I Refuse to Tell You What to Eat

A recent tweet from JAMA, the journal of the American Medical Association, urged me andother doctors to “include nutrition counseling into the flow of [our] daily practice.”

Along with the tweet came a link to an article that outlines “relatively small” dietary changes, based on the latest Dietary Guidelines for Americans, that can “significantly improve health.”

My response to the tweet was swift and knee-jerk.  I will not do it.  I simply will not.  I refuse to follow dietary guidelines or recommend them to my patients.

“What are you saying?!” “Are you the kind of self-interested doctor who only treats disease and cares nothing about prevention?!”  I imagine my outraged critics erupting in a chorus of disapproval.

Is my reaction unwarranted?  After all, the recommendations themselves seem sensible enough:  Eat fast food less often; drink fewer sugary sodas; consume more fruits and vegetables.  What’s not to like?

Unhealthy guidelines

I don’t know.  Perhaps it’s dietary guideline fatigue.

For more than 40 years, the nutrition experts have instructed us with guideline after guideline, food pyramid after food pyramid.  But what have they got to show for?  The obesity epidemic followed the introduction of dietary recommendations, and some doctors even blame those recommendations for causing the epidemic!

The blame may be far-fetched, but there’s something un-natural and perhaps even unhealthy about dietary guidelines.

Take the recommendations in the JAMA article.  Even though the authors claim that only “small steps” need be taken, the whole message occupies 2 pages of fine print.  What’s more, the doctor is supposed to start the process by asking patients to fill out a questionnaire.  Who has the appetite for yet another questionnaire?!

The recommendations themselves come in the usual manner of adding or subtracting “servings:” increase vegetables by one serving per day; decrease sodas by one serving per day; replace one serving of crackers with one handful of nuts, etc…

But why think about meals in terms of discrete servings of food and beverage stuff?  A meal is one thing, one experience.  To break it up into physico-chemical or caloric components makes sense for laboratory animals, and perhaps for patients with serious metabolic disorders.  But does it really work for most human beings in their natural environment?

The article correctly points out that “conflicting and confusing nutrition messages from popular books, blogs, and other media further complicate patient decision making.”  Indeed, some gurus advocate a strict reduction in carbohydrates in favor of proteins and fats, while others promote a strict vegan diet and complete abstinence of animal protein.  Both sides offer what appears to be compelling evidence for the effectiveness of their favored diet.  Yet they can’t be both right.  Something’s seriously amiss here.

However, the academic community that informs nutrition policy has lost much of its authority and finds itself unable to be the voice of reason.  For example, its prior recommendations against saturated fats were overly negative and not based on sound science, and the discredit has limited the ability of mainstream academics to influence eating behaviors.

Missing ingredients

The main problem with nutrition guidelines and diet fads is that they all conceive of people as passive organisms who “are what they eat.”  They hardly take into account the complexity of human behavior and of the individual who is the target of the dietary intervention.

Unlike a beast rummaging for food in the forest by instinct, people choose their meals.  They may also choose to eat or not to eat.  The physical, chemical, financial, psychological, cultural, and spiritual elements that enter into those choices are not so simple.

People’s diets are imbalanced because people’s lives are frequently out of balance.  Not addressing the bigger picture may miss the main cause of the problem and makes following nutritional guidelines and fads another chore, another imposition.  If nutritional counseling is to be effective—and there’s no question that counseling can help—it must go beyond the stomach and address the whole person.

Less is more

For what it’s worth, I frequently do give dietary advice.  My advice invariably involves a four-letter word:  LESS.

From what I see, we are surrounded by food, drinks, and other edible items made available to us for easy consumption.  We find food and drink to be a convenient and, in the short term, effective way to satisfy some inner desires, but those desires are rarely simply nutritional in nature.  Therefore, telling patients to eat less is part of my routine, but not necessarily where my advice ends or where the solution lies.

So, no.  I will not add my voice to the cacophony of generic nutritional advice.  I will not sheepishly follow the recommendations of yet another academic article on the subject.  I refuse to tell you what to eat!

Michel Accad is a cardiologist based in San Francisco

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11 replies »

  1. Keep eating exactly what the oldest people are eating.
    No…Keep eating what the smartest–least demented–people are eating.
    No…Keep eating what the happiest people are eating.

  2. Full disclosure: I was one of the people who read the headline and self-righteously tweeted at Michel before reading his full post. Running this post is my penance.

    When you’re right, you’re right.

    The problem is that there are people out there – and I don’t think you’re one of them, Michel – who for political reasons, weaponize this argument and use it to stoke the flames of partisan hatred

    It’s one thing to say that nutritionists are bad (translation = suck) at communicating a complex subject, it’s another to sue to block posting calorie counts and burn research you don’t like ..

  3. All literature on diet should be assumed to be bad. If it looks like it might make sense, remember the rule. You are probably just missing something.

  4. ‘You should know that “another academic article” is not the answer, common sense is’

    Dispensing common sense ain’t in my job description.

  5. “Family Mealtime” might be more useful topic to think about dietary advice, if any. Michael, you’re talking to the choir.

  6. The problem is that the standard nutrition advice over the past 40 years feigned rigor and certainty and appears likely to have been completely wrong! The Big Fat Surprise by Nina Teicholz (not a Ph.D. nutritionist) blew it all up in her award winning book (won citations by The Economist and the WSJ/the key finding saturated fats aren’t bad and carbs/vegetable oils are bad) It seems wise for a doctor to be cautious about giving detailed advice other than eat in moderation and exercise.

  7. “So, no. I will not add my voice to the cacophony of generic nutritional advice. I will not sheepishly follow the recommendations of yet another academic article on the subject. I refuse to tell you what to eat!”

    You’re part of the problem not the solution. You should know that “another academic article” is not the answer, common sense is – like your mother used to tell you.

    America has reached another obesity milestone, How does ignoring this contribute?

  8. You make a lot of sense, but all I can think of is Thanksgiving. My wife has a problem. We have one on the whole plant food diet with a preference of olives instead of olive oil, a couple of vegetarians, one on a protein diet who perceives apples to be dangerous, one with shellfish allergies and another with peanut allergies. Then we have a few with strong personal preferences and some with diets that have to meet medical criteria.

    All we need is additional input from every person’s physician to even complicate things further.

  9. Very nice article Dr. Accad. Although I did read this while eating girl scouts cookies I bought from my little cousin.

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