20 August 2010

JAMA: Dietary Guidelines in the 21st Century - a Time for Food

The Journal of the American Medical Association (JAMA) has a commentary in the August 11 edition entitled: "Dietary Guidelines in the 21st Century - a Time for Food" by Darius Mozaffarian, MD, DrPH and David S. Ludwig, MD, PhD.

The purpose of this post is to summarize and review the article and to talk about whether it is consistent with the e4e dietary recommendations. Special thanks to Ashley at itsofinterest.com for providing me with a copy of the article.

Commentary Overview

The second part of the title is a great start. A time for food. The article itself is in three parts, I will summarize the parts below.

Section 1 - Introduction
In the introduction in the commentary, they talk about how the last 200 years have been characterized by the discovery of finer and finer detail of the nutrients and nutrient deficiencies that led to widespread disease. This has led to a reductionist perspective in our food choices.

Section 2 - Dietary Guidelines in the Age of Chronic Disease

This reductionist view led to guidelines in the 70s and 80s around minimum and maximum intakes of nutrients. Although appealing, the RDAs have not worked, perhaps simply because of the complexity involved in translating these recommendations into real dietary choices. I will copy the last paragraph of this section directly with some highlights of my own. It is an amazing admission.

"Nutritional science has advanced rapidly, and the evi-
dence now demonstrates the major limitations of nutrient-
based metrics for prevention of chronic disease. The propor-
tion of total energy from fat appears largely unrelated to risk
of cardiovascular disease, cancer, diabetes, or obesity. Satu-
rated fat—targeted by nearly all nutrition-related profes-
sional organizations and governmental agencies—has little re-
lation to heart disease within most prevailing dietary patterns.
Typical recommendations to consume at least half of total
energy as carbohydrate, a nutrient for which humans have no
absolute requirement, conflate foods with widely divergent
physiologic effects (eg, brown rice, white bread, apples). Foods
are grouped based on protein content (chicken, fish, beans,
nuts) despite demonstrably different health effects. With few
exceptions (eg, omega-3 fats, trans fat, salt), individual com-
pounds in isolation have small effects on chronic diseases.8
Thus, little of the information found on food labels’ “nutri-
tion facts” panels provides useful guidance for selecting
healthier foods to prevent chronic disease."

All I can say is WOW.
To sum up:
Fat ingestion, in general, is fine.
Saturated Fat is not bad.
Carbohydrate food sources are not necessary and are not created equal.
Protein food sources are not created equal.
Individual compounds in isolation are largely unimportant.
Food labels suck.

The only thing that I wildly disagree with in this paragraph is that they included salt as a compound as an exception to the compounds in isolation comment. Salt is nowhere close to the villain that people make it out to be.

Section 3 - The Need for a New Approach

This is the longest section, and I would have broken it into at least two parts, but I digress.

They start this section by citing associations between food classes and disease from a paper called "Dietary Patterns and risk of mortality from cardiovascular disease, cancer, and all causes in a prospective cohort of women", by Heideman, Schulze, Franco, et al.

They go on to say that the effects of foods "likely reflect complex, synergistic contributions from
and interactions among food structure, preparation methods, fatty acid profile, carbohydrate quality (e.g, glycemic index, fiber content), protein type, micronutrients, and phytochemicals." So far so good.

Then they say that "Healthy eating patterns share many characteristics, emphasizing whole or minimally processed foods and vegetable oils, with few highly processed foods or sugary beverages. Such diets are also naturally lower in salt, trans fat, saturated fat, refined carbohydrates, and added sugars; are higher in unsaturated fats, fiber, antioxidants, minerals, and phytochemicals; and are more satiating." This is mostly ok, but they are somewhat contradicting their earlier statement that saturated fat is ok. They're still missing the boat on salt, and unsaturated fats are a mixed bag. Unsaturated fat is not by itself good or bad. The devil is in the details.

They continue by saying that the nutrient based approach to diet has fostered products that replace fat with refined carbohydrate, "providing an aura of healthiness but without
actual health benefits." A national obesity prevention program categorizes whole-milk yogurt and cheese with french fries and donuts as foods together (eat only occasionally). Puts sauteed vegetables  and canned tuna in the same category as pretzels and processed cheese spread (eat sometimes).  Puts trimmed beef and vegetables and fat free mayonnaise as foods to eat almost anytime. They fortify processed food parts with vitamins and call them healthy.

Recently, there has been movement towards recommending food rather than simply nutrients. Nutrients are still important, we should not simply throw away the last several decades. Although this is a promising direction, they believe that much research work still remains to be done.

They finish with the following:

"The relatively recent focus on nutrients parallels an increas-
ing discrepancy between theory and practice: the greater the
focus on nutrients, the less healthful foods have become. As
national and international organizations update dietary guide-
lines, nutrient targets should largely be replaced by food-based
targets. Such change would facilitate translation to the pub-
lic, correspond with scientific advances in chronic disease pre-
vention, mitigate industry manipulation, and remedy wide-
spread misperceptions about what constitutes healthful diets.

"Although this approach may seem radical, it actually rep-
resents a return to more traditional, time-tested ways of eat-
ing. Healthier food-based dietary patterns have existed for
generations among some populations. Modern nutritional
science now provides substantial evidence for how foods and
food-based patterns affect health, guiding the design of more
effective approaches for the prevention of chronic disease."

e4e Take On This

Wow. This is great. It is generally consistent with the e4e recommendations in, "Eat Food, Light on Carbs, Mindfully." I talk about some general targets for macronutrients, depending on goals, but interestingly once you go light on carbs and stick to the fringes of your grocery store (food), it's hard to go too far wrong.

Regarding my comments on salt, please read the article "The (Political) Science of Salt" by Gary Taubes.

The 2010 food pyramid looks like it will be more of the same old stuff. This commentary represents a significant step towards dietary sanity in a mainstream medical journal. Is sanity finally winning?

01 August 2010

Sex Addicts? - Tiger Woods? Spitzer? Sanford? Moffat? The SEC?

I'll start with some discussion of sex addiction or sexaholism. Addiction, in general, is a continuum. It is difficult and arbitrary to draw a line between addiction, obsession, kinky, or just plain love.
Sex addiction is tricky. If one is a sex addict, simply going cold turkey is not a good long-term solution. Sex, like food, is a part of the human condition and a good thing by itself. It's only when sex or food take on a purpose and control one's life that they become addictions.

Addictions aren't good because ultimately,  "Mental health is commitment to reality at any cost." The following folks did not exhibit that. They put up tremendous stakes, ranging from presidential ambitions to the health of their wives, to vast sums of money. They convinced themselves that they could get away with it. So basically they had unlimited downside. The upside, you decide...

Tiger On The Road

Tiger is the latest in a string of high-profile Americans who have been identified as sex addicts (or possible ones). Mark Sanford and Elliot Spitzer are a couple other recent examples.

Tiger did everything that sex addicts do. He risked everything in his private life to spend a night or two with women who were very much out of his league. He had unprotected sex, thereby endangering his wife's health as well as his own. He risked hundreds of millions of dollars.

Here's a cynical view on it.

What makes an addict or, more specifically, a sex addict? And what distinguishes a sex addict from a "player"?

Infidelity News

SF Examiner

Tiger, in his public apology, used a lot of the right words that one who is receiving treatment for sex addiction would use. Many criticized him for his scripted speech, but I think it was a great first step.

e4e Verdict: Tiger is a sex addict. Risking and losing tens of millions of dollars, his reputation, family, and health to have sex with women well below his status. His only gain here was sex on the road.

The Curious Case of Eliot Spitzer

Another prominent sex scandal had to do with Eliot Spitzer, governor of New York. His case is different in a few ways than Tiger's. First, he wasn't having sex with random people while on the road. He chose to use prostitutes. And not just prostitutes, but very expensive ones.

The prostitutes that he was using charged several thousand per night, and reputedly provided a "girlfriend experience." It is more than just having sex with someone, but actually going on a date. Conversing, a meal, perhaps a show followed by making out, and sex is the modus operandi.

Spitzer had the high rank and a lot to lose by his actions, so that certainly fits the mold. I wonder if his case is a little different. He is essence was going out with actresses, women who knew how to be a blank slate, and as Sasha Grey says in The Girlfriend Experience, "Sometimes clients think they want the real you, but, at the end of the day, they want what they want you to be. They want you to be something else... If they wanted the real you, they wouldn't be paying you." and "You really have to adapt and become something that they want." So they come across as a young, beautiful, intelligent girl who is truly interested in him as a person--perhaps what his wife was like when they were courting.

He feels that spark again that has been gone for so long--the first stage of falling in love. Deep down, presumably, he knows that it is a facade, an image of a real relationship with a real person, but he pays the big bucks to get that feeling again. From a political standpoint, he doesn't have to get divorced and he doesn't have to deal with a real relationship. I am guessing that he saw this as a lower risk way to have an affair. It's all upside...

Until you get caught. Affairs are not illegal and would perhaps be less damaging to a political career. That's why I think that he is towards the middle of the sex and love addiction spectrum. His motives were more about the thrill of a new relationship rather than simply notches in the bedpost, but he took big risks in his personal life. I am assuming that his sex was protected. If not, that would put him further towards the addict side.

Here are some other views on Spitzer.

Often times these high-end prostitutes do not even have sex with their clients.

This article from Slate has the following quote:
"The last time I met him, I gave him a bath," she told me. "I told him he was the most sensitive man I'd ever met. I never tell him he's a piece of shit; I make him feel like superman." (This was not about Spitzer).

e4e Verdict: More love addict than sex addict. Definite problems by risking his career and marriage for thrills. If he had marital problems he should have dealt with those directly. I'm not justifying his actions. I suspect he was lonely and not receiving emotional props at home.

Mark Sanford and His Argentine Girlfriend

In contrast to Spitzer, Mark Sanford, governor of South Carolina was apparently having an actual girlfriend experience. He, in essence, threw out his marriage and possibly his political career for an Argentine woman, who was not a prostitute.

e4e Verdict: I don't think he's a sex addict, just a male who is in the first stage of love, where his hormones are completely dominating his common sense.

Robert Moffat of IBM

Although less well-known than some of the others, Moffat was a high level executive at IBM who got mixed up with an attractive analyst/former beauty queen who fed information from him to a hedge fund operator. He lost something on the order of $65MM. His wife of over 30 years had her MS flare up. Moffat apparently did not benefit financially from the arrangement, but that is not required to convict him. The only need to demonstrate that he obtained a benefit of some kind. Receiving sexual favors is considered a benefit.

Moffat is quoted in the article as saying, "Everyone wants to make this about sex. Danielle had an extensive network of business people. And she added clarity about what was going on in the business world...I know in my heart what this relationship was about: clarity in the business environment." The author reveals his skepticism by saying, "He may even believe that."

e4e Verdict: He is delusional. He was getting exciting sexual favors in exchange for information, and rationalized it away by his lack of financial benefit and by convincing hinself that he was getting "clarity in the business environment." Moffat is not mentally healthy. He is probably a sex or love addict of some kind. There was not enough information in the article to make a clear call. He did some really foolish things though, had no upside and lots of downside.

There is an excellent article in Fortune on this if you want more details.

The SEC?

What does the SEC have to do with this? In this article from the Atlantic Monthly, the author asks the question, "Did porn cause the financial crisis?".

e4e Verdict: not addicts, but the regulators were fiddling with themselves excessively during work hours, as the financial system was burning. I wouldn't be surprised if some of those involved are sex addicts. Maybe they're just immature.

Some additional reading and resources:

Helen Fisher on Why We Love and Cheat in Ted Talks

Willard Harley from Marriage Builders on how infidelity can sometimes be misinterpreted as sex addiction

Scientific American article on Why Men Buy Sex
Covers all the bases.