Call me crazy. Or Ishmael, for that matter. I think “Dietary Guidelines for Americans” should be something vaguely like, well, oh I don’t know, maybe: guidelines for Americans. About how to eat well.
What does “dietary guidelines” make you think? Doesn’t it sound an awful lot like: guidelines for people’s diets? Doesn’t that, in turn, sound quite a bit like: here’s what we (whoever ‘we’ is) think you should eat, presumably for health? And doesn’t “guidelines” suggest “guidance” from “guides” who ought to know where they are going, suggesting that the “we” involved should qualify as such?
Yes, that’s exactly what it sounds like. And if we go a step further, and call something “Dietary Guidelines for Americans”- and we don’t say “some” Americans, or Americans in food assistance programs, or Americans eating in school cafeterias- if we just simply say “for Americans”- then doesn’t it sound an awful lot like: this is what we (whoever ‘we’ is) think ALL Americans should be eating?
You bet it does.
And so my friends, we come to it: a steaming mound of misleading BS. Watch where you step.
Somewhat ironically, I returned from Manhattan that same day to a waiting email from a colleague, forwarding me a rather excoriating critique of integrative medicine on The Health Care Blog, and asking me for my opinion.
The juxtaposition, it turns out, was something other than happenstance. The Cleveland Clinic has recently introduced the use of herbal medicines as an option for its patients, generating considerable media attention.
Some of it, as in the case of the Katie Couric Show, is of the kinder, gentler variety. Some, like The Health Care Blog — is rather less so. Which is the right response?
One might argue, from the perspective of evidence based medicine, that harsh treatment is warranted for everything operating under the banner of “alternative” medicine, or any of the nomenclature alternative to “alternative” — such as complementary, holistic, traditional, or integrative.
One might argue, conversely, for a warm embrace from the perspective of patient-centered care, in which patient preference is a primary driver.
I tend to argue both ways, and land in the middle. I’ll elaborate.
I know it seems like the obvious choice, but I would not run a randomized clinical trial.
I have recently lamented the pernicious influence, within my domain of public health practice, of hyperbolic headlines proclaiming “this,” followed unfailingly by equally and oppositely hyperbolic headlines reactively proclaiming “that.”
But we are obligated to acknowledge that there are, generally, research studies underlying the headlines, however extreme the pop culture distortions of the actual findings. So to some extent, the problem originates before ever the headlines are a gleam in an editor’s eye, with our expectant anticipation of the next clinical trial, and the next, and the next.
By all means, bring on the clinical trials! They serve us well. They advance the human condition. I run a clinical research lab — my career is devoted to just such trials.
But still, I wouldn’t conduct one if my foot caught fire.
Of course, there is a very good case for running such a study, as many vitally important questions about the right response to a foot on fire are at present unanswered. What, for instance, would be the ideal volume of water? Should it be hard water, or soft? Fluoridated, or not? A controlled trial is very tempting to address each of these.
The vessel is even more vexing. What would be the best kind of bucket? What size should it be? What color should the bucket be, what composition, and what’s the ideal kind of handle? I think the variations here are the basis for an entire research career.
Perhaps the notion of running randomized, double-blind, controlled intervention trials to determine the right response to a foot on fire seems silly to you. But if so, you must be suggesting that science does not preclude sense.
With the exception of rare and particularly bleak days, I don’t tend to think of myself as a moron — nor, as far as I can tell, do those who know me well and love me. I will hazard a guess that neither you nor those who love you think of you as a moron, either.
So let’s be bold, proffer one another the mutual benefit of any disparate doubts, and declare: We are not morons!
I propose, then, that this be the year we stop ingesting as if we were. Still with me? Let’s find out.
On the matter of morons, I think they are very much the exception rather than the rule. I have met a lot of people over my years. I’ve taken care of many patients over decades and come to know their intimate thoughts as the privilege of doctoring uniquely allows and requires. So I know firsthand that most of us are endowed with our fair portion of both sense and sensitivity. Formal education, the color of a collar, degrees and credentials don’t distinguish us nearly as much as some might like to think. In most ways that matter, most people have that practical brand of folksy wisdom and intelligence that serve most handily on any given day.
And yet, as a matter of routine we are fed a steady diet of both food and food for thought as if we were abject morons. That’s how it’s served to us — but of course, only we get to decide whether or not to swallow such insalubrious slop. It’s a New Year, and time for new chances. Here’s our chance to stop the slop.
Tis the season to, well, buy stuff. Increasingly, the stuff we buy is electronic. In fact, not only that, but increasingly the stuff we buy with is electronic, too. We are using gizmos to shop for gadgets, or possibly gadgets to shop for gizmos.
In any event, we are ever more frequently in the company of the energy fields our electronic devices, and in particular our smart phones, generate. This deserves more attention than most of us accord it.
Don’t get me wrong — I am not suggesting we return to the pre-cell phone days when we lived in dark caves. We are fully ensconced in the electronics era, and there appears to be no going back. I am as fully dependent on electronic devices as anyone, and maybe more than most, living much of my life these days online. Like so many, I am both beneficiary and victim of the attendant efficiencies. On the one hand, I can’t recall how we ever got anything done in the days before instantaneous communication and push-of-a-button document transmission.
On the other, I do long for the freedom of the time before an unending stream of emails became my manacles. I did sleep better in the days before bedtime meant checking one last time to see who in the world needed what, and/or finding out that someone in cyberspace thinks I’m a moron. Oh, well.
But the greatest and most insidious risk of cell phone use pertains to the electromagnetic fields of non-ionizing radiation they produce. What makes this risk insidious is our potential to dismiss it altogether, in part because it is convenient to do so, and in part because it’s hard to take seriously a potential menace that is totally invisible. I suspect we are all at least somewhat prone to a “what I can’t see, feel, taste, smell or hear can’t hurt me” mentality.
But of course, that’s clearly wrong, as we all have cause to know. Anyone who has ever had an X-ray has experienced first hand the power of an invisible force, in this case ionizing radiation, to penetrate deeply into our bodies. Anyone who has had a MRI has experienced the capacity of non-ionizing electromagnetic fields to do the same. What we can’t see or feel can, in fact, reach to our innermost nooks and crannies, both to produce vivid images of our anatomy — and exert other effects.
Since the new paper is just a commentary — one doc’s opinion — and not a new study, and since this opinion has been asserted many times already, I’m not sure I really get the reaction. But hey, I just work here. Let’s deal with it.
Is it, in fact, time to absolve saturated fat? No, it’s not. But then again, it was never time to demonize it in the first place. I will lay out my case that we are ill-served to think of saturated fat as either scapegoat or martyred saint.
1) Ancel Keys was never really wrong.
The case against saturated fat, its implication in the development of atherosclerosis, inflammation, and chronic diseases, notably heart disease, involves a vast expanse of research over many years by thousands of researchers around the world. But dealing with all of that in this column would be a terrible bother, so let’s just blame it all on Ancel Keys. Keys was certainly among the first to emphasize the association between saturated fat intake and heart disease.
Keys looked at rates of disease around the world and correctly noted that heart disease was more common in societies that ate more meat and dairy. His mistake may have been to look past that dietary pattern for the “active ingredient” in it, which led to the convictions of dietary cholesterol, saturated fat, and to a lesser extent overall dietary fat.
There’s much that could be said about this. Whole columns could be written about dietary cholesterol, dietary fat, and saturated fat and ways we went wrong. In fact, I — along with innumerable others — have written just such columns. Simply click the inserted links.
There is a certain irony in the nearly immediate juxtaposition of the rare introduction of a new FDA-approved drug for weight loss (Belviq) to the marketplace and the recognition of obesity as a “disease” by the AMA. A line from the movie Jerry Maguire comes to mind: “You complete me!” Drugs need diseases; diseases need drugs.
And that’s part of what has me completely worried. The notion that obesity is a disease will inevitably invite a reliance on pharmacotherapy and surgery to fix what is best addressed through improvements in the use of our feet and forks, and in our Farm Bill.
Why is the medicalization of obesity concerning? Cost is an obvious factor. If obesity is a disease, some 80 percent of adults in the U.S. have it or its precursor: overweight. Legions of kids have it as well. Do we all need pharmacotherapy, and if so, for life? We might be inclined to say no, but wouldn’t we then be leaving a “disease” untreated? Is that even ethical?
On the other hand, if we are thinking lifelong pharmacotherapy for all, is that really the solution to such problems as food deserts? We know that poverty and limited access to high quality food are associated with increased obesity rates. So do we skip right past concerns about access to produce and just make sure everyone has access to a pharmacy? Instead of helping people on SNAP find and afford broccoli, do we just pay for their Belviq and bariatric surgery?
If so, this, presumably, requires that everyone also have access to someone qualified to write a prescription or wield a scalpel in the first place, and insurance coverage to pay for it. We can’t expect people who can’t afford broccoli to buy their own Belviq, clearly.
There is, of course, some potential upside to the recognition of obesity as a disease. Diseases get respect in our society, unlike syndromes, which are all too readily blamed on the quirks of any given patient and other conditions attributed to aspects of character. Historically, obesity has been in that latter character, inviting castigation of willpower and personal responsibility and invocation of gluttony, sloth, or the combination. Respecting obesity as a disease is much better.
And, as a disease, obesity will warrant more consistent attention by health professionals, including doctors. This, in turn, may motivate more doctors to learn how to address this challenge constructively and compassionately.
But overall, I see more liabilities than benefits in designating obesity a disease. For starters, there is the simple fact that obesity, per se, isn’t a disease. Some people are healthy at almost any given BMI. BMI correlates with disease, certainly, but far from perfectly.
A recent meta-analysis published in the American Journal of Clinical Nutrition suggests that coenzyme Q10 is of benefit in congestive heart failure. For those who like the idea that food and nutrients can be excellent medicine, this paper is interesting at the very least. But there is a case to be made that it is far more than that. There is a case to be made that it is, in a word, miraculous.
For resurrection, after all, is a miracle. And according to a paper published in the Annals of Internal Medicine in April of 2000, coenzyme Q10 for heart failure was a dead concept. The authors reported 13 years ago that “coenzyme Q10 has been studied in randomized, blinded, and controlled studies and … these studies have found no detectable benefit” and that “coenzyme Q10 should not be recommended for treatment of heart failure.”
The final nail had been driven into the CoQ10-for-heart-failure hypothesis 13 years ago — and yet now, it’s back. If that’s not a miracle — then what is going on?
First, a bit of relevant orientation. The condition in question here, congestive heart failure, occurs in particular in the aftermath of one or more heart attacks (myocardial infarctions) which cause portions of the heart muscle to die for want of oxygen. Those areas stop pumping, of course, and the whole heart does its job less well.
The pumping efficiency of the heart is routinely measured using ultrasound as the “left ventricular ejection fraction” (LVEF), which, as the name suggests, is the proportion of blood the left ventricle is able to pump out of itself when it contracts. Roughly 55 to 70 percent is considered normal. High values can occur when the heart is stiff and muscle-bound, and tend to mean the heart empties well, but fills poorly. Congestive heart failure is associated with low values.
According to a widely circulated op-ed in the New York Times by Paul Campos, a law professor at the University of Colorado with whom I don’t believe I have ever managed to agree on anything, our “fear” of fat — namely, epidemic obesity — is, in a word, absurd. Prof. Campos is the author of a book entitled The Obesity Myth, and has established something of a cottage industry for some time contending that the fuss we make about epidemic obesity is all some government-manufactured conspiracy theory, or a confabulation serving the interests of the weight-loss-pharmaceutical complex.
In this instance, the op-ed was reacting to a meta-analysis, published last week in JAMA, and itself the subject of extensive media attention, indicating that mortality rates go up as obesity gets severe, but that mild obesity and overweight are actually associated with lower overall mortality than so-called “healthy” weight. This study — debunked for important deficiencies by many leading scientists around the country, and with important limitations acknowledged by its own authors — was treated by Prof. Campos as if a third tablet on the summit of Mount Sinai.
We’ll get into the details of the meta-anlysis shortly, but first I’d like to say: Treating science like a ping-pong ball is what’s absurd, and what scares the hell out of me. Treating any one study as if its findings annihilate the gradual, hard-earned accumulation of evidence over decades is absurd, and scares the hell out of me. Iconoclasts who get lots of attention just by refuting the conventional wisdom, and who are occasionally and importantly right, but far more often wrong — are often rather absurd, and scare the hell out of me.
There are two reasons not to talk about gun control in the immediate aftermath of the Newtown atrocity, and opposition by the NRA and its adherents is neither of them.
The first is that addressing gun control right after innocents are shot might in some way seem exploitative. The second is that no imaginable degree of stringent gun control could fully exclude the possibility of an unhinged adult shooting a kindergartener.
But both of these objections are as porous as the sands of our shores battered by Hurricane Sandy. And a consideration of those shores readily reveals why.
With regard to exploitation, there was no thought of it as post-Sandy ruminations turned to how we might best prevent or at least mitigate the next such catastrophe. It was not exploitative to look around the world at strategies used to interrupt storm surges, divert floodwaters, or defend infrastructure. Those reflections continue.
Similarly, it’s not exploitative when my clinical colleagues and I speak to our patients in the aftermath of a heart attack or stroke about what it will take to prevent another one. In fact, these exchanges have a well-established designation in preventive medicine: the teachable moment.
It is opportunistic, but in a positive way: There is an opportunity to do what needs to be done. Admittedly, it’s better to talk about preventing heart disease, or the drowning of Staten Island, or of New Orleans, or the shooting of children, before ever these things happen. But the trouble tends to be: Nobody is listening then.
We are constitutionally better at crisis response than crisis prevention.