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Wednesday, May 18, 2016

Diet, deafness, and the drums of war

A commentary just out in JAMA says many reasonable things about diet and health. The author notes that the overall low quality of the prevailing American diet is an anchor on life expectancy itself. Amen to that. No, multicolored marshmallows are NOT part of a (sane) complete breakfast. Really.

The commentary begins with, and was apparently provoked by, new Centers for Disease Control and Prevention data suggesting that age-adjusted mortality rates for major diet and lifestyle-related diseases ticked up in 2015. The author and I agree: This is ominous.

To be clear, we have known for a long time that lifestyle practices in our culture militate against the full measure of both longevity, and vitality. We heard about the “actual causes of death in the United States,” also in JAMA, all the way back in 1993. We've had plenty of time, every opportunity, and ample reason to do more than count the cost.

We have known as well, and also for years, that reversing the lifestyle practices that conspire against lifespan and health span alike, tobacco, poor diet, lack of physical activity to name only the top 3, works just as hoped. Eating well and being active is reliably, if imperfectly, associated with lasting weight control, and when those 4 factors are combined, not smoking, eating well, being active, and maintaining a healthy weight, they dial down the risk for all major chronic disease by a stunning 80%.

We have seen this verified by the diverse yet kindred cultures of the Blue Zones, and the blessings of longevity and vitality they confer. We have seen this demonstrated in population-wide interventions across a generational expanse. We have seen this demonstrated in randomized controlled trials. A repetitive drumbeat of publications in the peer-reviewed literature has rapped out this message for years with remarkable, nearly metronomic consistency.

These are, or should be, drums of war. The enemy, a culture that willfully places profit ahead of the life expectancy of your daughter, and my son, is inside the gates. If such a clear and omnipresent menace does not inspire our passions, and unity of purpose, it's hard to imagine what would. The skin in this game is that of the people we love most in the world. What are we waiting for?

The commentary author and I, as best I can tell, agree about all this. But we do seem to disagree about what will help us, at long last, overcome our apparent deafness to the invitation of those drums.

My answer is: stop arguing long enough to hear them. We have missed the common invitation of the drums for decades in the persistent noise of our perpetual discord.

I can't help but think in terms of an analogy. We might imagine we are actual soldiers, and I am from New York, say, and you are from Chicago. We argue over which of the two is the greater city, and miss the warning hiss of artillery, incoming. We might instead be Americans together, acknowledge the greatness of both cities, and take the next hill.

In the world of diet, details are the stuff of such dangerous diversion. There is a veritable cottage industry these days in pointing out the relative advantages of diets higher in total fat. Such arguments, like the case for Chicago over New York or vice versa, are invariably selective, reliably omitting any study that shows an advantage in the other direction. The real-world evidence implies that macronutrient levels are effectively irrelevant. When cultures eat wholesome foods in sensible combinations, they do just fine whether their fat intake is high, or low.

Similarly, endless debate about the esoterica involved in the burning of calories tends to play out by the light of fires burning arguments of straw. Allegedly, those of us who maintain that calories do, in fact, count are oblivious to consideration of the quality of food choice. The JAMA commentary even implies that the 2015 Dietary Guidelines Advisory Committee went awry by noting the relevance of calories to weight, despite the explicit emphasis of their report on wholesome foods, not calorie counting, as the essential means to desired ends.

There is so far as I know no law obligating a choice between the importance of calorie quantity, and quality. To the contrary, we have abundant reason and have had such reason for longer than many may realize to respect the indelible links between the 2. One of the defining virtues of high “quality” food is that it tends to fill us up on fewer calories. One of the defining features of “junk” food, and intentionally so, is that … nobody can eat just 1.

Simple, wholesome, minimally processed or unprocessed foods tend to have many virtues, satiety among them. There is no need to make a choice between the quantity and quality of calories; eat high quality foods, and quantity tends to take care of itself, with at times astonishing benefit. Nor is there a need here to line up behind the banner of one macronutrient or another. People readily over-consume calories from high-sugar, fat-free sodas; we also readily over-consume French fries, which get their calories almost equally from fat and carbohydrate, or, for that matter, honey-roasted almonds, which get almost 75% of their calories from fat. What these items have in common is not macronutrient distribution, but processing in the service of … certainly not health.

In contrast, plain, unprocessed, high-fat nuts are very satiating. So are high-carb beans, and lentils, and apples for that matter. So are baked potatoes, naked and unadorned. Simplicity is the common theme here.

There's no need to choose this nutrient or that, quantity or quality and there's certainly no value in endless argument that forestalls collective action. Discord lends comfort only to the enemy. Ancel Keys no more meant, “eat Snackwells,” than Robert Atkins meant, “eat low-carb brownies.” Having seen both such variants on the follies of history, and others besides, the only question now is: do we learn from them and move on, or just keep repeating them?

There are, and there will long be, many unanswered questions about the particulars of nutrition. Good will surely come of plugging those gaps in our knowledge, but not from plugging our ears to all but the opinions we already own. Not if we squander the opportunities in what we already know between now and then. I am sure there are many interesting metrics as yet untallied that would allow for refined comparisons among the great cities in America. We don't need them to know that all such cities are on the common ground of this country.

John Donne warned us centuries ago about the common implications of the bell. It rings true today, and of drums as well.

The threat to life expectancy is present and more than sufficiently clear to give us common cause. The lives in question are those of our children, and grandchildren, establishing our common interest. We certainly have questions left to answer, but have enough answers already to protect our loved ones robustly.

But we do need to stop arguing long enough to hear, and heed that percussive taunt and rally to the common battle, in defense of our common ground.

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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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