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Monday, February 22, 2016

The greatest diet myth of all

I was rather disheartened to discover that The New York Times decided to start off the year by pretending to dispel diet myths, while actually propagating the biggest of them all. The great dietary shibboleth of our time is that no 2 experts in nutrition agree about anything, and that expert opinion is both unreliable and unstable. This is nonsense.

The New York Times clearly suffers from its own ambivalence on the topic, perhaps a by-product of discord in the editorial ranks. They have published pieces that highlight clearly and compellingly where the true faults in the modern diet lie, and how we might effectively, and simply (if not easily) navigate past them. They have, on their own rarefied real estate, showcased the basic dietary theme associated with the best evidence of benefit there is: longevity, conjoined to vitality.

But they have gone the other way many times as well, featuring the perspectives of iconoclasts. Sadly, this seems to be the evolving editorial preference, and perhaps for obvious reasons. Diet stories sell. They sell newspaper pages just as they sell morning show segments. For stories to sell segments and papers, there must be sellable stories.

There may have been a time when the New York Times was above such fray, but we all know those days are gone. The competition is no longer just the Washington Post; it's the Huffington Post, and Buzzfeed, and Yahoo. For the New York Times to survive, it must feel a certain compulsion to sell the stories people want to buy. When it comes to diet, the last thing on everyone's shopping list appears to be the simple, unadulterated truth.

And so it is we wind up again with copy telling us about the instability and unreliability of expert opinion, and citing “experts” to make the case. Such things are done quite craftily, however. In a world of hundreds of thousands of true content experts, articles such as these preferentially cite a few contrarians, expert or otherwise, and imply that they represent some kind of expert consensus about the lack of expert consensus. They do not.

This is not wishful thinking on my part. For one thing, if we really did lack any basic understanding or consensus about healthful eating, I would have no wish to refute that. I would be too confused to bother, and too busy trying to figure out what I should eat, what my family should eat, and what on earth I should tell patients. The simple fact is, I am not confused, and know what to practice personally, and preach, because the relevant evidence is clear. Those buying into the “lack of expert consensus” myth should pause to wonder: what do the experts actually eat?

That's the thing about diet; it's not a hypothetical enterprise. Every one of us has to make real choices in the real world every day. Perhaps you'll be surprised, but frankly I doubt it, to know that the world's nutrition experts overwhelmingly, whenever possible, choose food, not too much, mostly plants. We might all chew productively on the contention that this camp pretty reliably eschews the very glow-in-the-dark foods that populate the aggressively peddled typical American diet. It's not rocket science, folks. We are not confused.

But the New York Times, like all media outlets, may have a vested interest in making sure you are. Diet is rivaled perhaps only by weather in generating daily fascination. Weather, however, has the intrinsic advantage of changing every day. Get diet advice to do the same, as our media, with some unfortunate help from a small minority of scientists, do, and you wind up with a goose laying golden eggs.

Alas, the public's goose may get cooked as a result, as reflected in the notorious obesity and diabetes trends. And speaking of cooking, we might constructively juxtapose this treatment of diet with that of climate change. On that latter topic, the New York Times, if not necessarily media in general, has been a staunch defender of the consensus of experts over the dissent of renegades. Why the difference? Why, in the case of climate change, does the Times seem committed to advancing the consensus of global experts about the weight of evidence, while in the case of diet they seem more inclined to treat the relevant science like a ping-pong ball?

I can only speculate. One reason, I think, is as noted above: pseudo-confusion about diet sells. Another, perhaps too generously, allows for true confusion in the editorial ranks. Perhaps editors at the New York Times think we are fatter and sicker because we followed bad dietary advice. Admittedly, dietary advice has always been imperfect, and while it advances, will remain so. But the great liabilities of modern public health are mostly a result of failure to follow dietary guidance, not because it was so errant. Advice to limit our intake of carbs was never advice to eat low-carb brownies, but that's what we did. No one advocating for low-fat eating recommended Snackwell cookies, but that was our cultural response.

Yet another reason may be the dangerously misguided notion that climate is public, but diet is personal. What I mean is this: I, and editors at the New York Times, can eat perfectly well even if you don't because you are too damned confused. In contrast, we, the Time's editors and I, cannot be spared the extreme manifestations of climate change unless you are, too. Perhaps—and again, I am just speculating—there is precept behind some closed editorial door that stipulates: it's OK to propagate confusion about the basic care of individual bodies, less so with regard to the body politic. After all, our own skin is in the latter.

That would be regrettable thinking if it were even true, but it's not. We've all got shared skin in both games, if only because there is only 1 game. Dietary choices massively influence the climate and the environment. Even if we were confused about the best, basic dietary pattern for human health—and we are not—there would be a perfectly clear mandate to drink water instead of soda, to eat mostly minimally processed plants, and to cut back enormously on beef consumption in particular, and to a lesser extent overall meat intake, for the sake of the planet. That the interests of human and planetary health converge here simply makes the mandate even more decisive.

How, then, is it even possible to propagate the myth of prevailing cluelessness about the basic care and feeding of Homo sapiens? Well, for one thing, as noted, you can always find a renegade or iconoclast if you are looking for one. Were we so inclined, even now we could be handing the megaphone to a line-up of climate change deniers with variable credentials, and might, accordingly, have denied ourselves the hope of the Paris Accord. For another, the appearance of discordant answers is readily generated by a given approach to questions.

For instance, ask 2 nutrition experts if a low-carb diet is best, and 1 will say yes, and another will say no. The same is true of low-fat; or vegan; or Paleo; or Mediterranean. There you have it: no 2 nutrition experts agree! We are hopelessly befuddled!

Nonsense. Those questions could translate readily to: within the basic context of sound, sensible, salutary eating, do you have a particular, personal preference? No one would be surprised to learn that since every nutrition expert eats every day, everyone does, indeed, have a personal preference, and those preferences vary. Re-read those several questions above, and see that they could be perfectly compatible with just such an account.

What reveals that veiled explanation? Posing questions aimed at establishing core principles, rather than discordant preferences. I can assert from evidence in hand, garnered from both an extraordinary conference to close out the old year, and a global campaign to welcome the new, that the worldwide coalition of experts and influencers in the nutrition space agree massively about those core principles. I contend, again from actual evidence, that the agreement in question ranges all the way from vegan to Paleo. I can go further, perhaps just a bit out on a limb, and assert that even most of the seeming contrarians join the chorus when the right questions are posed.

What questions? Questions like these:
1) Do you agree that the best diets generally are abundant in fresh, minimally processed vegetables and fruits?
2) Do you agree that the best diets generally, and generously, incorporate beans and legumes?
3) Do you agree that the best diets generally incorporate nuts and seeds?
4) Do you agree that the best diets generally, if not always, incorporate whole grains?
5) Do you agree that best diets often include fish?
6) Do you agree that the primary beverage in best diets is water, and that sugar-sweetened beverages are excluded, mostly or entirely?
7) Do you agree that best diets minimize fast food, junk food, and hyper-processed food in general?
8) Do you agree that best diets emphasize recognizable foods direct from nature?
9) Do you agree that when best diets include meat and animal products, those animals in turn should be fed a wholesome, native diet?
10) Do you agree that carbohydrate content or fat content is a poor and unreliable way to characterize the overall quality of a diet; that the foods of which it is made up do that job far better; and that best diets can traverse a range of total carbohydrate, total fat, and to a narrower extent, total protein values?

The list could go on, and might well extend to matters of ethics and environmental stewardship, but we can leave it there. Ask a who's who in nutrition, medicine, public health, sustainability, and the culinary arts these questions, and the answers are all “yes.” I am not speculating; I have proof. This is even true for some of the folks apt to be quoted as prominent contrarians. Answers are seldom better or more clarifying than the questions that invite them.

These days, the most common take-away about diet and health is that everything we thought we knew about diet and health is a myth. As best I can tell, however, the notion that reputable journalistic platforms are interested in getting at a reliable, stable truth about diet and health is the myth. The reality is that afflicting the comfortable with sequential doubts, only to comfort the afflicted with a dose of science and sense until they are comfortable enough to warrant more affliction, is the standard operating procedure in our media, and our culture. The harder it gets to compete for attention, the less and less a lofty journalistic pedigree defends against this temptation. To whatever extent the imprimatur of the New York Times was once an alibi against such motivations, those days are apparently gone.

We are not clueless about the basic care and feeding of Homo sapiens. There is a massive, global, evidence-based consensus. The same fundamentals of salutary eating would be warranted for the sake of the planet if not for human health, as well as vice versa. As it happens, fortuitously, they serve both. But we, instead of ingesting accordingly, are served a daily dose of hype and hooey -- and just keep eating it up. If ever there was a vivid display of the triumph of desperate hope and abject gullibility over science, sense, and real-world experience, this is it.

There is, indeed, a great myth about diet, but it's not the one you've heard regarding dissension in the ranks, or misguided guidance. It's the notion that media in general, our culture at large, or the New York Times is committed to helping you eat well. With all due respect to those concerned, they are selling newspapers.

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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