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

Monday, November 30, 2015

Fats, carbs, and what Jane Brody meant to say

Jane Brody published a very sensible reality check about diet in yesterday's New York Times. That it proved sensible was all but inevitable, as her column was clearly much informed by an interview with the eminently sensible, and extremely knowledgeable Dr. Frank Hu of Harvard, late of the Dietary Guidelines Advisory Committee, and newly elected to the National Academy of Medicine. I happily take this opportunity to offer my public congratulations to Dr. Hu for that last item, among the highest honors a biomedical professional can receive, and certainly very well deserved in this case.

As noted, Ms. Brody's column was very sensible, telling us there are good and bad fats, good and bad carbohydrates. But with all due respect to her august journalistic pedigree, I think it fell slightly short of the mark by failing to go beyond macronutrients altogether. What Jane Brody meant to say, in other words, is what I was privileged to say jointly with Dr. Hu: wholesome foods in sensible combinations. Dr. Hu and I in in turn owe a debt of gratitude to Michael Pollan, who first threw down that gauntlet with: food, not too much, mostly plants.

Ms. Brody's column rightly belies the currently prevalent, cacophonous nonsense about saturated fat. No, there is no evidence that eating more saturated fat is “good” for us, and certainly none that health (of people, let alone the planet) is promoted by eating more meat, butter, and cheese. As recipes go, that argument has been egregiously overcooked from the start.

Similarly, and obviously guided by Dr. Hu's wisdom, she notes that it matters what we eat instead. This crucial consideration, so often ignored by those with dubious motives where a devotion to public health ought to be, was the subject of a recent paper in the Journal of the American College of Cardiology, which concluded on the basis of science precisely what sense would predict. Replace saturated fat calories (and the foods providing them) with sugar and refined starch calories, and health outcomes are comparably poor both times. Well, what else would one expect as an outcome of inventing more than one way to eat badly?

However, replace those saturated fat calories with either whole grains or unsaturated oils (and the foods that provide them, notably nuts, seeds, olives, avocados, and fish), and health outcomes improve markedly. I am sure there must be something related to relativity or quantum physics in the mix here that I am overlooking, but as far as I can tell, this translates to: eat food that is good for you, and it will be good for you.

Yep, that's the punch line, folks. Food that is good for us is good for us. And that's what Jane Brody meant to say, and didn't: it's not about macronutrients at all; it's about food. Eat wholesome foods, mostly plants, in sensible combinations, and the macronutrients, and micronutrients, and glycemic load, and all the rest- generally sort themselves out quite handily.

The evidence for this proposition is overwhelming. Dr. Hu and I have both had cause to look it over from altitude, in the service of independent review papers in the Lancet, and Annual Review of Public Health, respectively. Our confluent conclusions in those two unrelated projects are what prompted us to write together about “wholesome foods in sensible combinations” in the first place.

In my own case, even more evidence figured in the mix in the writing of the most recent edition of my nutrition textbook, spanning some 50 chapters, 750 pages, and approximately 10,000 scientific citations. There are admittedly excruciating details in that mix, but the gist condenses to: wholesome foods, mostly plants, in sensible combinations. And that was the very conclusion reached by the 2015 Dietary Guidelines Advisory Committee in an extensively referenced, 572 page report.

Finally, it's just what one sees through the lens Dan Buettner has provided us to the Blue Zones of the world, those places where people live the longest and the best. Their diets vary considerably, but all vary on a common theme. You guessed it: wholesome foods, mostly plants, in sensible combinations. No Blue Zone is mostly runnin’ on donuts, any more than any Blue Zone is mostly runnin’ on meat, butter, and cheese. Rather, the emphasis is consistently where the evidence suggests it ought to be: on vegetables, fruits, whole grains, beans, lentils, nuts, and seeds.

Why not let Jane Brody have the last word? Because the last word really needs to be food, not nutrient. We have already demonstrated our nearly endless capacity to pervert almost any nutrient preoccupation into a public health boondoggle. A fixation on nutrients plays directly into the hands of industry elements that can design new inventories of junk food faster than most of us can say “monosodium glutamate.”

For decades, we have fixated on one nutrient at a time, and wound up with lipstick on a pig for breakfast, lunch and dinner. Rather than renouncing the folly of subjugating foods and dietary patterns to mononutrient preoccupations, we have instead reacted with all the subtlety of a block of rock subject to Newtonian impulses: equal and opposite reactions. If saturated fat wasn't the right scapegoat, let's try carbohydrates; or sugar; or fructose; or gluten. Let's not.

Let's eat wholesome foods, mostly plants, in sensible combinations- and put an end to this era of fatuous fixations, and profits over public health. That's what the evidence has long indicated. That's what a massive, if as yet little known, consensus among the world's leading experts favors. That's just what the 2015Dietary Guidelines Advisory Committee concluded.

And it is, I presume, what Ms. Brody meant to say.

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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