I refuse to tell you what to eat

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Note: I first published this on the website of Athletic Heart SF, my cardiology practice.

A recent tweet from JAMA, the journal of the American Medical Association, urged me and other 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!

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