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Tuesday, December 13, 2016

Of plate, state, and the calculus of hope

In my customary purview, nutrition, public health, and disease prevention, I have had cause to lament periodically the apparent hegemony of Newton's third law. For every silly action we've taken over recent decades to address the effects of badly constituted diet on weight and health, we have appended an opposing, but comparably misguided reaction. Believe it or not, this pertains to the high drama of our current political situation, too.

Let's start with our plates; the state of the State can wait.

In principle, and famously, we had advice some decades ago to reduce our intake of dietary fat. For purposes here, we need not belabor the relevant provisos: the advice originated with studies showing the advantages of the high-fat Mediterranean diet. So, really, it was advice to reduce our intake of saturated fat from the usual sources. The message got mangled as it was passed along, just like in a game of ‘telephone.’ The idea that all dietary fat should be cut, while genuinely favored by some, was actually a distortion of the original mainstream message, but took on a life of its own.

Be that as it may, nobody with any actual expertise- not proponents of eating low fat, and not opponents of eating low fat- ever advocated for low-fat junk food. The original idea was to reduce dietary fat intake by swapping out the salient sources in the prevailing diet- fatty meats, processed meats, processed dairy, fried and fast foods, snack foods- for foods naturally low in fat: vegetables, fruits, whole grains, beans, and lentils, for instance. And, where that was actually done, rates of heart disease and premature death were slashed, and life expectancy extended dramatically. It just hasn't played out that way in America.

No one worth listening to ever said: just eat Snackwells, and all will be well. But, of course, that, or something much like it, is just what the makers of Snackwells, along with every other version of low-fat junk food, implied. And since they implied it with all of the resources of “Big Food” at their disposal, they implied it to great effect.

How great? Well, intake of all the best, natively low-fat foods changed almost not at all in the U.S. over the past 40 years. For that matter, total dietary fat intake never even went down. Rather, fat only ever went down as a PERCENTAGE of total calories, because total calorie intake has gone up, driven mostly by, you guessed it, low-fat junk, laden with added sugar and refined carbohydrate. Total fat intake, actually has trended up over recent decades, it's just that total calorie intake has gone up even more. That is the legacy of the “low fat” era in America. As they say in the old country: oy, vey.

Then, to make matters worse, Newton's third law kicked in. Apparently, human nature shares an affinity for it with all the rest of nature. Perhaps it's because it is so much easier to say, “I was wrong,” than to admit, “I DID wrong.” What's the difference?

If the low fat message simply “was wrong,” then we got bad advice, and can scarcely blame ourselves for following it. If we had actually cut fat, and gotten fatter and sicker- we may have been given bad advice, but what we did, we did well. That's the kind of admission we seem inclined to make: I was wrong, but I was misled.

Far harder, it seems, is this: the advice was fine, but I bungled its implementation horribly! This confession, unlike the other, leaves us little space to avoid a self-indictment of gullibility, nincompoopery, and/or fundamental incompetence. That's a very bitter pill to swallow, so apparently, most of us spit it out.

Instead, we claim: It's not that we implemented advice to cut fat (and, really, saturated fat) moronically; rather- the advice must have been wrong! Much easier to lay the blame there.

But it's just not true. In the U.S., we did, indeed, apply advice about dietary fat as moronically as possible: we conflated saturated fat with total fat; we never reduced our intake of fat anyway, nor even our intake of saturated fat more than trivially; and we added low-fat junk food. If anyone can legitimately claim surprise that THIS formula didn't vanquish obesity and chronic disease, I will give up my day job and become a hula dancer.

So we took the easy way out. We blamed the advice, rather than our monumentally stupid response to it- and then surrendered ourselves to Newton's third law. It was, obviously, time for some equally silly, but opposing reaction, like: cutting carbs. And so we did, bungling it every bit as badly as the “cut fat” message that preceded it.

Whatever the merits or demerits of Atkins' platform, it's only fair to note that he never advocated for low-carb junk food, any more than Keys ever advocated for Snackwells. But at the Atkins' Diet heyday, low-carb junk food is just what we got- and it has stuck with us ever since.

Nor were those sequential boondoggles enough to cure us of our Newtonian proclivities. We have since welcomed the advent of non-GMO junk; gluten-free junk food; “no longer made with high-fructose corn syrup” junk food; and probably other varieties I'm overlooking.

And that brings us, however tangentially, from the state of our plates, to the state of our Union. For, as opposed to Nate Silver, it may be that Isaac Newton correctly predicted the outcome of this election.

It is rather ironic that a population of allegedly thinking Homo sapiens behaves so much like the native inertia of celestial flotsam. Ironic, but apparently true.

The past eight years represented a remarkably progressive action in American politics. Those personally disappointed, for whatever valid reason, by their trajectory during that span, were presumably invited to express that disappointment with an equal, opposing, and by the reasoning of many of us, regressive, reaction. So here we are.

As with our plates, it is convenient and expedient to blame any personal disappointments on the bluntness of the action, rather than all the subtleties of context and implementation. The Affordable Care Act, like a car with no wheels, was designed to “fail,” by those wanting it to do so. The administration of the past eight years faced relentless obstructionism, and if we are honest- racism, too. And, of course, the Obama era began in the gaping hole of the Great Recession. There is a limit to how “good” getting back to ground level can ever feel, relative to reaching actual heights- no matter how monumental the climb out of the depths actually is.

Whether the topic is the content of plates, or the status of our State, physics itself seems to stipulate that an uninterrupted sequence of forward steps is little less than unnatural. But equal and opposite need not mean equivalent and self-canceling. When you run, you push against the ground, and the ground pushes back; but the ground stays put, while you move. Progress is possible.

In spite of it all, the objectively measured quality of the typical American diet has improved over recent years, albeit it little, and slowly. But it's progress just the same, and maybe the only kind the third law allows. And perhaps what's true of dinner is true of our democracy.

As for Newton, he bequeathed us other gifts too, like calculus. Conjoining that to the third law, I wind up with the calculus of hope. Progress is possible, even likely, but not likely ever to be linear. In accord with the rest of nature, human nature too is disposed to a meandering path of actions and reactions.

Here's to progress, in all areas, accordingly.

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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