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.
Wednesday, November 23, 2016

Can post-election anxiety be a clinical diagnosis?

How are you feeling post-election?

In the practice of medicine, we use validated questionnaires like the PHQ-9 to screen for depression or the GAD-7 to screen for anxiety.

My wife, a family doctor, administered the GAD-7 to a patient of hers this week; post-election, I started wondering how many Americans could be diagnosed with generalized anxiety disorder right now.

Go ahead and take the quiz yourself. What's your score?

A score of five or more indicates mild symptoms. Ten or more moves you to moderate. Fifteen or more means you are highly likely to have diagnosable anxiety disorder, what the experts call generalized anxiety disorder.

If you're in this highest category, think about getting help. You can start with your primary care physician. She can help you directly or refer you to other community mental health resources that can be helpful.

Generalized Anxiety Disorder (GAD), according to the Diagnostic and Statistical Manual of Mental Disorders (DSM-5):

A. Excessive anxiety and worry (apprehensive expectation), occurring more days than not for at least 6 months, about a number of events or activities (such as work or school performance).

B. The individual finds it difficult to control the worry.

C. The anxiety and worry are associated with three (or more) of the following six symptoms (with at least some symptoms having been present for more days than not for the past 6 months):

Note: Only one item is required in children.
1. Restlessness or feeling keyed up or on edge.
2. Being easily fatigued.
3. Difficulty concentrating or mind going blank.
4. Irritability.
5. Muscle tension.
6. Sleep disturbance (difficulty falling or staying asleep, or restless, unsatisfying sleep).

D. The anxiety, worry, or physical symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning.

E. The disturbance is not attributable to the physiological effects of a substance (e.g., a drug of abuse, a medication) or another medical condition (e.g., hyperthyroidism).

This post by John H. Schumann, MD, FACP, originally appeared at GlassHospital. Dr. Schumann is a general internist. His blog, GlassHospital, seeks to bring transparency to medical practice and to improve the patient experience.

The lives of your children are in your hands

I've never lost a patient to polio. Or tetanus. Or whooping cough, but to be honest, I have an unfair advantage on the whooping cough: only kids die of whooping cough, and I only treat adults. I have seen my fair share of pertussis cases (as whooping cough is more properly known). It's terrible; uncontrollable fits of coughing, so violent that people vomit, wet their pants, break ribs. But adults, at least, don't die.

Babies are another matter. About half of kids under a year old who get whooping cough end up in the hospital. About 1/100 die of it. And you and I are to blame. (This link will take you to a video of a baby with whooping cough. It's hard to watch, but do it anyway.)

We're to blame in two ways: first, we fail to vaccinate our babies against pertussis, even though it couldn't be easier. Second, we fail to vaccinate ourselves. Immunity from the vaccine doesn't last very long, but it lasts long enough to get a baby through that critical first year. By the time we're adults, though, our protection has often worn off, unless we get a booster shot.

Adults can walk around with whooping cough, thinking they have a nasty cold. They can then pass it to parents or babies. And watching a kid with pertussis try to breathe is terrifying.

It's so simple, really. We vaccinate parents before babies are born, and I try to make sure all my patients have their shots up to date. But there will always be people in whom the shot doesn't work well, and there will always be people who say “no” to it, either on their own behalf or their child's. And that's a tragedy.

As you, dear reader, know, whooping cough isn't the only disease we can prevent with vaccination. Thankfully, there are dozens of known killers that we have locked up with the help of medical science. Some of them, like polio, haven't yet returned to the U.S., thanks in large part to vaccination and to public health measures such as the delivery of clean water. Others, like measles, mumps and whooping cough are enjoying a resurgence, thanks in large part to adults who refuse to get vaccinated, and deny their children this simple life-saving treatment.

I know I'm asking a lot of you to keep reading a long piece on a nice fall day, but stick with me because this is important.

At the University of Wisconsin, Madison, health officials are scrambling to get meningitis shots to all students. Two have come down with meningitis type b, a somewhat uncommon brain infection. And while it is rare compared to, say, influenza, it's deadly. Over the last several years outbreaks have occurred on U.S. college campuses, often killing young adults. Until one woman in Michigan lost her daughter to this rapidly fatal disease, a vaccine wasn't available in the U.S. Alicia Stillman made it her mission to bring the vaccination here and promote its use so no child would die of a preventable disease and no parent will suffer the same loss. She's been incredibly successful in getting the word out, and the shot into people's arms.

And now it's flu season, a time when hundreds of thousands of Americans get very, very ill, and thousands die from a preventable disease. The flu is one of the most contagious human viruses, but also one of the most preventable. Flu shots protect millions every year from losing time at work, from ending up in the hospital, from getting pneumonia, and from death. Since there is not a single downside to the shot (at least not compared to the disease itself), it's a massive public health failure that so many Americans miss it each year.

Cancer. We have a vaccine against cancer. Not all of the hundreds of kinds of cancers that affect humans, but against a bunch of them. Human papilloma virus (HPV) causes cancers of the cervix, penis, head and neck (e.g. tonsils, back of the throat), and anus. As an astute reader you've caught on to the pattern here: some cancers are sexually transmitted.

Every time you go for your Pap smear that's what they are looking for: pre-cancerous changes, and cancer cells on the cervix. And now there is a shot that can prevent that callback from the gynecologist, that fear, the painful surgeries. It can prevent the radiation treatments to the neck that dry up your saliva and burn your throat while trying to save your life. This vaccine saves lives. The trick is, it's best to get it before any sexual activity, so basically, in pre-adolescence. Some parents are scared of the idea of their kids growing up and having healthy sex lives, but it's going to happen. There's no conceivable reason to deny your kids this life-saving shot. Other than the pain of the needle, there are no side-effects. Despite what you might read on facebook or anti-vaccine blogs, this shot is as safe as safe can be, and it prevents cancer from attacking your children.

And this is the frustration I face as a medical professional and as a father. There is a small but vocal subset of people who think they are public health experts despite the obvious fact that they are not. I have spent the last twenty-some-odd years studying and practicing medicine. I've learned how to read and interpret medical studies, how to sift through data to find the difference between tall tales and facts. This is not knowledge that is available to everyone, because it takes years to become an expert. Anyone can learn to be a good parent, but not everyone can learn to be a doctor. I spent the time, money, sweat, and sleepless nights learning this because I could. I have been given the responsibility to help care for my fellow human beings. And I take responsibility this very seriously.

While getting parenting advice from strangers online may be helpful, getting medical advice from the same “experts” isn't so smart. What we do is very hard. And what you do, and who you listen to, will make the difference between saving the lives of you and your children, or giving them up to an amoral microbial world that doesn't care what you read online.

Get your shots. Save your life, and the lives of your kids. I'd much rather hold my daughter's hand as she cries from a shot than hold it while she gets chemo.

Save a life. It's as easy as calling your doctor.
Tuesday, November 22, 2016

If you think the elite, pollsters were Trumped, try health care next

The presidential election result shook the world. As the vote counts started to come in, most of the country descended into a state of collective shock and disbelief, even Mr. Trump's own supporters. Nobody seemed more surprised than the political pundits on all the cable news channels, who had for months incorrectly predicted the opposite result.

Let me take a step back for a moment before I sound like somebody who is rejoicing in Mr. Trump's victory. Far from it. In the last few weeks, I've written articles against his candidacy, denouncing his divisive and inflammatory rhetoric, and looking at it in a more historical context.

But in the days after Hillary Clinton's defeat, like millions of people across the country, I reflected on what had happened and tried to understand how everything had gone so unexpectedly wrong. Then I began thinking more about some of his talk about a “privileged and disconnected elite” (although some may say he was part of that), “power of big business interests” and “too much regulation.” I couldn't help but bring it all back to health care and draw some parallels. As someone who has written extensively on the subject of physicians losing autonomy, facing excessive bureaucracy and documentation requirements, and what we need to do to make health care more patient-centered, I couldn't help but wonder if, on a superficial level, a similar phenomenon could be playing itself out in health care.

Doctors (and patients) have witnessed an avalanche of changes in health care over the last decade. These include the relentless push towards consolidation and the corporatization of medicine, increasing government regulation, and the decimation of small private practice. Ask most doctors who have been around for any length of time, and they will confirm the detrimental effects all of this has had on the practice of medicine and the doctor-patient relationship. Patients too are unhappy and frustrated with what's happened; nobody ever asked them if it's what they wanted. It's no longer about the doctor and patient, but rather about the regulator, administrator and patient—often with a computer and a series of tick-boxes in between. Other folks such as information technologists and the “Big Data people” (so many of whom roam around my home city of Boston, and I'm personally very skeptical of) are increasingly hanging around at the peripheries of health care too.

When pundits in the political realm, usually so-called “experts” talk about people like numbers, they frequently scoff at “emotion” and don't understand why pure emotion drives people to vote. It happened in this election, and I also witnessed the same thing with Brexit several months ago. The same situation exists in health care too: A total disconnect from the realities of everyday frontline medicine. Many people pulling the strings simply do not understand people, and just look at them as numbers. Healthcare however, is an extraordinary emotional arena. Emotion is what makes us human and there's nothing wrong with it. Of course, there has to be logic too in human interactions and decision-making, but it's highly irritating whenever emotion and real human feelings are discounted.

I'm trying to put myself into the shoes of a typical Trump voter, who for months has watched political pundits and news organizations (a good example would be the New York Times website, which consistently gave Hillary Clinton a greater than 85% chance of winning). How good it must have felt to vote on Election Day and give them a “kick in the teeth” and show them that it's the people, not statisticians, who decide elections. I may fundamentally disagree with their logic and seeing their candidate as the man to rescue them, but I do understand this raw feeling, especially when you feel that your concerns are not being listened to.

Many of the people at the front lines of health care are also disillusioned with the powers that be. Those who are the most important, patients, doctors, and nurses, are pretty fed up with what they've seen happen over the last few years, and a vast segment of them are also yearning for change. A change that simplifies medicine and brings the doctor-patient paradigm back to the center of all decision making. Hopefully, it's only a matter of time before we go back to health care in its purest form.

After this election, many corporate health care stocks fell rather dramatically (at the same time pharmaceutical stocks went up). Why do you think this was? If, and this may be wishful thinking, Mr. Trump's election and the demise of Obamacare means an end to the relentless push towards consolidation, big corporate medicine, increasing government regulations, and excessive bureaucracy—as long as we retain protections for patients and keep pushing for lower costs—I for one won't be shedding any tears about that.

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. This post originally appeared at his blog.

Sign up for a no frills colonoscopy

Cleveland took a major economic hit a few years back when United Airlines cut most of its flights from our city. An airport is the heart of a metropolis. Lack of their direct flights means that business meetings, leisure travel, conventions and trade shows will likely opt for more convenient locales. This was a business decision for United which I am sure was rational. Nevertheless, their gain was our loss.

As a result, we have had several low cost carriers who have swooped in to gain market share. We have Frontier, Spirit, JetBlue, and now Allegiant. Not a day goes by that I don't receive an e-mail blast from one of them announcing fares so low that it seems simply not possible. Many of the flights' stated fares are less than it would cost me to drive to the destinations. How do they do it?

Of course, the fare price that is stated is not what you will pay. The total cost of your flight has been fractionated resulting in an a la carte payment system where every additional service adds to the cost. The airlines justify this with idiotic PR pronouncements that state that this payment system serves the customer who can only purchase the services he actually needs. The fallacy here is that most travelers will need to purchase several airline services, so that the falsely low bait price is deceptive as nearly no traveler will pay it. I suppose that if you were traveling without luggage, were departing at convenient times such as 2 a.m., eased yourself into the commodious middle seat and brought a carry on piece about the same size of the pencil cases we used in elementary school, then you could actually pay the base price. If however, you have any checked luggage or carry-on items, want to choose your own seat, want enough legroom to allow some circulation to reach your toes, want a beverage, want an oxygen mask that works, want a flotation device that floats, then you will pay for every one of these luxurious upgrades.

Even with all of their pick-pocketing, the costs are still generally less than conventional airlines. But the gap between them is less than you might think.

Perhaps, this is how we should market colonoscopy: COLONOSCOPY for $49!

Once we've signed up the customers, we would review some of the optional services that they may wish to purchase to enhance their colonoscopy experience. Just like with the airlines, they are free to bypass these extras and can then pay our low base price. Here are some of the high end upgrades available to those who want a Cadillac colonoscopy.
• greeting from the receptionist.
• a properly disinfected instrument.
• supplemental oxygen
• sterile needles
• economy class anesthesia
• business class anesthesia
• treatment for side effects of anesthesia
• monitoring vital signs beyond initial free blood pressure check
• sober nurses
• charge for withdrawing the colonoscope. The base charge only includes insertion of the instrument.
• use of the restroom before or after the procedure.
• forward report to the referring physician.
• explain results to your family members, Base charge includes “thumbs up” or “thumbs down” gestures only.

There's no reason that this pricing approach couldn't apply to your business. Soon, we'll be reading ads for new cars for $2,500, vacations to exotic beaches for $149, Five Star restaurant meals for $7 and a remodeled kitchen for just $99!

Why not just tell us the truth. How much extra would that cost?

This post by Michael Kirsch, MD, FACP, appeared at MD Whistleblower. Dr. Kirsch is a full time practicing physician and writer who 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.
Monday, November 21, 2016

Lessons for organized medicine from the election

KevinMD reprinted a Medrants post – Will someone actually let actually help patients? This post has had wide reposting on Twitter and Facebook.

As we read and listen to “experts” dissect the Trump victory, one theme seems to emerge, the lack of respect for the working class. While many remain mystified with Trump's appeal, many opine that he convinced many that he heard them and understood them. An interesting op-ed in the Wall Street Journal, How Donald Trump Filled the Dignity Deficit, contains this paragraph:

“Too many Americans have lost pride in themselves. We sense dignity by creating value with our lives, through families, communities, and especially work. That is why American leaders so frequently talk about dignity in the context of labor. As Martin Luther King Jr. taught, ‘All labor that uplifts humanity has dignity and importance and should be undertaken with painstaking excellence.’ Conversely, nothing destroys dignity more than idleness and a sense of superfluousness—the feeling that one is simply not needed.”

Perhaps I am stretching a bit, but as I talk with physicians in private practice and academe, I too often hear despair. The New England Journal of Medicine has another article bemoaning the current state of medicine and medical training, Meaning and the Nature of Physicians' Work, that says:

“We believe that if meaning is to be restored, the changes needed are complex and will have to be made nationally, beginning with a dialogue that includes the people on medicine's front lines. Perhaps the greatest opportunity for improving our professional satisfaction in the short term lies in restoring our connections with one another. We could work on rebuilding our practices and physical spaces to promote the sorts of human connections that can sustain us—between physicians and patients, physicians and physicians, and physicians and nurses. We could get back to the bedside with patients, families, and nurses. We could get to know our colleagues from other specialties in shared lunchrooms or meeting spaces.”

For many physicians and trainees, we have lost much. We want to focus on patients, but (and use this term a bit sarcastically) “the elites” have imposed dysfunctional EHRs, performance measures, report cards and an inane payment system.

Patients want healthy interested physicians. Patients want us to connect. They want to feel that we care about them a people first, and disease second. We cannot measure this function, but we all know its importance. We physicians know the feeling when we hear the patient's concerns and address them to their satisfaction. We patients have the same feeling when we believe that our physician has our best interests at heart.

Since we cannot really measure these feelings, we have difficulty convincing the insurance companies and policy wonks, since they want measurables. There are things worth measuring in medicine, but just because we can measure them does not mean that the measurables define quality.

So I beseech myself and all other physicians to demand a change. These battles will not be won easily. ”The elites” do not really understand. But we have a moral obligation to let them know that the current regulatory environment hurts patients and physicians.

db is the nickname for Robert M. Centor, MD, FACP. db stands both for Dr. Bob and da boss. He is an academic general internist at the University of Alabama School of Medicine, and is the Regional Associate Dean for the Huntsville Regional Medical Campus of UASOM. He still makes inpatient rounds over 100 days each year. This post originally appeared at his blog, db's Medical Rants.

Sugar: my position

Sugar seems to be everywhere these days, and I don't just mean in the copiously over-sweetened standard American diet (“SAD”). I mean in the news about diet, too.

Partly, this is as it should be, as one of the principal liabilities of a dreadfully junk-laden and hypocrisy-laden diet, literally engineered to subjugate the health of the many to the profit of the few, gets the attention it deserves. Partly, though, it is the result of a well orchestrated, well funded effort by those with ties to the beef industry, and/or interest in sticking butter in your coffee, to divert your attention from the harms to people and planet alike of all those bacon-cheeseburgers, through the time-dishonored expediency of a scapegoat.

In conjunction with all this attention to sugar, there has been a fair amount of attention in media and social media to my positions on sugar, because I say things like I just said about bacon, beef, and butter, and the peddlers of those don't like it. I've got trolls, in other words.

Fortunately for me, though my trolls misrepresent my position on sugar egregiously, the truth is a matter of public record, running through columns I've written, educational programs I've helped develop and test, and algorithms I've engineered. But finding all of that scattered information is a challenge, particularly for those disinterested in the truth. So here it all is in one place, with selective links to some of those vintage materials.

1) Sickly sweet.

I don't know how to put it much more bluntly than I already did above: excess added sugar is one of the principal liabilities of the prevailing American (and, increasingly, “modern global”) diet, noteworthy for its many liabilities. From my perspective, there are three salient harms of excess added sugar in the diet: (1) excess sugar itself is metabolically harmful, via its effects on insulin release and fat deposition; (2) sugar contributes to the excess calories propagating obesity, and without any redeeming nutrient value; and (3) sugar is used expressly to make foods, even foods not overtly sweet, hyperpalatable, and thus contributes disproportionately to overeating in general.

None of these positions is remotely new. They figure prominently in a book I wrote more than 15 years ago, and a nutrition textbook I wrote before that, and have recurred in my writing ever since.

2) Sum of parts.

It's the total dose of added sugar in our diets that matters much more than which kind of sugar it is. The many aliases of sugar in the food supply are confusing, and problematic. We have taught children, and their parents, how to defend themselves against this deception for nearly 15 years in our well-studied, freely available food label literacy program, Nutrition Detectives®.

An interesting anecdote on this matter, courtesy of my work on a nutrient profiling algorithm (the Overall Nutritional Quality Index, or ONQI™; more on that below). Many years ago, a shopper in a supermarket featuring this system, known as NuVal®, expressed concern that several different jars of apricot jam all scored a lowly “1” (lowest nutritional value) on the scale from 1 to 100. Why the concern? All but one of the jars had sugar as the first ingredient, but one of them had apricots as the first ingredient, but that one scored a 1 as well. We were asked to look into it, and did.

What we found was a precautionary tale about food labels almost as dubious as the products they adorn. Ingredients are listed in order of abundance, and in the apricot-first jam, apricot was indeed more abundant than any other single ingredient for one reason only: the product used 4 or 5 different “kinds” of added sugar, and listed them separately. So, while apricot was more abundant than any one of the added sugars, it was less abundant than total added sugar, just like all the other jams that listed sugar first. The shopper was deceived by this, just as the manufacturer intended, but the algorithm was not. It prompted us to take this issue to the FDA and USDA, with the request that labels consistently use “total added sugar” to establish the order of entries in an ingredient list, even if they go on to enumerate the varieties of sugar.

3) What's in a name?

Per the above, I think the many aliases used to indicate added sugar in processed foods are confusing, and thus harmful. There are dozens of alternatives, all of which are really just “added sugar.” I am not sure anyone knows the exact number, as the food industry is ever adept at adding more, but Prevention Magazine came up with 57!

My view, now as ever, is that the right approach is to list “total added sugar” and situate that in the ingredient list wherever that cumulative dose belongs, and then, in parentheses, spell out the kinds of sugar in order of abundance.

Here, too, history adds some interest. Given how vilified high-fructose corn syrup (HFCS) has become (more on that below), I think many have forgotten that one of the advantages of its use in the early days was that even sugar-conscious shoppers didn't reliably recognize it for what it was, and thus tended to overlook it. (The other, salient advantage was that it was a cheaper alternative to sugar derived from cane or beets.) We called it, accordingly, a “wolf in sheep's clothing” in Nutrition Detectives®, and by distributing that program around the world in some 50,000 free DVDs, were in the vanguard of those raising awareness, and opposition, to this pernicious ingredient.

4) Hyperbole about harms, and the harms of hyperbole.

Some have claimed, famously, that sugar is “poison” and fructose is “toxic.” These contentions are, simply, untrue. Sugar includes the lactose in breast milk, and the glucose that floats constantly, and essentially, in our bloodstreams; it is absurd to declare the composition of mother's milk and our own blood intrinsically “poisoned.” Rather, the dose makes the poison.

As for fructose, it occurs naturally in all fruits and many vegetables. If it is “toxic,” by extension, apples and berries are toxin delivery systems.

I have consistently warned those colleagues involved, some of whose efforts on behalf of public health I very much appreciate, that hyperbole about harms would result in three harms of hyperbole. My warnings mostly fell on deaf ears, and only convinced these colleagues that they disliked me. Oh, well. Alas, my warnings about the three harms have all been borne out over time.

(1) Exaggerated focus on fructose invites the “sideways to sucrose” phenomenon.

There are really two issues here. The first is that if “fructose” is vilified, the public in general will not necessarily know that fructose is nearly as abundant in table sugar (sucrose) as it is in HFCS. The food industry is thus invited to put big banner ads on the front of products that say something like, “now without high-FRUCTOSE corn syrup” with the emphasis on fructose, and thus derive a halo effect, under which a host of ills can be concealed. This has certainly happened. We can file this one under: “Tell them what they've won, Johnny!Log Cabin original syrup, now FREE of HFCS, has just plain “corn syrup” as the first ingredient, sugar as the third, and maple … nowhere on the list!

The second is that if fructose is “the” villain, it implies that everything else is exonerated. Again, since the public tends not to know that table sugar is half fructose, it allows for replacing HFCS with sugar, and pretending that's anything other than a lateral move. It is not. But Pepsico, among others, has tried to get credit for just such an exercise in going nowhere.

(2) If fructose is evil, can apples be far behind?

Another of my anxieties about excessively vilifying fructose is that it would invite people to extend the indictment to the premier delivery vehicle for this nutrient, fruit. There is no justification for this, as fruit intake is not only good for health in general, but specifically associated with protection against the very harms of excess sugar intake, notably diabetes. But, sadly, this prediction has also come true. I have received innumerable emails over the years since fructose first became “toxic” asking me if it's OK to eat whole fruits; and this matter has caused such widespread confusion that the New York Times felt obligated to address it. What a sad waste of time we can't spare, though, to need to convince people that whole fruits are … still good for them!

(3) The “sugar did it” proviso.

The third liability of hyperbolizing the harms of sugar, or fructose, is that it lets all of the other bad actors off the hook. Yes, excess sugar is bad, but that does nothing to exonerate trans fat, processed meats, food chemicals, salt, refined starches, or for that matter, butter. But that's exactly the case currently being made, or feigned, by the agents of meat, butter, and cheese. They are exploiting the hyperbole about the toxicity of sugar to imply that sugar is solely responsible for the sorry state of our diet, which is, in a word, baloney. Baloney also contributes to the sorry state of our diets, both when it does (yes, it sometimes does), and when it doesn't contain added sugar.

5) Industrial light and magic: of conflicts, confluence, and contracts.

My lab has run studies funded by industry over the years, which my various detractors have cited to imply I have conflicted interests. I do not; I have no interest in the sales of anything we've studied. Rather, their contentions are conflicted, since most of them want you to buy meat and butter, their book about them, or both. The noise is just so much CGI smoke.

My lab, of course, has had IRB approved contracts for every study we've ever run. That process probes for conflicts of interest, and prohibits them.

But we have set the bar much higher than that. Our contracts have always guaranteed the lab full autonomy and guaranteed our rights to publish, no matter the outcome. The result is that we have published both positive and negative outcomes of industry-funded studies.

Our studies of food have been agnostic with regard to food type, and have rather followed our hypotheses, ranging from the effects of egg intake on diet quality and cardiovascular health, to the effects of soy on vascular status at menopause, to the effects of walnuts on body composition, to the effects of snacking on appetite and weight.

Only once have we focused specifically on sugar, and when we did, we indicted it. We studied the effects of cocoa and dark chocolate on vascular health, finding benefits, as have the many others who have studied this. However, we found that sugar-free cocoa was decisively better than sugar-sweetened cocoa, or stated alternatively, we found that sugar significantly attenuated the vascular benefits conferred by cocoa.

The whole topic of industry-funded research is obviously fraught. I know of some thoughtful colleagues devoting dedicated attention to the matter now, and look forward to the results of their efforts. My view is that there is certainly the risk of conflict in this realm, but also the possibility of confluence, and that we are best served by scrupulous efforts to distinguish between the two.

6) Of trials, and tribulations.

I serve occasionally as an expert legal witness. I hate it. It's tedious, inconvenient, and when it involves deposition and cross-examination by hostile attorneys, extravagantly unpleasant. I do it when I care passionately about the case, or absent that, when two criteria are met: first, that I believe the side seeking to engage me is right; and second, that I am compensated suitably for my pains. Frankly, that sum is set absurdly high, which works as intended to drive away the uncommitted. But some say, “OK,” and I engage accordingly.

The result is lots of attention in social media to two lawsuits pertaining to sugar in which I served as an expert witness.

In one, the yogurt maker, Chobani, was being sued for deceiving the public by using “evaporated cane juice” as the name for added sugar in its products. I've noted my position about the many aliases used for sugar above, and that has never changed. But, frankly, since almost everyone knows what “sugar cane” is, I think “evaporated cane juice” is one of the least deceptive in the mix. More importantly, until or unless the FDA changes the rules, the simple fact is that many names are in use for sugar throughout the food supply. I have examined the issue carefully, and “evaporated cane juice” is used preferentially by many of the most virtuous, corporately responsible food companies out there, and appears on the very select products that make it into my own home.

The bottom line in this case, and this is the position I took all along, was that suing Chobani for being deceptive about sugar was like suing the maker of Prius for carbon emissions and climate change. Yes, it might be true in both cases that they contribute to the prevailing problem, but in both cases, they are well above the standard, not pulling it down. Singling out Chobani was absurd, and almost certainly involved ulterior motives.

The other suit was, in essence, one sugar producer versus another. I said in deposition and in open court that as far as I was concerned it was the case of the “pot versus the kettle,” and that the principal public health problem was too much of both of their products. But the case was about a very specific question: can the human body ‘tell’ the difference between HFCS and sucrose. As a simple matter of fact, the human body can, even if the body politic doesn't have much cause to care. That was my position then, as it is now.

7) Are artificial sweeteners better?

I really don't know, because nobody knows for sure. The literature on this topic is mixed with some studies showing benefit from cutting out sugar and calories through the medium of no-calorie, “artificial” sweeteners. Other studies, however, suggest that the currently prevailing sugar substitutes may do significant damage of their own. Whether or how this pertains to the newer entries such as stevia, or monk fruit extract, is still a work in progress.

What I can say is that I avoid artificial sweeteners personally for three reasons. First, the precautionary principle, which argues that it's safer to assume harms until they are disproven than it is to assume harmlessness until it is confirmed. Second, when sugar is “put in its place“ and one's diet is made up overwhelmingly of unprocessed foods, there is neither need, nor place, for artificial sweeteners. And third, I think there is a better way to reduce sugar intake, which I call “taste bud rehab.” By trading up choices and eliminating stealth sugar first, and more overt sugar after, you can cut your intake of sugar and calories; avoid any actual or potential harms of chemical additives; and rehabilitate/sensitize your palate into the bargain, so you actually come to prefer more wholesome, less copiously sweetened food.

8) Of attitudes and algorithms.

I suppose simply because facts can be inconvenient and innuendo is easier, on-line comments have suggested that the ONQI®, in nearly 2000 supermarkets nationwide under its consumer-facing name, NuVal®, somehow favors sugar. This is mathematically confirmed nonsense. The two most severely penalized nutrient entries in the formula are trans fat, and added sugar. The ONQI (the world's most robustly validated nutrient profiling system, to the best of my knowledge) differentiated between total sugar (which includes the lactose in dairy, and the fructose in whole fruit) and added sugar long before the FDA concluded they should do the same. Both are penalized, as is glycemic load, but added sugar is penalized preferentially. The result is that copiously sugary products, such as sodas, are the lowest scoring items in the entire food supply.

The bottom line is that I have been among the prominent critics of excess sugar in our diets for nearly three decades, and but for minor refinements to keep pace with research findings, my position has never wavered. It is consistent across columns and books, research studies and review articles, programs and algorithms. I hasten to add that I have been in excellent company all along. Despite the long line of claimants that has queued up under the “I discovered the harms of excess sugar last Thursday, so buy my book” sign, the reality is that advice to limit sugar has been not just present, but prominent, in the Dietary Guidelines for Americans since the first, in 1980.

Through clinical trials, and the tribulations of lawsuits, my position on the considerable harms of excess added sugar in our diets is pretty much the same as it ever was.

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.
Friday, November 18, 2016

An open letter to all health care information technologists and regulators

Dear health care technologist or regulator,

The world of health care is changing exponentially. Speaking as one the nation's over 800,000 physicians, I can confidently say that most of us understand the fact that the current health care system is unsustainable, and can't carry on as is. There are many potential solutions to explore, and everyone in health care needs to try to come together in an attempt to address these problems and determine an appropriate future direction.

One of the biggest changes to physician practice over the last decade has been with regards to our interaction with information technology. The need to expand the use of technology in health care and bring it into the 21st century is understood, and of vital importance as we seek to improve quality and care for our patients. The government's Meaningful Use program, initiated with vastly increased health care information technology spending as part of the Federal Stimulus Package in 2009, gave health care organizations and individual physicians large financial incentives to expand their use of information technology at the frontlines of medicine. But alas, the software solutions available to us were not yet ready for primetime, and have caused something of a disaster for the practice of medicine.

Simply put, you need to understand that they simply take too much time to navigate and use. Studies are now showing that doctors (and nurses) are spending an absolute minimal amount of their day in direct patient care, with the majority of the rest staring at a screen and clicking boxes. You have to realize that most of us in health care chose our profession because we want to interact with our patients and spend the bulk of our day in direct patient care. The effect of having to spend excessive amounts of time documenting and performing data-entry tasks contributes hugely to burnout rates and negative job satisfaction. Furthermore, it is a huge waste of education, talent and resources. As for patients, most of them are increasingly frustrated by their ever-decreasing time slots with their physicians, and the fact that a lot of the time, their doctor is just staring at the screen rather than looking at them.

We understand that electronic medical records do bring huge benefits in terms of being able to find and retrieve patient information. They are definitely the way of the future, but we are nowhere near where they need to be.

The American Medical Association and other specialty societies have previously called for significant improvements in the usability of Electronic Medical Records for at least the last couple of years. We at the frontlines have been patiently waiting, but these improvements are yet to materialize. It is therefore now time for a massive call to action for the world of information technologists and regulators to work with doctors on designing vastly better information technology solutions, reducing bureaucratic burdens, while keeping in mind that health care is all about humanity and direct patient care. Nothing short of a major overhaul is required. This will not only improve quality and efficiency at the frontlines, but also most importantly, make our patients happier too.

Yours Sincerely,

Suneel Dhand MD

Attending Physician, Internal Medicine

Boston, MA

Founder, HealthITImprove

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. This post originally appeared at his blog.
Thursday, November 17, 2016

Tips for attendings: Learning is more difficult than teaching

As a newly minted journal faculty member rounding on the wards, I had great internal pride in my teaching ability. Like many residents and junior faculty I assumed that my teaching would result in the learners growing dramatically (especially since I had delivered the messages so brilliantly {please read that phrase with true sarcasm}).

During my growth as an educator I learned that teaching can help, but not as dramatically as I would have liked.

Try this yourself. Teach something to your learning group. Wait a week or two and then quiz them. At first you will be despondent, but then take time to reflect. How long did it take you to learn things?

About 15 years ago, the housestaff helped care for an unfortunate young woman with Wilson's disease. One resident presented the story at morning report, and I missed the diagnosis. I had never seen Wilson's disease, and really did not know much about how patients with Wilson's disease presented.

Approximately 2 weeks later, a different resident presented her story at a different morning report. I missed the diagnosis again.

The third time (yes this patient's story was recycled for a variety of presentations), I did remember the story. I now know the big clue is the very low alkaline phosphatase in a young patient with new liver disease.

Learning is complex. We learn better with repetition. We learn better with the use of different sensory inputs.

What should this mean for our teaching?

First, never apologize for repetition. Just yesterday I quizzed my team on something I had taught the previous week. One of four remembered the concept. So we repeated the key teaching points.

Second, encourage your learners to read about what they learn each day. I recommend that learners keep a small notebook (or enter notes into their smart phones). Each day they should pick 2 topics to reinforce. Spend 10 to 15 minutes on the topic. Reading about something that you just heard helps solidify the memory.

Understanding the difficulty of learning medicine should inform educators. Our job is to help our learners grow. This growth requires repetition. We owe our learners a great deal. Understanding and repetition are a good start.

db is the nickname for Robert M. Centor, MD, FACP. db stands both for Dr. Bob and da boss. He is an academic general internist at the University of Alabama School of Medicine, and is the Regional Associate Dean for the Huntsville Regional Medical Campus of UASOM. He still makes inpatient rounds over 100 days each year. This post originally appeared at his blog, db's Medical Rants.
Wednesday, November 16, 2016

Outcome bias

I grew up in Wheaton, Ill., one of Chicago's western suburbs, and became a Cubs fan by default. All my friends were Cubs fans, my dad took us to Wrigley for games (never Comiskey!), and the Cubs games were televised on channel 9 while the White Sox were usually on a UHF channel (44) that was hard to tune in (if you remember wiggling a dial to get your grainy local UHF signals, you are old like me). This photo is from a game I attended in 1969 with my family. That year, and every year since 1945, ended the same way: with the Cubs failing to win the NL pennant.

So last night's victory is a gigantic step forward for the Cubs, who will now play Cleveland in the World Series. By now you're asking, “yes, but that's a game and this blog is about infection prevention, what's the connection”?

See Cub manager Joe Maddon's quote in this piece, about how he approaches challenges:

“When you get to this particular moment, to try to avoid being outcome-biased, just … continue to work on the process, which is inning by inning—score first, win the inning. Those are the kind of thoughts that get you beyond this moment.”

I think you can interpret this quote in two ways, each of which applies to infection prevention.

First, he may have meant to say “avoid being outcome-focused.” In other words, stop wasting energy worrying about your outcomes, instead put your energy into the processes that you know will, eventually, move the outcome in a favorable direction. This is becoming increasingly difficult in infection prevention as Centers for Medicare and Medicaid Services pay-for-performance programs put more and more pressure on rates. The temptation is to put time and energy into activities that might impact the outcome quickly but without doing anything to improve the safety of patients (gaming the definitions, empiric treatment approaches, changing lab practice). Counterproductive, and in many cases also bad for patients.

Alternatively, he could have been literally referring to “outcome bias,” which is an error in evaluating the quality of a decision, or the effectiveness of a practice, when the outcome is already known. This might lead one to deviate from an effective practice because a bad outcome occurred in the past when the practice was in place, or to institute a dubious practice because prior implementation was coincident with a favorable outcome. This ignores the fact that outcomes are often influenced by a myriad of factors, many of which are not understood or not under the decision-maker's control.

The infection prevention take-home from either interpretation? Focus on those practices that have been demonstrated to improve outcomes—keep your eye on the process and the outcomes will follow. Avoid gimmicks that might move the outcome needle but for which no evidence exists that patients will benefit.

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. This post originally appeared at the blog Controversies in Hospital Infection Prevention.
Tuesday, November 15, 2016

The importance of medical judgement--part II

Last week, I offered up an argument on why medical judgement means more than medical knowledge. In other words, being a really, really smart doctor is not the essential qualification for practicing excellent medicine. I ended last week's post with some examples of medical ads that are familiar to all of us.

Here are some ads and slogans that you won't see on highway billboards or in press advertisements.

“Bring your back pain to our orthopedists. They probably won't operate on you since most back pain is not effectively treated surgically. You don't want unnecessary surgery, do you?”

“Wanna lose weight? Consult with our bariatric surgeons who will refer you to one of our certified dieticians so you can endure yet another diet. Who wants a trigger happy surgeon anyway?”

“Come to our oncology center for a second opinion. Don't expect any new treatments, since ‘promising’ experimental treatments are exactly that – experiments. We're not rolling the dice with your life.

The public equates technology and active medical intervention with excellent medical quality. That's why ad copy from doctors and hospitals often uses phrases such as, cutting edge, robotic, laser, state-of-the-art, etc. Most patients would not react as positively to an ad championing conservative doctors who don't order too many tests or write many prescriptions, even if these practitioners are better physicians.

We tend to respect medical professional who do stuff more than we do those who don't do stuff or just slug it out preventing disease. Which doctor will command more respect in the community, a cardiac surgeon who is renowned for his expert craftsmanship on performing bypass surgeries, or a family physician who succeeds in getting patients to quit cigarettes so they never need bypass operations?

Sure, I know how to do a colonoscopy, after having done 30,000 of them. Any technician can be taught how to do this procedure skillfully. But is this enough? Patients deserve sound medical judgment, not just technical prowess. When you see your gastroenterologist in the office, and colonoscopy enters the conversation, judgement needs to be in the room also.
• Is colonoscopy truly necessary?
• Is there a better or safer test that should be done instead?
• Are the risks of colonoscopy too high considering my personal medical circumstances?
• Has my doctor explained how the colonoscopy results will affect my care?

This last item is absolutely critical. If your doctor orders a test, make sure that you are persuaded that the test result will shape or change your medical advice. For example, if your doctor is going to recommend exercise and medications for your new onset of back pain as initial treatment, then an MRI of the back doesn't make sense.

I hope that I have given you enough knowledge to make good judgments.

Medical knowledge has the sizzle. But, medical judgement is the steak.

This post by Michael Kirsch, MD, FACP, appeared at MD Whistleblower. Dr. Kirsch is a full time practicing physician and writer who 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.
Monday, November 14, 2016

Meat, potatoes, and mortality

Q: When are car crash fatalities more likely: when a population has more cars and drives more, or when a population has fewer cars and drives less?

A: Hold that thought …*

A study just published in Food and Nutrition Research reports that meat intake in general, and saturated fat intake in particular, though associated with elevated blood cholesterol levels, are not associated with cardiac disease. The authors go on to say that it is actually potatoes and cereal grains that are associated with heart disease, and that “dietary recommendations regarding CVDs should be seriously reconsidered.

This conclusion, and almost everything else in the paper, is egregiously misrepresented, memorably misguided, and extravagantly wrong.

Before getting into the particulars that justify that harsh indictment, a few words of preamble. First, I mean no disrespect to the study authors; I'm sure they meant well. They simply didn't do well.

However, they did do an incredible amount of work. It was a rather massive effort to read through this paper, running to dozens of pages and well over 30 figures. I can only imagine how much effort went into conducting this sadly pointless analysis and writing it up. I am also inclined to imagine that the editors who decided to publish it took pity on the authors in deference to that volume of work, knowing full well the paper was mostly nonsense. Either that, or they simply never managed to read through it all in the first place.

Second, when I am debunking in this manner, it is generally because a paper has been covered copiously, and misleadingly, in mainstream media. That is not the case here. To the best of my knowledge, there has been almost no media coverage of this paper, and that is very much to the credit of the editors and producers who knew to give this study, whatever its titillation value, the thumbs down.

Unfortunately, that lack of conventional media attention no longer suffices to contain the echoes of such a provocation; they reverberate through social media, and cyberspace. I first found out about this paper, in a relatively obscure journal I don't read, when celebratory noise about it in the so-called “low-carb, high-fat” community (LCHF) was retweeted enough hundreds of times to make it into my social media feed. When I discovered this study was getting lots of love from the “just put butter in your coffee and all will be well” crowd, I decided to take a closer look.

One final thing before addressing the particulars of this new study: I fully support the value of well-conducted observational epidemiology, interpreted in the context of all relevant evidence. This is in no way an indictment of observational research. It is, as you'll see, an indictment of poorly conducted and poorly interpreted research (observational or otherwise); and, in particular, of double standards and hypocrisy.

The study in question examined the mean intake of 62 food items in 42 European countries, and compared the variation in those foods with variation in cardiac risk factors, and cardiovascular disease, or so the authors claim in their abstract. It's not quite true. They did not measure dietary intake at all; they had information about food availability per capita, by country, and simply assumed that available food reliably indicated food consumed.

That's already a big problem, but it's not THE big problem. The big problem is that this study was ecological, meaning it looked only at information in the population, not individuals. Ecological studies are a notoriously weak kind of observational research, famously prone to the “ecological fallacy,” in which both A and B occur in the same population, but are true, true, and unrelated. So, for instance, countries with good Internet access don't have polio. The ecological fallacy invites the conclusion that Internet use, rather than the immunization provided by developed countries, prevents polio.

In this study, we have no information about individuals at all. Rather, there are estimates of the mean intake of certain foods at the population level. We have population level estimates of prevalence for cardiac risk factors, and for behaviors like smoking. This study did not, and cannot, examine any direct links between behaviors and outcomes in the same people. There is a good reason, in other words, why this mammoth study was published in a very low impact, obscure journal and not The Lancet.

The findings are nothing less than bizarre. Meat intake and saturated fat intake were associated with cholesterol, but not heart disease. Tobacco actually seemed to protect women against heart disease.

Rather than pick at the findings, let's deal with the methods. How can a study like this produce massively misleading results?

Consider the possibility that more affluent countries eat more meat in general (this is an established fact), and have higher cholesterol levels (also an established fact), and also have better, modern health care in general (yet another established fact). Well, then, you might see the following: high intake of meat, high levels of cholesterol, and a relatively low rate of heart attacks. Is this because high blood cholesterol is suddenly irrelevant? No, it's because modern countries with modern medical care identify and treat cardiac risk factors, and prevent heart attacks pretty adeptly.

The 42 countries included in this analysis encompassed both Western and Eastern Europe. The issues of livelihood, stress, mental health, housing, family size, and poverty- among others- were not addressed. Which countries in Europe have the lowest intake of meat, relative to potatoes and cereal grains? Poor countries in Eastern Europe, for the most part, where poverty, duress, stress, and disadvantage are hyperendemic. Past the many pages of mind-numbing number crunching, this paper may simply show that poor, unhappy populations have more heart disease.

Not convinced? OK, then here are some actual data about European countries to help get you there.

The highest rates of death from cardiovascular disease in Europe are seen in Bulgaria, Romania, and Serbia. Meat intake in Romania, Bulgaria, and Serbia is, indeed, lower than in, say Germany, France, and Italy. It is, in general, higher than in Japan. It's lower than in Switzerland and Sweden.

But, life expectancy at birth is higher in ALL OF THOSE COUNTRIES than in Bulgaria, Romania, and Serbia. In fact, Japan- with particularly low meat intake- has one of the highest life expectancies of the world (in the top 3). In contrast, Bulgaria, Romania, and Serbia all have more than 100 countries ahead of them on a total listof 224.

While exonerating meat, the authors of the new study indict potatoes and cereal grains. Depending on how potatoes are prepared and grains are processed, they can have a relatively high or low glycemic load, and a low or high overall nutritional value. It is certainly plausible that potatoes processed into chips and fries, and grains stripped of their bran do contribute to cardiometabolic diseases. But this study is simply too flawed to count on any of the findings, whether they make sense or not.

Let's have a closer look at potato intake. It is, indeed, high in Eastern Europe, notably Latvia – where mortality is high and life expectancy low. But potato intake is also impressively high in the UK, which enjoys about 6 years more average life expectancy than Bulgaria, and is almost 90 spots higher up on the global life expectancy list.

So, what does all of this really mean? It means meat and potatoes cannot explain anything about mortality in an analysis that overlooks the elephant in the room: the massive influence of social factors that differ by country.

Just in case you are not yet thoroughly convinced of the flagrant liabilities of ecological research run amok, let's change the subject and talk about cars.

Bulgaria, Romania, and Latvia are near the bottom of Europe's list in terms of car ownership per capita. Maybe the take away message, then, is: if you don't want to have a heart attack, buy a car! But wait, it gets a whole lot weirder.

Romania is near the bottom of the list for number of cars per 1000 citizens, and near the top of the list for total number of annual car crash fatalities. This leads ineluctably to the conclusion that the best way to avoid dying in a car crash is to own and drive more cars. Or, the more cars your country has, the fewer car crash deaths you'll have. Or, the fewer cars your country has, the more likely someone living there is to die in a car crash.

Perhaps you are thinking that Romania is just a fluke, but it's not. Latvia also has one of Europe's lowest rates of car ownership per capita, and has had the highest number of car crash deaths over recent years.

I can do this all day, but let's not. The case is clear. Unless you are willing to accept that car ownership prevents both heart attacks and car crashes, you have to accept that ecological research is glaringly prone to the “garbage in, garbage out” phenomenon. I am genuinely sorry for the authors in question that so much work went into the manufacture of epidemiologic garbage, but alas, it is what it is.

Whatever the value of observational studies in general- and again, it can be quite high in my opinion- ecological studies such as this are generally useful only for generating hypotheses, not testing them. But that's what you do before you have answers from far more robust methodologies. Here, it is a flagrantly backward step, since intervention studies, even at the level of a whole population, have tested and affirmed the hypothesis that shifting from meat-centric to plant-centric diets, reducing saturated fat intake, and lowering mean cholesterol levels causes heart disease rates to plummet, and life expectancy to soar.

As for the endless round of tweets that brought this rubbish heap to my attention, it reeks of hypocrisy. Certain members of the “eat more meat, butter, cheese” tribe have pretty much built their careers and reputations by maligning observational epidemiology. Their favorite target, the work of Ancel Keys, is of embarrassingly (for them) higher quality and vastly greater scope than this study they are now busy celebrating.

One would think, and hope, that if seats on the LCHF train were filled by something other than hypocrites, then this new study would have been disqualified as a source of their raptures under the “what's good for the goose is good for the gander” clause. Observational studies are either of potential value, or not. I certainly think they are of value, or at least can be when done well and interpreted appropriately- but celebrated members of the LCHF club have built their rarefied reputations claiming they are not.

Alas, people with strong biases, who favor their ideology over epidemiology, don't play fair. Observational studies are bunk if they reach a conclusion they don't like; but are cheered, unchallenged, and retweeted a gazillion times if they reach a conclusion they do like.

Note that the remedy to this tendency of amplifying one version of junk science is certainly NOT to amplify another. Those of us who know that diets of wholesome foods, mostly plants, are best may also be tempted to amplify bad science that happens to support that position. We should not, or we encourage that bad practice. Fortunately, we have no need to do so: the remedy is to follow the overall weight of evidence, based on quantity, quality, and diversity.

The case for any finding in biomedical science is best made when mechanistic studies in vitro and in animal models; observational epidemiology in all of its guises; diverse intervention studies; randomized trials; and outcomes at the level of whole populations over generations align- as they do for a diet of mostly plants. This very conclusion has been reached by diverse authorities around the globe again, and again, and again, and again, for very good reason.

Just how inappropriate is it to use an ecological study of this kind to claim that “dietary recommendations regarding CVDs should be seriously reconsidered”? It's nearly as preposterous as using passages from the bible and an abacus to argue that “heliocentrism and the shape of the earth should be seriously reconsidered,” despite the modern evidence involving advanced math and physics, orbiting satellites, and actual images from space. It is backwards to the point of bizarre. Doing the best you can with an abacus when an abacus is the best you've got makes good sense. Going back to it in the age of Hubble bespeaks ulterior motives, and a thinly veiled effort to cook the books.

For the many LCHF enthusiasts with no actual knowledge of epidemiology, ignorance is the likely excuse for retweeting nonsense (i.e., some people, presumably, actually don't know that the earth isn't flat, and revolves around the sun). But this ludicrously extreme example of it should at least serve as a precautionary tale for next time: you can't assume a study is of value just because you like the conclusion.

For the experts, and perhaps pseudo-experts, also busily retweeting this rubbish: well, shame on you. Either you didn't recognize it as rubbish, in which case your ability to interpret the literature is very much in doubt. Or, you knew it was rubbish, but pretended it wasn't because you liked the conclusion- in which case, your shame is greater, because that hints at charlatanism.

When, in other words, science was mangled and understanding killed in a hit-and-run on the “information” superhighway, the traffic cameras show clearly that you were driving the bus.

-fin

*A: As the statistics cited above show, when a population has fewer cars and drives less! This, of course, is not because there is a paradoxical protection against car crashes that comes from driving a car. Rather, it's because societies that can afford more cars per capita can also afford, and have, better cars, better roads, better law enforcement, better emergency response systems, better hospitals, generally lower rates of alcoholism, and so on- all leading to lower car crash fatality rates. The relationship between meat intake and mortality is subject to much the same contextual influences.

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.
Friday, November 11, 2016

The day MBAs no longer need to answer to physicians

A few months ago I wrote an article about a 28-year-old MBA who attempted to tell an experienced physician where to round first. The article was widely circulated and went a bit viral. Clearly, the scenario resonated with thousands of physicians across the country.

It was interesting that afterwards I received many messages from various people who had read it. The majority of these were messages of support and solidarity from fellow physicians, who had seen similar situations unfold themselves. But intriguingly I also received several emails from people on the corporate side of health care, who almost expressed apology for the scenario I described, and attempted to make me understand their perspective as administrators and MBAs. Seeing these types of messages from the very people physicians are so wary of, made me somewhat proud. I was proud because of the fact that medicine is still such a respected and relatively autonomous (and I use the word relatively) profession, that the business folk feel they need to reach out so quickly. Even if it's an attempt to defend the indefensible.

The last couple of decades have seen the rapid “corporatization” of health care. Instead of medicine being about the small private practice of Dr Smith around the corner, it is now all about mega multi-specialty groups, huge for-profit organizations, and multi-million dollar mergers. Don't get me wrong, I'm quite capitalist at heart, and definitely middle of the road when it comes to politics. Many of my close family and friends have gone the corporate route. But I just think healthcare is very different from every other industry—and not as amenable to pure business thinking. Healthcare has, and always will be, about humanity, compassion and real life emotions at its core. And thereby is the essential clash between those of us including physicians, and the business world that will always be driven primarily by profits. Of course, we need administrators in every industry, but I'm of the belief that only healthcare professionals—whether they are doctors or nurses—should be administrating in healthcare (with or without a business qualification). Not a non-clinical MBA.

It's very obvious, especially with our current political discourse and environment, that much of the middle class feels crushed and increasingly squeezed. There is so much raw anger out there against globalization, huge corporations, and massive administrator and CEO compensation. Large swathes of the country believe that it's these very factors that have brought Middle America to its knees over the last few decades.

So going back to those MBAs who reached out to me following my article. Most times and in most industries, criticism against their roles would be completely ignored and glossed over by those in the C-suite. After all, why would they care when they hold all of the power? Yet despite all the changes we've seen in healthcare, MBAs still appear to feel that they need to answer and defend themselves against what doctors are saying. They know that they have a case to answer—for now anyway. But let's not be under any illusions as to the trajectory of this path. Because when the day comes that they no longer feel like that, physicians would have joined the ranks of the other “coal-face workers” in the rest of America. Working and working, giving their corporate masters all the profits with little say as to how things are done.

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. This post originally appeared at his blog.
Thursday, November 10, 2016

The statin controversy

A friend asked me recently about statins. He takes a statin for primary prevention, but is concerned that he has muscle pain and weakness as a side effect. So he posed the question: “How important is the statin?”

The Washington Post had this recent article, “Who should take statins? A vicious debate over cholesterol drugs”.

But while nearly all experts agree that statins are beneficial for people at a substantial risk for heart disease, some medical researchers argue that statins do little or no good—and possible harm—for people at lower risk of heart disease. The conflict has burst into public view in the United Kingdom—and is likely heading here, too.

A bruising battle has played out for several years between Britain's two leading medical research journals, the Lancet and the British Medical Journal (BMJ), which have accused each other of endangering public health. The debate has gotten so heated that it has made tabloid headlines (“STATIN WAR,” blasted the Daily Mail). It began when BMJ first questioned statins' usefulness in 2014, publishing two articles that argued that the drug was being overprescribed to people with low risk of heart disease. It also claimed that the side effects from the drugs were worse than previously thought.

Statins have two major effects. First, they lower cholesterol levels. Lowering cholesterol likely decreases plaque size, therefore patients will less likely have atherosclerotic complications. Second, they stabilize plaques, making plaque rupture and therefore clot formation less likely.

In patients with known atherosclerotic disease (previous myocardial infarction, atherosclerotic stroke or symptomatic peripheral vascular disease), statins clearly decrease the probability of further events. Some patients with significant genetic predispositions, and most patients with type II diabetes mellitus also fit into this secondary prevention category. For these patients we really have no debate.

For the remaining patients, the debate becomes much more complex. Primary prevention (prevention in patients who do not fit into the previous paragraph) has a minimal impact. Statins do decrease the risk of coronary artery disease, but the risk reduction is rather small. Statins (like almost all drugs) are not benign. They have side effects. The question therefore becomes the classic one: How does one balance the potential of the benefits and risks? (or more simply put, is the juice worth the squeeze).

I explained this as best I could to my friend. I would not encourage statins for true primary prevention. Strong genetic predisposition and type 2 diabetes fit into a separate category. Statins help many patients and the benefits are strong as a secondary prevention medication. But the side effects are real and make the primary prevention question much more difficult. Currently I do not favor primary prevention.

db is the nickname for Robert M. Centor, MD, FACP. db stands both for Dr. Bob and da boss. He is an academic general internist at the University of Alabama School of Medicine, and is the Regional Associate Dean for the Huntsville Regional Medical Campus of UASOM. He still makes inpatient rounds over 100 days each year. This post originally appeared at his blog, db's Medical Rants.