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

Monday, February 15, 2016

2015 Dietary Guidelines are a plate full of politics

I won't mince words: In my opinion, the 2015 Dietary Guidelines for Americans, are a national embarrassment. They are a betrayal of the diligent work of nutrition scientists, and a willful sacrifice of public health on the altar of profit for well-organized special interests. This is a sad day for nutrition policy in America. It is a sad day for public health. It is a day of shame.

I know, I should tell you what I really think. Maybe next time.

I want to make clear that the scientific report on which these new Dietary Guidelines for Americans (DGs) were allegedly to be based was outstanding. Perhaps not perfect—What ever is?—but truly outstanding.

That's a position I have asserted before, many times, encompassing the report's very appropriate inclusion of sustainability. I raise it again now for two reasons.

First, I want to make unmistakably clear that my criticism here is of the political adulterations of the excellent work of scientists, and not one iota about the work of those scientists. Second, the 2015 Dietary Guidelines Advisory Committee (DGAC) Report has been subject to unprecedented abuse since the day it was released. Many in the vanguard of those assaults have pretended it was an effort to challenge, and thus improve, the quality of the science. It was not. It was foreplay for this. It was softening up support for the work of true public health scientists so that politicians could stick it to the American people and line the pockets of their influential friends.

There will be—indeed, it has already begun—a Tsunami of ink (well, electrons, mostly) allocated to this topic, today and after. It will be parsed in its every particular. I myself may weigh in again, and get more specific. For now, a rather high-level critique will suffice.

Where the DGs are good, and there aren't many places in the lengthy document, it's where they preserved key components of the DGAC report. For example, they respected recommendations about key nutrient thresholds, such as limiting saturated fat intake, not limiting total fat intake, and perhaps most importantly, limiting added sugar. They also preserved the idea, if not a sensible representation of it, of healthy dietary patterns, and provided examples to show that these are variations on a theme. I can give this very little bit of credit where so little credit is due.

Otherwise, as compared to the DGAC Report, the DGs represent a disgraceful replacement of specific guidance with the vaguest possible language. A term that recurs often, clearly intended to sound like something while saying next to nothing, is “nutrient dense foods.” That replaces reference to specific foods that populate the original document. It might mean broccoli, it might mean Total Cereal. I guess it might even mean pepperoni. We can't tell, and that is clearly by design.

There is an astonishing effort to shoehorn in advice to keep consuming “all food groups.” When is the last time we have even heard that term? Not only is this document a display of complete submission to special interests, it is a submission to special interests stuck in 1950! Seriously, eat from all “food groups”?

There is a disgraceful backtracking on clear recommendations to eat less meat and more plants. The report advises particular age groups of men and boys to cut back somewhat on meat intake, but all this does is highlight the abandonment of the recommendation in the DGAC Report that “less” meat was advisable to the general population for the sake of people and planet alike.

There is overt hypocrisy on display as well. The DGs explicitly, even in the Executive Summary, emphasize the importance of physical activity. I am entirely in support of this recommendation, make no mistake. But how is this a “dietary” guideline? Congress decided, some months ago, that sustainability would NOT be included in these guidelines because it was beyond the mandate of the DGAC. Really? The ability to keep supplying the food recommended is not considered relevant enough, but a topic that isn't about food at all is? I really don't think you even need to be able to spell hypocrisy to smell it here.

While the report talks about foods being emphasized over nutrients, recommendations about what NOT to eat (or, even, what to limit) are entirely cast in terms of nutrients. We are advised to limit our intake of saturated fat, for instance, but there is virtually no language, and none featured prominently, indicating what foods to avoid to achieve that. Much the same is true of added sugar. Clearly advice about eating less of anything conflicts with the interests of some big industry sector the federal agencies and their bosses in Congress don't want to upset. So, somehow, we are left to cut back on our intake of saturated fat and sugar while washing down our corned beef with Coca-Cola. Good luck, folks.

The DG document is not even internally consistent. There is a specific recommendation FOR eating meat and poultry, as well as fish, ostensibly in the service of achieving a “variety” of protein sources, and eating from all food groups. Nonetheless, the DG does offer a vegetarian pattern as an example of healthy eating. This made perfect sense in the context of the DGAC Report, which made it clear that less meat was a good idea. It looks like lip service and gobbledygook in the context of a document specifically recommending meat intake. The DG, shockingly, even carves out space to say it is “okay” to eat “processed meats and poultry” provided that nutrient thresholds are respected. This is absurd in the aftermath of a WHO report identifying processed meat as carcinogenic, in addition to its many other established liabilities. It is also another example of hypocrisy in these guidelines, since we are told the emphasis will be on foods rather than nutrients, but then told it's fine to eat bad foods as long as certain nutrient levels are vaguely … good.

The 2015 Dietary Guidelines for Americans is, alas, a virtuoso display of linguistic contortionism to remove from the nation's official nutrition policy document the actionable clarity of the DGAC at every opportunity. Specific advice about what to eat more of, and especially what to eat less of, has been replaced with the vaguest possible language about food groups, nutrient dense foods, and the idea that everything is OK provided a few nutrient thresholds are minded. The DGs include the topic of “shifts,” allegedly how to trade up by replacing foods in our diets with better choices, but here, remarkably, the language itself “shifts” again from food to nutrients, so we have no hope of knowing what we shouldn't eat. Perish the thought, that would be money out of someone's pocket. We are left with a very clear, and genuinely helpful notion that we can probably just eat whatever the hell we want, and all will be well.

Except it won't. We are awash in preventable chronic disease. We are eating away our own health. We are eating our children's health, and their food, and drinking up their water. We are, into the bargain, devouring our very planet. Yet we are told here to keep on keeping on. That's what you get when it is politics, rather than science, on the plate. Bon appétit.

The good news—and there isn't much this day—is that we don't have to swallow this. Having chewed on it, and choked on it, we can just spit it out (Aim carefully, please; there are nice shoes out there).

I call on you to do just that. The 2015 DGAC Report is in the public domain. Our hypocrisy, thank goodness, has not yet advanced to the level of expunging the work of true scientists entirely. So, ignore the DGs, and turn to the DGAC Report for guidance instead. It is accessible to you, and it is about you, not the wealth of Congressional cronies.

I call upon my colleagues in public health and science, as indeed I have done, to band together and express our views directly, and in a common voice, cutting out the political middleman. We have the capacity to do that, and the public has the opportunity to decide whom to trust.

The bad news is that our Dietary Guidelines are pretty awful. The good news is that guidance isn't guidance if no one follows, and we don't have to follow where this national embarrassment leads. We have been betrayed; but we don't have to eat it.

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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