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

Tuesday, March 29, 2016

Fatness, affluence, adaptation, and hope

Colleagues and I recently submitted a grant application to a large foundation, seeking funds to support a cause that I founded, the True Health Initiative. The funds, should we be fortunate enough to secure them, will accelerate the development of a global communication campaign to convey the evidence and consensus-based fundamentals of healthy living, and notably, healthy eating. In particular, the grant would support a rigorous evaluation so that we could demonstrate the replacement of widespread confusion and doubts about consensus related to healthful, sustainable eating at baseline, with clarity and understanding by virtue of our efforts.

The True Health Initiative is global, and the research project is intended to be as well. Our application calls for targeted interventions, aimed at raising awareness, in five or more countries around the world. Those countries were chosen to represent both places where the so-called “Western” diet is long established, such as the U.S., England, and Australia; and places where that diet is fast replacing local traditions in the wake of cultural transition, such as China, India, and much of the Middle East.

While working on this grant, and thinking about its geographic scope, something odd to the point of paradoxical kept pestering me. In the U.S. and much of the long-industrialized world, one of the principal risk factors for obesity, and attendant metabolic mayhem, is poverty. In the U.S., the fattest and sickest among us tend to be the poorest, while affluence is a robust, if imperfect, defense against obesity and related chronic diseases.

In contrast, in the fast-developing countries, including but not limited to the massive populations in India and China, the situation is just the reverse. Affluence, at the population level, is propagating the tidal wave of obesity and chronic disease by which these nations are being engulfed. Within those populations, the most affluent are first in line to acquire the very morbidities that extract the greatest toll of years from lives and life from years, and which we have been striving for decades to overcome.

How can it be that affluence, at the same time but in different places, is both apparent impediment, and invitation, to obesity, diabetes, and so on?

I believe the 1 word answer is ”adaptation,” and there is a glimmer of genuine hope in it.

For many years, I have occasionally incorporated into my talks what can only be called an epic, if whimsical and rather Seussian, original poem entitled: Polar Bears in the Sahara. Delivery of the poem is routinely accompanied by a sequence of slides, including the eponymous image, which has become my figurative trademark over the years. I suspect I am known in some quarters as “that polar bear guy,” and it suits me fine.

These days, alas, that image could pertain to climate change, and a grim fate to which these extraordinary animals may be subject, more or less. My reference, though, going back some 25 years, is not about that. My reference is to adaptation.

I note that polar bears, marvels of survival though they may be, are adapted to a particular habitat, and the very traits, tendencies, and attributes that foster their survival in it would conspire against them in another. Soak up and retain heat where it's very scarce, it helps keep you alive; do the same beneath the burning Sahara sun, where the survivalists dissipate heat rather than concentrating it, and it is sure to cook your goose.

We humans, so goes my argument, are the same. Throughout almost all of human history, calories were relatively scarce and hard to get, and physical activity unavoidable. The latter was called survival, no gym membership required, and everybody just did it every day. We have devised a modern world in which physical activity is scarce and hard to get, and calories unavoidable. We have not adaptations to such a world; no native defenses against caloric excess or the lure of the couch, having contended only with their opposites throughout all the ages.

No defenses, I go on to say, save one: great, big Homo sapiens brains. We are, arguably, smarter than the average bear- and have the potential, at least, to think ourselves out of this mess of our own devising.

Which brings us full circle, back to that grant, ourselves, the future, and fundamental truths about healthy, sustainable living.

The Western diet, alternatively known, here at least, as the “typical American diet,” or “standard American diet” (referred to, aptly, as SAD) is a public health disaster. Despite all the noisy debate over whether its ills are a product of sugar, saturated fat, or something else, the simple reality is that it is a diet of dubious foods and drink in misguided combinations and excess. Its liabilities include both saturated fat and sugar, and are by no means limited to them.

But it is tasty to a species long adapted to crave sugar, salt, and fat. So when we can first get our hands on it, we do, and greedily. That's just what is going on now in China, India, South Africa, Qatar and elsewhere, with rather calamitous consequences.

Here, though, at the epicenter of this mayhem, we have had some time to habituate. Those with the most resources, inevitably the affluent, are starting to mount a defense. The wealthy and well educated are seeking, and finding, alternatives to a diet of hyper-processed grains, added sugar, soda, meat, butter, and cheese. The resource-rich are finding their way first, past the obstacles in our culture, to a diet of wholesome foods, mostly plants, in sensible combinations, and water when thirsty.

A stanza near the beginning of my poem, referring to the age-old struggle to get enough to eat, goes like this:
“... now, come to have when once had not
it's clear we've overshot-
in fact, by quite a lot.
So the challenge that emerges
as our culture clearly verges
on the brink of several scourges-
heart disease, obesity, stroke, diabetes
perils immune to our pleas and entreaties
is related to excess;
can we manage to suppress
the menace mingled with success?”

The answer, it seems, is a qualified yes. Given some time to get used to the temptations of bagels and burgers, Pop Tarts and pepperoni, the advantages of affluence help overcome them. Where the wealthy are starting to navigate past the perils of the modern, glow-in-the-dark diet, we are witnessing evolution, albeit cultural rather than genetic evolution. We are seeing it over an accelerated timescale play out around us, and it has important implications for the health of the world- people and planet alike.

There are 2 key lessons here, and 1 urgent call to action.

The first lesson is that the popular meme advocating for more “meat, butter, and cheese” is utter nonsense. It is belied not just by research, including randomized trials, but by perhaps the largest natural experiment of all time. As populations around the world with traditional diets of simple, minimally processed, mostly plant foods adopt a Western diet with greater emphasis on both highly processed foods, and animal foods, their health goes to hell in the proverbial hand basket. As the privileged members of Western populations find their way back to diets of simple, wholesome foods, mostly plant, in sensible and often time-honored combinations, they wind up with far better health than everyone around them.

The second lesson is that we can, apparently, adapt to, and overcome, the temptations of the modern diet. We can, in fact, out-think this mess of our own devising.

The urgent call to action is, of course, the obvious. We cannot stand idly by while huge populations around the world follow in the footsteps we know lead to folly. We cannot abide a divide in our culture where the health of the relatively disadvantaged is scavenged to fill the coffers of corporate profit.

We are seeing some early indications that, yes, we can, with time to adapt, and resources at our disposal, rise to meet the menace mingled with our success. If the affluent are gradually acquiring defenses against the assaults of the modern diet on health, those defenses must be generalized. Practices that help add years to lives and life to years cannot be the exclusive purview of the privileged. Those of us in public health are duty bound to identify these very practices, and do our utmost to propagate them. Our grant application, and the True Health Initiative, are devoted to just this proposition, so here's to their success.

Resources help us acquire the things we want. There is an urgent need to alert the global, human family that we need to be very careful about what we wish for, or we may get it. There is a need, in our culture, to share the advantages of affluence, and in cultures elsewhere to shift aspirations from running on a diet of donuts, to time-honored sustenance in the service of longevity, vitality, and a better life.

We are a uniquely adaptable species. It has led us into trouble that imperils ourselves, and our planet alike. There are early indications of hope that it could lead us out as well.

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.

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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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