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

Monday, November 28, 2016

How dieticians can save the world

I was honored, and genuinely delighted, to take the stage at FNCE 2016 (the annual meeting of the Academy of Nutrition and Dietetics, for those who don't know the lingo) with Dr. Walter Willett of Harvard, and Kathleen Zelman of WebMD, our session moderator. Kathleen was fresh from her speech, earlier the same day, as this year's recipient of the Academy's prestigious Lenna Frances Cooper Award.

As for Walter, the most published and cited nutrition researcher in history, he needs no introduction to anyone nominally tuned in to matters of food and health. I will simply note two things. First, this was, in a sense, the “Walter and Dave Show, part 2”, as he and I co-chaired a conference last fall on the same theme: the common ground of healthful, sustainable eating. That conference was sponsored by the not-for-profit Oldways, which advocates for “health through heritage.”

The one other thing I will say about Walter is that I respect and love him almost like a father. Only those who know how much I love and respect my actual father will appreciate just what that means. Moving on.

Walter provided a thoroughly evidence-based review of the fundamentals of healthful, sustainable eating, reprising the themes laid out at the Common Ground Conference a year ago, and updating the case with studies published since. I followed with a discussion of how we can be so prone to perpetual, pseudo-confusion in the first place when the relevant evidence is so abundant and so clear.

In particular, I talked about how scientists can seem like they disagree even when they agree far more; how a whole sequence of mono-nutrient fixations have been converted into nutrition boondoggles spanning decades; how the harms of sugar were not discovered by some currently best-selling diet book author last Thursday, but rather have been salient for years; and how utterly appropriate the recommendations of the 2015 Dietary Guidelines Advisory Committee were, before politicians adulterated them under the influence of lobbying, or bullying, if there really is any difference.

We are not clueless about the basic care and feeding of Homo sapiens. On the basis of massive aggregations of science, even mean applications of sense, the global consensus of diverse authorities from many relevant fields, and the experience of whole populations over generations, a diet emphasizing minimally processed vegetables, fruits, beans, lentils, whole grains, nuts, seeds, and water preferentially for thirst, is unassailably right for people and planet alike. So it is, and so we said.

During the Q&A that followed our brief presentations, a dietitian in the audience asked what to me seemed a beautiful, and refreshingly humble question: what can dietitians do better to help advance the public understanding of the fundamentals just discussed?

My part of the answer was that we only have the strength, or even the volume, to get anything meaningful done, if we are unified. If genuine understanding of the common ground of health-promoting, sustainable eating is to become common knowledge, it must do so courtesy of common cause.

Why? Well for one thing, we live in a massively noisier world than anyone before us has ever known. It's almost shocking to me to hear myself talk about the “pre-Internet” portion of my career to young colleagues, but there actually was such a thing! I miss it, to be honest.

Now, though, we are all irrevocably caught up in the endlessly amplified echoes of every opinion, expert and more often otherwise, courtesy of the blogosphere and social media. If our best understanding of eating well is the signal we hope to transmit, the challenge of doing so rises directly with the volume of static it must overcome.

Accordingly, those of us who have relevant expertise, and truly do mostly agree, must lead with that message. All too often, it is our native tendency to do otherwise.

It's our tendency because we are human, and all want to talk about “the thing“ that matters most to us, be it passion, priority, or pet peeve. But there are two salient problems in this domain. The first is that non-experts also have their passions, priorities, and pet peeves related to nutrition, and in cyberspace, they can readily broadcast those in the guise of facts, their lack of relevant qualifications generally undeclared, and routinely overlooked. If actual experts, dietitians and others, broadcast a comparable scattershot of disparate opinion, how is the public to know what's what, let alone who's who?

While there is plenty of room for variation among the prioritized particulars any one of us might favor, the basic theme of eating well for longevity, vitality, and the sake of the planet is simply not negotiable. Experts know that, and can both help the public know it, and distinguish expertise from impersonations of it, by reaffirming it every chance we get. Non-experts, hoping to be heard in the cyberspatial din, need to subordinate reliable, time-honored, evidence-based understanding to titillation and provocation. Experts can afford to do the opposite.

That does not preclude the appendage of personal priorities. Maybe you think artificial sweeteners are the absolute worst. Or maybe you think they are much preferable to sugar. Maybe you want to make a case for including dairy in the diet, or maybe, for excluding it. Maybe you think sodium gets too much attention, or maybe you think, not enough. Maybe you are convinced that artificial dyes and flavorings contribute to behavioral disorders in children, or maybe you consider that evidence inconclusive. Maybe you are all about gluten, or GMO foods, or resistant starch, or the microbiome.

By all means, tell the world, but to use a food metaphor, tell the world where the common cake ends, and your bit of favored frosting begins. If our commonality is the cake, and our differences relegated to the icing, we can have that cake, and serve it, too.

I meet very few, if any, dietitians who don't agree with the proposition that diets and health would improve (in the U.S. and other developed countries) with more vegetables, fruits, whole grains, beans, lentils, nuts and seeds and water in the place of almost any other beverage almost all the time. Over the years, however, I have met many who tended to talk much more about some narrowly bounded, personal priority, than the expanse of common ground we share.

The result of that is the obvious: the public doesn't know we agree nearly as much as we do. Deriving the impression that no two nutrition experts agree or hold the same opinion for more than 20 minutes at a stretch, the public learns distrust of us, if not disgust with us, which opens the door wide to a never-ending parade of fools and fanatics with something to sell.

We have the strength to change prevailing diets and health for the better only in unity. If we collectively defend the fundamentals of healthful, sustainable eating, and then append our personal priorities, whatever they may be, we can be the change we hope to see in the world, and stay true to ourselves as well. We can be greater than the sum of our parts, yet still part over given particulars as inclined.

The answer was intrinsic to the lovely, humble, generous spirit of the question. We can each take the most effective stand in support of our personal priorities for health if we do so resolutely, consistently, and emphatically on the common ground we share.

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.

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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.

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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.

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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.

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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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