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President's Desk, October 2015
David L. Katz, MD, MPH

Standing With Friends

Before I launch into the focus of this month’s column, bear with me for a brief promotional message about the American College of Lifestyle Medicine. Be sure to read the Spotlight article below- exciting developments, indeed. I look forward to seeing you in Nashville come November 1 as we kick off Lifestyle Medicine 2015- if you haven’t registered yet, please do!

I am proud that the American College of Lifestyle Medicine expressed public support for the work of the 2015 Dietary Guidelines Advisory Committee when their 572-page report was first issued.  I am proud that we have reaffirmed that support now that the work is encountering predictable abuses from the usual suspects.  The scientists comprising the DGAC are friends, indeed, to lifestyle medicine.  They are now friends in need as well.

Over recent days, the work of the DGAC was excoriated in the British Medical Journal, and then subjected to scrutiny before Congress which apparently resembled something like a circus.  We have, unsurprisingly, learned that behind all of this mischief are those constant perils to public health: profiteering, self-interest, and politics as usual.

All of this might be understandable if the DGAC had suggested anything truly radical.  Invoking the weight of evidence, however, they did the very opposite.  This language is directly from the report’s executive summary:

The overall body of evidence examined by the 2015 DGAC identifies that a healthy dietary pattern is higher in vegetables, fruits, whole grains, low- or non-fat dairy, seafood, legumes, and nuts; moderate in alcohol (among adults); lower in red and processed meats; and low in sugar-sweetened foods and drinks and refined grains. Additional strong evidence shows that it is not necessary to eliminate food groups or conform to a single dietary pattern to achieve healthy dietary patterns. Rather, individuals can combine foods in a variety of flexible ways to achieve healthy dietary patterns, and these strategies should be tailored to meet the individual’s health needs, dietary preferences and cultural traditions. Current research also strongly demonstrates that regular physical activity promotes health and reduces chronic disease risk.

Many factions, including our own at ACLM where passions run strongly in favor of plant-based eating, might wish for a bit more of this, or a bit less of that.  But admittedly, these conclusions are temperate and sound, evidence-based and eminently reasonable.  How can they even be made to seem controversial?

People tend to speak quite indiscriminately about “consensus,” generally telling us about its absence.  Some of these people are scientists, from whom we expect precision and fidelity to the operational implications of definitions.  When they tell us there is “lack of consensus,” we are invited to believe they have data.  But they don’t.

Of course there is lack of universal consensus on any topic; all that requires is for someone, no matter how misguided, to disagree.  I don’t think most of us care about that.  Most of us take consensus to mean the prevailing interpretation of people with the requisite aptitudes and expertise to do the interpreting in the first place. 

We also, I suspect, have some quantitative threshold in mind, whether or not we have situated it with numerical clarity.  If, for instance, 99% of all experts agree about dietary guidance, or climate change for that matter, and 1% disagrees- would that be “lack of consensus”?  Most of us, I suspect, would say no; that sounds more like consensus to us.  That’s not proof that the consensus is correct- that’s a different matter entirely; it’s just proof that it exists.  If 99% doesn’t do it for you, how about 99.9%?  At some point, a majority becomes enough to qualify as a consensus.

But in this day of the blogosphere, the 1%, or the 0.1%, have no trouble making noise.  If they fortify one another’s noise in an echo chamber, they may seem to be the tip of a non-existent iceberg.   In other words: if I assert that we lack consensus, and several folks come along to say -“hear, hear!”- we may leave our audience with the impression that there are thousands more just like us who feel the same.  But it’s also possible that we are all there is.

Second, there is a serious problem with the prevailing definition of “research,” a term I see used routinely by bloggers, many untrained in research methods.  The term is used routinely to mean: I searched for sources that affirmed the opinion I owned at the start.  In the case of our litigants, such research would be: I talked to several people who agree the cow is mine!

This is not research; it is canvassing.  The true work of research when testing a hypothesis requires allowance for the result you don’t want.  When reviewing accumulated evidence, it requires comparable attention to sources whether they conform to your hopes, or oppose them.  Along with expertise, alas, such stipulations about research seem these days to be on life support.

Third, and finally, there is what we might call the “lens” problem.  Some perfectly legitimate scientists and accomplished researchers seem prone to overlook the parable of the blind men and the elephant, and the dependency of the lens on the view.  An electron microscope is a very powerful tool, but of little use when assessing hurricane damage to a coastal town.  A huge telescope can help us peer into the distant space and time of the universe, but helps not at all when screening for skin cancer.  So, too, expertise in, say, cell biology might allow for erudition about lipid metabolism, yet cause one to overlook other parts of the elephant in the room- or the dietary pattern in the Blue Zones.

The alleged discord currently roiling the world of nutrition as it pertains to populations in (principally) industrialized countries stunningly reduces to this: one side recommends our diets should be comprised principally of vegetables, fruits, whole grains, beans, lentils, nuts and seeds with lesser amounts of other items and nothing hyper-processed that glows in the dark, for the sake of our own health, and that of the planet; the other side says we should eat more meat, butter, and cheese.

There is, of course, a patina over this fundamental divide, in the form of many nits related to this fatty acid, and that; this variety of sugar, and that.  The picking of such nits is then somehow transmogrified into a fundamental “lack of consensus” about, apparently, anything- and uncertainty about whether it would be healthful to eat more spinach, or sausage.

We are by no means clueless about the basic care and feeding of Homo sapiens, and we well know that diet is a centerpiece of lifestyle as medicine.  On that basis, we stand with the DGAC, currently, friends in need.  Thus far this alliance is not enough to overcome the forces of profit-driven discord.  But it’s a start, and the True Health Coalition is a global army coming together at our backs to help advance the mission.  We can lose a battle, and win the war.

For now, I am proud that we have chosen to stand with our colleagues in public health nutrition.  I would say that we have taken a seat with them at the same table, but we all know that, like “more meat, butter, and cheese,” more sitting...is a bad idea!

Preventive Medicine, Lifestyle Medicine, and Functional Medicine all profess to target the true causes of disease, and there is a valid basis for each such claim.  The specific contentions of each enterprise are the substance of that manuscript now in the works; it’s not my place here to preempt those better arguments, by better sources.

I can, however, illustrate the effort by noting the pedigree of Lifestyle Medicine’s claim.

We might trace the origins of our mantle to Hippocrates, who famously advanced the cause of lifestyle medicine with such admonishment as: “let food be thy medicine.”  There is little left to append there other than: amen.

We might, alternatively, constrain our timeline to the modern era, in which case McGinnis and Foege, rather than Hippocrates, are parents to our cause, flag bearers in our forward progress.  Their seminal publication in JAMA in 1993 made the case for causes not only explicit, but even eponymous: “Actual causes of death in the United States.”

Those “causes” extended to a list of ten factors.  Most noteworthy for our camp is the overwhelming predominance of lifestyle on that list.  The first three entries, accounting for 80% of premature deaths in 1990, and reaffirmed in diverse publications since and current to this day, were tobacco use, dietary pattern, and physical activity.  As this readership likely knows, I refer to those routinely as our daily applications of feet, forks, and fingers.  The evidence base substantiating these as master levers of medical destiny is little short of irrefutable.

So the legitimacy of our claim to causal devotion is not to be trifled with; it is not to be discredited.  But there is perhaps some danger in the very blatancy of that legitimacy. 

We in Lifestyle Medicine may be overly inclined to invoke that robust and riveting literature.  We might get carried away with the idea that lifestyle practices are, indeed, the actual causes of most of what ails us in modern society- or the remedy to that very problem.  We are right to do so, up to a point.  Beyond that point, though, the claim may make us proud, and insular.  It may isolate us.  It might make us exclusive.

But in fact, our claim, however legitimate, cannot be exclusive; for it is contingent on a more nuanced reality.  Even causes have causes.

The treatment of an effect we can administer may be better than the treatment of its cause we cannot.  The closer we get to bedrock, the better – but whatever we do in the neighborhood of roots will reverberate far more profoundly than the pruning of peccant branches in the canopy.

Consider, for instance, the social determinants of health.  We in lifestyle medicine are not prone, I trust, to dismiss the fundamental importance of poverty versus privilege; of environmental security versus squalor.  Poverty is not a lifestyle choice, however; it is a circumstance in which lifestyle choices play out.  The choices we make are, ultimately, subordinate to the choices we have.  Some lives are so focused on the immediate exigencies of survival, there is no place for “style.”  The appendage of “style” to life is, itself, something of a privilege.  Perhaps we focus on lifestyle because the deeper layers of causality are beyond our reach.

There is a need to highlight the primacy of causes, to rally in defense of the respect they warrant, to allocate more resources in their direction.  Modern, conventional medicine is routinely, if inadvertently neglectful of causes, in its preferential attention to effects.  This was elaborated recently and well by our colleague from South Africa, Dr. Derek Yach, and his co-authors writing in the American Journal of Preventive Medicine.

If we are to change something so formidable as the established allocations of the NIH, it will require a considerable counterforce.  Such strength is unlikely in the absence of unity.

If we can allow that lifestyle factors have causes upstream, and effects downstream that matter; if we can acknowledge that none of us has a monopoly on best methods; if we can concede that the “good” we can do may trump the “better” we cannot- it has the potential to illuminate common ground.  If we can recognize that even causes have causes, it may unite us in common cause.

Therein lies the best way forward, for there are arduous miles to go – and only, I think, in unity, the strength to go the distance.

As I write this, the American College of Lifestyle Medicine and the American College of Preventive Medicine have made considerable progress toward a prenuptial agreement that may allow for the mutual rewards of marriage in the foreseeable future.  As I write this, those two entities along with the Institute for Functional Medicine have made considerable progress toward the drafting and submission of a joint manuscript elucidating the perhaps overlooked architecture of our native alignment.

The former endeavor is, ultimately, much about the details of practice, and the practicalities of administration.  The latter is all about principles.  The first principle underlying a mutual devotion to causes is this: even causes have causes.

Preventive Medicine, Lifestyle Medicine, and Functional Medicine all profess to target the true causes of disease, and there is a valid basis for each such claim.  The specific contentions of each enterprise are the substance of that manuscript now in the works; it’s not my place here to preempt those better arguments, by better sources.

I can, however, illustrate the effort by noting the pedigree of Lifestyle Medicine’s claim.

We might trace the origins of our mantle to Hippocrates, who famously advanced the cause of lifestyle medicine with such admonishment as: “let food be thy medicine.”  There is little left to append there other than: amen.

We might, alternatively, constrain our timeline to the modern era, in which case McGinnis and Foege, rather than Hippocrates, are parents to our cause, flag bearers in our forward progress.  Their seminal publication in JAMA in 1993 made the case for causes not only explicit, but even eponymous: “Actual causes of death in the United States.”

Those “causes” extended to a list of ten factors.  Most noteworthy for our camp is the overwhelming predominance of lifestyle on that list.  The first three entries, accounting for 80% of premature deaths in 1990, and reaffirmed in diverse publications since and current to this day, were tobacco use, dietary pattern, and physical activity.  As this readership likely knows, I refer to those routinely as our daily applications of feet, forks, and fingers.  The evidence base substantiating these as master levers of medical destiny is little short of irrefutable.

So the legitimacy of our claim to causal devotion is not to be trifled with; it is not to be discredited.  But there is perhaps some danger in the very blatancy of that legitimacy. 

We in Lifestyle Medicine may be overly inclined to invoke that robust and riveting literature.  We might get carried away with the idea that lifestyle practices are, indeed, the actual causes of most of what ails us in modern society- or the remedy to that very problem.  We are right to do so, up to a point.  Beyond that point, though, the claim may make us proud, and insular.  It may isolate us.  It might make us exclusive.

But in fact, our claim, however legitimate, cannot be exclusive; for it is contingent on a more nuanced reality.  Even causes have causes.

The treatment of an effect we can administer may be better than the treatment of its cause we cannot.  The closer we get to bedrock, the better – but whatever we do in the neighborhood of roots will reverberate far more profoundly than the pruning of peccant branches in the canopy.

Consider, for instance, the social determinants of health.  We in lifestyle medicine are not prone, I trust, to dismiss the fundamental importance of poverty versus privilege; of environmental security versus squalor.  Poverty is not a lifestyle choice, however; it is a circumstance in which lifestyle choices play out.  The choices we make are, ultimately, subordinate to the choices we have.  Some lives are so focused on the immediate exigencies of survival, there is no place for “style.”  The appendage of “style” to life is, itself, something of a privilege.  Perhaps we focus on lifestyle because the deeper layers of causality are beyond our reach.

There is a need to highlight the primacy of causes, to rally in defense of the respect they warrant, to allocate more resources in their direction.  Modern, conventional medicine is routinely, if inadvertently neglectful of causes, in its preferential attention to effects.  This was elaborated recently and well by our colleague from South Africa, Dr. Derek Yach, and his co-authors writing in the American Journal of Preventive Medicine.

If we are to change something so formidable as the established allocations of the NIH, it will require a considerable counterforce.  Such strength is unlikely in the absence of unity.

If we can allow that lifestyle factors have causes upstream, and effects downstream that matter; if we can acknowledge that none of us has a monopoly on best methods; if we can concede that the “good” we can do may trump the “better” we cannot- it has the potential to illuminate common ground.  If we can recognize that even causes have causes, it may unite us in common cause.

Therein lies the best way forward, for there are arduous miles to go – and only, I think, in unity, the strength to go the distance.

As I write this, the American College of Lifestyle Medicine and the American College of Preventive Medicine have made considerable progress toward a prenuptial agreement that may allow for the mutual rewards of marriage in the foreseeable future.  As I write this, those two entities along with the Institute for Functional Medicine have made considerable progress toward the drafting and submission of a joint manuscript elucidating the perhaps overlooked architecture of our native alignment.

The former endeavor is, ultimately, much about the details of practice, and the practicalities of administration.  The latter is all about principles.  The first principle underlying a mutual devotion to causes is this: even causes have causes.

Preventive Medicine, Lifestyle Medicine, and Functional Medicine all profess to target the true causes of disease, and there is a valid basis for each such claim.  The specific contentions of each enterprise are the substance of that manuscript now in the works; it’s not my place here to preempt those better arguments, by better sources.

I can, however, illustrate the effort by noting the pedigree of Lifestyle Medicine’s claim.

We might trace the origins of our mantle to Hippocrates, who famously advanced the cause of lifestyle medicine with such admonishment as: “let food be thy medicine.”  There is little left to append there other than: amen.

We might, alternatively, constrain our timeline to the modern era, in which case McGinnis and Foege, rather than Hippocrates, are parents to our cause, flag bearers in our forward progress.  Their seminal publication in JAMA in 1993 made the case for causes not only explicit, but even eponymous: “Actual causes of death in the United States.”

Those “causes” extended to a list of ten factors.  Most noteworthy for our camp is the overwhelming predominance of lifestyle on that list.  The first three entries, accounting for 80% of premature deaths in 1990, and reaffirmed in diverse publications since and current to this day, were tobacco use, dietary pattern, and physical activity.  As this readership likely knows, I refer to those routinely as our daily applications of feet, forks, and fingers.  The evidence base substantiating these as master levers of medical destiny is little short of irrefutable.

So the legitimacy of our claim to causal devotion is not to be trifled with; it is not to be discredited.  But there is perhaps some danger in the very blatancy of that legitimacy. 

We in Lifestyle Medicine may be overly inclined to invoke that robust and riveting literature.  We might get carried away with the idea that lifestyle practices are, indeed, the actual causes of most of what ails us in modern society- or the remedy to that very problem.  We are right to do so, up to a point.  Beyond that point, though, the claim may make us proud, and insular.  It may isolate us.  It might make us exclusive.

But in fact, our claim, however legitimate, cannot be exclusive; for it is contingent on a more nuanced reality.  Even causes have causes.

The treatment of an effect we can administer may be better than the treatment of its cause we cannot.  The closer we get to bedrock, the better – but whatever we do in the neighborhood of roots will reverberate far more profoundly than the pruning of peccant branches in the canopy.

Consider, for instance, the social determinants of health.  We in lifestyle medicine are not prone, I trust, to dismiss the fundamental importance of poverty versus privilege; of environmental security versus squalor.  Poverty is not a lifestyle choice, however; it is a circumstance in which lifestyle choices play out.  The choices we make are, ultimately, subordinate to the choices we have.  Some lives are so focused on the immediate exigencies of survival, there is no place for “style.”  The appendage of “style” to life is, itself, something of a privilege.  Perhaps we focus on lifestyle because the deeper layers of causality are beyond our reach.

There is a need to highlight the primacy of causes, to rally in defense of the respect they warrant, to allocate more resources in their direction.  Modern, conventional medicine is routinely, if inadvertently neglectful of causes, in its preferential attention to effects.  This was elaborated recently and well by our colleague from South Africa, Dr. Derek Yach, and his co-authors writing in the American Journal of Preventive Medicine.

If we are to change something so formidable as the established allocations of the NIH, it will require a considerable counterforce.  Such strength is unlikely in the absence of unity.

If we can allow that lifestyle factors have causes upstream, and effects downstream that matter; if we can acknowledge that none of us has a monopoly on best methods; if we can concede that the “good” we can do may trump the “better” we cannot- it has the potential to illuminate common ground.  If we can recognize that even causes have causes, it may unite us in common cause.

Therein lies the best way forward, for there are arduous miles to go – and only, I think, in unity, the strength to go the distance.

As I write this, the American College of Lifestyle Medicine and the American College of Preventive Medicine have made considerable progress toward a prenuptial agreement that may allow for the mutual rewards of marriage in the foreseeable future.  As I write this, those two entities along with the Institute for Functional Medicine have made considerable progress toward the drafting and submission of a joint manuscript elucidating the perhaps overlooked architecture of our native alignment.

The former endeavor is, ultimately, much about the details of practice, and the practicalities of administration.  The latter is all about principles.  The first principle underlying a mutual devotion to causes is this: even causes have causes.

Preventive Medicine, Lifestyle Medicine, and Functional Medicine all profess to target the true causes of disease, and there is a valid basis for each such claim.  The specific contentions of each enterprise are the substance of that manuscript now in the works; it’s not my place here to preempt those better arguments, by better sources.

I can, however, illustrate the effort by noting the pedigree of Lifestyle Medicine’s claim.

We might trace the origins of our mantle to Hippocrates, who famously advanced the cause of lifestyle medicine with such admonishment as: “let food be thy medicine.”  There is little left to append there other than: amen.

We might, alternatively, constrain our timeline to the modern era, in which case McGinnis and Foege, rather than Hippocrates, are parents to our cause, flag bearers in our forward progress.  Their seminal publication in JAMA in 1993 made the case for causes not only explicit, but even eponymous: “Actual causes of death in the United States.”

Those “causes” extended to a list of ten factors.  Most noteworthy for our camp is the overwhelming predominance of lifestyle on that list.  The first three entries, accounting for 80% of premature deaths in 1990, and reaffirmed in diverse publications since and current to this day, were tobacco use, dietary pattern, and physical activity.  As this readership likely knows, I refer to those routinely as our daily applications of feet, forks, and fingers.  The evidence base substantiating these as master levers of medical destiny is little short of irrefutable.

So the legitimacy of our claim to causal devotion is not to be trifled with; it is not to be discredited.  But there is perhaps some danger in the very blatancy of that legitimacy. 

We in Lifestyle Medicine may be overly inclined to invoke that robust and riveting literature.  We might get carried away with the idea that lifestyle practices are, indeed, the actual causes of most of what ails us in modern society- or the remedy to that very problem.  We are right to do so, up to a point.  Beyond that point, though, the claim may make us proud, and insular.  It may isolate us.  It might make us exclusive.

But in fact, our claim, however legitimate, cannot be exclusive; for it is contingent on a more nuanced reality.  Even causes have causes.

The treatment of an effect we can administer may be better than the treatment of its cause we cannot.  The closer we get to bedrock, the better – but whatever we do in the neighborhood of roots will reverberate far more profoundly than the pruning of peccant branches in the canopy.

Consider, for instance, the social determinants of health.  We in lifestyle medicine are not prone, I trust, to dismiss the fundamental importance of poverty versus privilege; of environmental security versus squalor.  Poverty is not a lifestyle choice, however; it is a circumstance in which lifestyle choices play out.  The choices we make are, ultimately, subordinate to the choices we have.  Some lives are so focused on the immediate exigencies of survival, there is no place for “style.”  The appendage of “style” to life is, itself, something of a privilege.  Perhaps we focus on lifestyle because the deeper layers of causality are beyond our reach.

There is a need to highlight the primacy of causes, to rally in defense of the respect they warrant, to allocate more resources in their direction.  Modern, conventional medicine is routinely, if inadvertently neglectful of causes, in its preferential attention to effects.  This was elaborated recently and well by our colleague from South Africa, Dr. Derek Yach, and his co-authors writing in the American Journal of Preventive Medicine.

If we are to change something so formidable as the established allocations of the NIH, it will require a considerable counterforce.  Such strength is unlikely in the absence of unity.

If we can allow that lifestyle factors have causes upstream, and effects downstream that matter; if we can acknowledge that none of us has a monopoly on best methods; if we can concede that the “good” we can do may trump the “better” we cannot- it has the potential to illuminate common ground.  If we can recognize that even causes have causes, it may unite us in common cause.

Therein lies the best way forward, for there are arduous miles to go – and only, I think, in unity, the strength to go the distance.


AMERICAN COLLEGE OF LIFESTYLE MEDICINE

The American College of Lifestyle Medicine (ACLM) is the world's flagship professional medical association for physicians, clinicians and allied health professionals, as well as those in professions devoted to advancing the mission of lifestyle medicine.

       

© 2015 American College of Lifestyle Medicine

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