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David Katz, M.D.

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Fruits, Nuts, and Friends Like These

Posted: 03/07/2013 5:57 pm

My career is devoted entirely to leveraging the incredible power of lifestyle as medicine to help people add years to life, and life to years. I espouse the importance of a short list of lifestyle factors, but concentrate my efforts in the area of improving diet, partly because that has proven so hard to do.

I am in excellent company. Many of my colleagues share that devotion to promoting health by improving diets. Many have been at it longer than I. And in many cases, we have both common cause and mutual means. We are clearly on the same team.

But in all too many cases, we have nominally common cause and widely disparate messages and methods. And so our band of brothers and sisters that should all be the best of friends and teammates, winds up at starkly crossed purposes.

With friends like these, in other words, heaven save us from our enemies! I'll tell you what I mean.

My message about diet and health is, I believe, consistent, and both simple and actionable. It distills down to this: Trade up your choices, eat close to nature, and come to love the foods that love you back.

This has been my message for years, and I've never been obligated to change it substantively as we've learned new things about nutrition. Personally, I had cut eggs out of my diet when we thought dietary cholesterol was far more harmful than it proves to be -- and have added them back (albeit occasionally) since. I was once more focused on restricting fat intake than I am now, and have shifted that emphasis to eating the right kinds of fat in the right proportions. But these are details. The basic message has comfortably moved along with the flow of evidence, remaining buoyant.

The fact that trans fat is far worse for us than we once thought does not change this message. The fact that transesterified fat may prove to be an equally bad idea does not change this message. The fact that we eat far too much sugar in the form of high-fructose corn syrup does not change this message. The fact that junk food is willfully engineered to be addictive does not change this message. The fact that we should eat plenty of fruits and vegetables, and very few of us do, does not change this message. The message reflects the notion that a recipe of sugar and chemicals and a trace amount of grain that is then "fortified with 11 essential vitamins and minerals!" makes for a very dubious part of "a complete breakfast."

Nor has the ebb and flow of scientific evidence substantially altered the utility of programs my associates and I have developed, and offered up mostly free of charge, to help us get there from here. A program, for instance, that teaches food label literacy will be of real value, no matter what the food industry mischief du jour happens to be. All you really need to know to identify all manner of junk food is how to identify what's actually good. Everything else is off the reservation.

Nor are there any provisos or caveats attached to that message. You can be a vegan and trade up your choices, eat close to nature, and come to love the foods that love you back. You can follow a Mediterranean diet and do so. Or a Paleo diet. Or, you can be more typical and eat the typical American diet -- and improve it by trading up your choices, eating closer to nature one step at a time, and by letting your taste buds slowly acclimate to ever better foods, learning to love the foods that love you back. No foods are excluded, no diets are excluded, no people are excluded. The emphasis is on the widely-accepted theme of healthful eating, rather than the various merits or demerits of any particular variant.

And there are no loopholes. You can't eat better by cutting sugar but adding salt, or cutting salt but adding sugar. You can't do it by replacing one kind of sugar with another, or all kinds of sugar with artificial sweeteners. You can't do it by replacing saturated fat with trans fat. You can't do it by cutting fiber along with salt, or adding refined starch as you reduce sweeteners. The only way to eat better is by eating foods that are actually, holistically... better.

I think a message comprised of reliable and fairly impervious truths is very important. I think it potentially makes eating better a common cause for otherwise diverse constituencies -- and in that unity, we may hope for strength. We need it -- because eating better has powerful enemies.

We were told about those powerful enemies recently by Michael Moss in the New York Times Magazine. We had been told about them years before in the Chicago Tribune. We have been told repeatedly and clearly that we have enemies. And, frankly, anyone paying even a little attention to the world around us has abundant opportunity to figure it out for themselves.

Eating well and healthfully has enemies, but that's not what worries me. If we worked and played well together, I think we could deal with our enemies. What worries me is our friends.


Pie in the Sky

I agree with just about all of Michael Pollan's advice, and along with the rest of his large following, admire his penchant for expressing it so well. But I draw the line at the rigid practice of that advice espoused, if not by Pollan himself, at least by some of his high-profile adherents with whom I have interacted directly. Yes, we should eat mostly plants -- but we don't, not even close. Only about 1.5 percent of Americans meet daily recommendations for fruits and vegetables. Only 1.5 percent! And it's been that way for decades.

And yes, we should eat "food." But people are, in fact, making choices overwhelmingly among items in bags, boxes, bottles, jars, and cans -- and that isn't going to change overnight. Besides, some decidedly real food comes in such packaging, such as canned tuna, bagged lentils, steel-cut oats, and so on. People looking for those oats may confront a whole array of cereal choices, each in a box adorned with marketing messages about nutritional attributes and implied health benefits.

People in the real world need to make such choices. The notion that all such choices can be avoided by eating "real food" is pie-in-the-sky.

There's no need for that. We can move closer to "food, not too much, mostly plants" one better choice at a time. We can choose packaged items with shorter ingredient lists, and better overall nutritional quality. We can trade up cereal, and bread, and pasta sauce. We can trade up chips. And for that matter, we can trade up pie. My wife makes a high-fiber, low-sugar pumpkin pie with a wholegrain/nut crust that's to die for -- and no helicopter is required to get to it. Just pull up a chair at the Katz family kitchen table.

The reality is that chronic disease risk and premature mortality can be reduced by trading up routine food choices. Pounds can be lost just by finding better choices in every aisle of the supermarket. There is no need to make perfect the enemy of good. Pollan is right, but we have to allow for getting there from here, one step at a time.


Going Nuts

We have a tendency to go nuts over the single approach to improving diets that most excites our imaginations in any given moment. We went nuts over dietary fat -- figuratively, and literally -- cutting fatty nuts from our diets. But Ancel Keys and other original advocates of lower-fat eating said eat less fat. They meant less of the fat we were mostly eating -- which came from the likes of fries, and shakes, and pizza, and hotdogs. We were never eating mostly walnuts. If the focus on cutting fat had been in the context of eating better overall, it would never have resulted in abandoning walnuts and almonds, and embracing SnackWell's cookies. But that's just what we did.

In fact, time trend data from the National Health and Nutrition Examination Survey indicate we never even really cut fat, per se. We just diluted down our percent of total calories from fat by eating ever more low-fat, highly-processed, starchy, sugary junk. And, of course, somebody was getting rich as we got fatter and sicker.

Our team is bedeviled by good intentions gone awry, and the law of unintended consequences. We are prone to misinterpretations of science by those untrained in it, who all too readily presume that a study that makes headlines must be gospel. We are prone to excessive reductionism, and unnecessary mutual exclusivism. Other than the fact that the message lacks the sex appeal of extreme simplicity, what ever prevented us from cutting both lousy fats and crummy carbs?

Libertarians, so afraid of the government transparently regulating anything about our food, give Big Food all the leeway it needs to do so clandestinely.

Iconoclasts invite us to revisit what we thought we knew about energy balance and calories, rather than allowing for the dull reality: The quantity of calories we consume does matter, and the quality of foods we choose influences that quantity. This is not rocket science. We heard "betcha' can't eat just one" about chips. We never heard it about bananas. There's a reason.

When vegans get captivated by their own virtue, they hurt the cause of healthful eating by not allowing for the evidence that other mostly-plant-based dietary patterns can also promote human health. Studies, both in the U.S. and hot off the presses in Europe, indicate that while processed meats are associated with chronic disease risk, "pure" meats probably are not. Our ancestors ate game with good effect; we doubtless could, too.

Proponents of the Paleo diet -- the most zealous of whom think the vegans a pack of malnourished loonies -- run amok in their advocacy for carnivorousness, however, both by misconstruing meatloaf for mammoth, and by failing to acknowledge that a population of some 7-plus billion cannot replicate the lifestyle of roaming bands of hunter-gatherers. We really don't need everybody else to be entirely wrong, for any us to be partly right.

Vegans and Paleo purists could rally around trading up, eating close to nature, learning to love foods that love us back. Instead, they mostly lob insults at one another through cyberspace. And most typical Americans keep eating the typical American diet.

Foodie-zealots of various stripes who fall in love with any given theory rush to indict anyone who doesn't happen to drink the same Kool-Aid. For instance, whenever I point out that sugar is not the only thing wrong with modern diets, I am accused of working on behalf of a sugar cartel. But I'm not out to exonerate Coca-Cola; I just don't think we should let McDonald's and Chuck E. Cheese's off the hook. As we attack one another, they are all rubbing their hands together in glee.


Throwing Out Baby (Carrots) With Bathwater

On a recent NPR interview conducted with us sequentially, I got to hear Dr. Robert Lustig say his message is "eat real food." That's a good message -- but it's not the message that went viral, gave him the spotlight, and put his book on the best-seller list. The message that did all of that is: Sugar, and specifically fructose, is toxic. That message is redolent with conspiracy theory, silver bullet, and renegade genius -- ingredients of every great fad. "Eat real food" is a good message, devoid of any such sex appeal. Bland truths stand the test of time, but they lack sex appeal. Hyperbole has sex appeal!

Dr. Lustig and I agree that we eat way too much added sugar, and that excess of added sugar is toxic. We agree it should be addressed -- both by individuals making better choices, and with policies directed at the supply side. Ideally, that would be all there is to it. We would be teammates, and friends.

But, alas, we stop agreeing when the message gets too sexy: Fructose is toxic!

Why? Well, I suppose I may just constitutionally be a pain in the ass. If you want to agree with that assessment, you'll have to take a number. But I like to think it's because I actually care about what happens in the real world. I suppose it's selfish, but I just can't stand the idea of the typical American diet being worse when I retire than when I started working to improve it. And I think messages like this can, indeed, make things worse. They have before.

The glycemic index and glycemic load, for instance, are very valuable measures. But the idea that everything important about nutrition could be captured by measuring this one property has led to some genuine craziness. Popular diets espousing the importance of glycemic effects, including the most widespread low-carb diets, actually advised people to stop eating fruits and certain vegetables, such as carrots, because of their glycemic index. Talk about throwing out the baby (carrots) with the bathwater! You find me someone who can blame obesity or diabetes on berries, or carrots -- and I will give up my day job and become a hula dancer. (Now there's a video destined to go viral.)

So, if we managed to talk ourselves into abandoning fruit before, then yes -- we have cause to worry that a "fructose is toxic" message could help us replicate such historical folly.

Dr. Lustig quickly and adamantly adds a proviso to his position: But I don't mean fruit! But a platform that can't support itself without a whopping and immediate proviso does not make a stable foundation for any kind of sustainable progress.

The statement that fructose is toxic is, simply, false. Fruit contains fructose. Honey, which has been part of the human diet since the Stone Age, contains more fructose than glucose. Saying that fructose is toxic but fruit is not is like saying that democracy is evil, but the United States is fine. Or that Judaism is wrong, but Jews are right. It makes no sense. And messages that make no sense get us into trouble.

What kind of trouble? Well, if fructose is evil, then a Coca-Cola sweetened with high-fructose corn syrup is actually trading up from fresh-squeezed orange juice, in which fructose is considerably more concentrated. Whatever one's views of fruit juice, that's a troubling notion.

But much worse is sure to follow. If fructose is toxic, then we are inviting soft drink makers to switch over to pure glucose. I envision a whole new array of soft drinks, with "No Fructose!" banner ads on the front -- intensively sweetened with glucose. And maybe, under the "fructose free" halo, we will feel justified drinking twice as much as before.

If this sounds far-fetched, it should not. Recall that the principle effect of the low-fat diet era was not a reduction in fat intake, but an increase in total calorie intake from such foods as SnackWell's cookies. If it said "low-fat," we interpreted that to mean: license to eat in huge quantities. My worries about glucose-sweetened soft drinks may run to morbid fantasy, but it's a nightmare well grounded in our recent dietary history.

And along with glucose-sweetened soft drinks, we can expect to keep runnin' on Dunkin', but with ever more artificially-sweetened donuts from which to choose. Does anyone really think that glucose-sweetened soda and aspartame-sweetened donuts will lead us toward health? If so, I have a bridge for sale.

Welcome to yet another way of getting fatter and sicker, while food industry executives laugh at us and count their money.


That Which We Call a Fruit

No, we should not cut fruit out of our diets. But then again, some of what we call fruit is, in fact, way too sweet.

Canned peaches, for instance, or pears, stripped of their skins and much of their nutrient value and packaged in heavy syrup are, in the eyes of trade groups, manufacturers, and even our federal agencies who attend to those constituencies -- fruit. But nutritionally, such products derive the vast majority of their calories from the syrup in which the fruit is floating. The fruit in such concoctions may be the nutritional equivalent of a rounding error.

Trading up, eating close to nature -- would defend against this. Fruits in nature are not packed in heavy syrup. But if even a good message like "eat more fruits and vegetables" is undone by adulterations of that which we call a fruit, then we don't need enemies to forestall our progress. We've got it covered, among friends.


Fool Me Thrice...

It's true, of course, that the real menace was not in any of the well-intended nutrition messages, per se -- but rather in what the food industry did with them. We might have cut fat by eating more fruits and vegetables -- but the food industry co-opted the message, and gave us SnackWell's cookies. We ate them, and got fatter and sicker.

We might have cut carbs by eating more salmon. But we ate low-carb brownies, and got fatter and sicker.

We might cut added sugar (both fructose and glucose) by eating pasta sauce and salad dressing without it, by drinking less soda, and by eating less dessert. Instead, we get diet soft drinks sweetened with aspartame. And there is no convincing evidence that helps with weight, let alone health. Whenever we tell the food industry there's "just one thing" to fix, they oblige and fix it. Alas, they tend to do so at the cost of breaking everything else. It's a cycle we could repeat endlessly, while getting nowhere. Frankly, I've had enough -- and I keep hoping I'm not alone.

Over-simplified messages are simple to corrupt. More complete messages -- for instance, trade up, eat close to nature, and learn to love food that loves you back -- lack sex appeal, but maybe they make up for it in their resistance to corruption.

In recent history, at least, the "just cut fat" message was perhaps the first time the food industry fooled us, and gave us low-fat junk food in the place of more salad. OK, shame on them for that one. But we've been fooled in just this way more than once, more than twice, and more than thrice. So we are well into the realm of "shame on us." Time for us to anticipate this vulnerability, and pre-empt it.


Now What?

I've spent some 3,000 words grousing about the problem. What should we do about it?

First, I think all of us who care about promoting health through nutrition should support the same fundamentals. I picture us joining ranks in something we might call The True Food Coalition, committed both to true food, and the truth about food (yes, I am thinking of creating it).

We could define and defend a basic theme of eating well, while allowing for reasonable debate about the best variations on that theme. And yes, we absolutely do know what that theme is! We are not clueless about the basic care and feeding of Homo sapiens, and how bizarre it would be if we were. We know what koalas and giant pandas and tropical fish should eat; how could we manage to know less about ourselves?

Both good vegan and Paleo diets, for instance, which might seem like diametrical opposites -- are not -- and could find room in that theme. Both are based on natural foods. Both are rich in plant foods. Neither would include highly processed industry manipulations. They are more like one another than either is like the diet that prevails in our society. As long as we pretend it's the differences that matter most, the typical diet that prevails -- will keep on prevailing.

All responsible nutrition experts could reaffirm the current, best consensus about the fundamentals of healthful eating every time we debate the latest data, or parse the particulars. We could acknowledge that both the quality and quantity of our calories matter. We really should be up to the task of saving the baby as we drain out bathwater.

And I do think we should honor the principle of loving the food that loves us back. Some of us are willing to eat for health even if there is no pleasure in it. But most of us expect eating to be pleasurable. Most of us would prefer to get health in the pursuit of pleasure, and pleasure in pursuit of health. The evidence that taste buds acclimate to, and come to prefer, healthful food is supportive of this enterprise. We should spread that word, because it will encourage many more people into our camp, and onto our team.

Friends Like These...

Public health nutrition has enemies. Those conspiring willfully to make junk food addictive come readily to mind. Those of us who want to help people eat better in the service of more years in life, more life in years -- have enemies. Big, powerful, deep-pocketed enemies. That would be bad enough.

But what may be even worse is our friends. All the times and ways we trip up one another, good intentions notwithstanding. With friends like these, we may not need enemies to forestall our best efforts. All too often when we meet the enemy, it is us.

-fin

Dr. David L. Katz; www.davidkatzmd.com
www.turnthetidefoundation.org

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