced by progress at the notorious speed of government. The Center for Science in the Public Interest has been making noise about the harms of trans fat since 1993 at least. My friend Dr. Walter Willett has been a leader in the campaign against use of this inadvertent Frankenfat based on data from his own research since at least 1997.

Even my own efforts began nearly a decade and a half ago. We have been advising children, and their parents, to look out for and avoid “partially hydrogenated oil” in any ingredient list since the very earliest version of our Nutrition Detectives program. We have warned as well that “0 grams trans fat” on the front of pack was unreliable, since federal rules allowed for the dubious combination of small portion size, and rounding down. The NuVal system, too, was designed from the start to penalize that hidden trans fat, since zero has not reliably meant zero.

The result of such efforts, and innumerable others like them, has been a decisive verdict in the court of public opinion. Concerned parents have long since cast votes against trans fats at the nation's cash registers. Attentive manufacturers, ever eager to keep the customer satisfied, have removed this toxin from more and more products.

The reason the FDA action will make a modest rather than a great difference is not because it is unimportant, but rather because it is late in the game.

As for the good that will result from the end of the trans fat era, there are reasons for caution even amidst the cheers.

For one, we have, for literal decades, fixed our eyes and our ire on one nutrient at a time, and missed the forest for the trees. What matters to health is the overall composition of foods, and the contribution they in turn make to the overall composition of the diet. The presence, or absence, of any given nutrient does not reliably indicate overall food, or diet quality. We have gotten this wrong before, in a dysfunctional collusion between demand and supply, and could conceivably get it wrong again. Let's be careful, see the big picture, and navigate around any replication of the costly follies of nutritional history.

For another, in a world of commerce, one supplier's loss is another's potential gain. While it's clear that trans fat is far worse for our health than the so-called “tropical oils” it displaced in its heyday, it is far less clear that those oils are the panacea their ardent proponents (and sellers) contend. The saturated fat in coconut oil is predominantly lauric acid, a short (12-carbon) fatty acid that accumulating evidence suggests may be innocuous. But that evidence is not yet decisive, and importantly, “innocuous” is as good as it gets. I have seen no evidence to suggest health benefits, just lack of harm. Those are not the same, however exuberant the marketing claims.

For yet another, we have surrendered the luxury of thinking about our foods and ingredients independently of their environmental impacts. Historically, the tropical oils to which the food industry will likely return to replace trans fat have come from orchards planted where tropical rain forests once stood. Much as I want to avoid trans fat, I don't want its replacement in my food to be the reason why the world's last orangutan can't find a tree to climb.

The propagation of trans fat through the modern food supply was, without doubt, a big, fat nutritional transgression. The FDA announcing the beginning of the end of that boondoggle is most welcome.

But the action is perhaps too late to matter much, since the government is only catching up with changes in both the demand, and supply of food. More importantly, the action is too little to confer reliable benefit. We could, if so inclined, eat trans-fat free junk food, just as we have managed to eat low-fat, low-carb, sugar-free, and now gluten-free junk food, and get fatter and sicker all the while.

The best approach to avoiding trans fat is the same as it ever was, and requires no action by the FDA; it is to choose wholesome foods in sensible combinations. Foods direct from nature, and minimally processed foods were never delivery vehicles for trans fat in the first place. Get the foods right, with a particular emphasis on the usual suspects, vegetables, fruits, whole grains, nuts, seeds, beans, lentils, and the nutrients generally take care of themselves, and us.

In other words, the best diet for our health depends, as it ever has, not on replacing trans fat with any one oil from any one nut up any one tree; but on seeing the forest. That same view is the best hope we have for not just avoiding trans fat, but actually eating well; and while we're at it, of preserving those trees for orangutans to climb; and for sustaining the forests that are the purifying lungs of the world. We don't need FDA authorization to start shopping accordingly today.

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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