A Nobel Prize-winning psychologist says most people don’t really want to be happy

We think we want to be happy. Yet many of us are actually working toward some other end, according to cognitive psychologist Daniel Kahneman, winner of the 2002 Nobel Prize in economics.

Kahneman contends that happiness and satisfaction are distinct. Happiness is a momentary experience that arises spontaneously and is fleeting. Meanwhile, satisfaction is a long-term feeling, built over time and based on achieving goals and building the kind of life you admire. On the Dec. 19 podcast “Conversations with Tyler,” hosted by economist Tyler Cowen, Kahneman explains that working toward one goal may undermine our ability to experience the other.

For example, in Kahneman’s research measuring everyday happiness—the experiences that leave people feeling good—he found that spending time with friends was highly effective. Yet those focused on long-term goals that yield satisfaction don’t necessarily prioritize socializing, as they’re busy with the bigger picture.

Such choices led Kahneman to conclude that we’re not as interested in happiness as we may claim. “Altogether, I don’t think that people maximize happiness in that sense…this doesn’t seem to be what people want to do. They actually want to maximize their satisfaction with themselves and with their lives. And that leads in completely different directions than the maximization of happiness,” he says.

In an October interview with Ha’aretz (paywall), Kahneman argues that satisfaction is based mostly on comparisons. “Life satisfaction is connected to a large degree to social yardsticks–achieving goals, meeting expectations.” He notes that money has a significant influence on life satisfaction, whereas happiness is affected by money only when funds are lacking. Poverty creates suffering, but above a certain level of income that satisfies our basic needs, wealth doesn’t increase happiness. “The graph is surprisingly flat,” the psychologist says.

In other words, if you aren’t hungry, and if clothing, shelter, and your other basics are covered, you’re capable of being at least as happy as the world’s wealthiest people. The fleeting feelings of happiness, though, don’t add up to life satisfaction. Looking back, a person who has had many happy moments may not feel pleased on the whole.

The key here is memory. Satisfaction is retrospective. Happiness occurs in real time. In Kahneman’s work, he found that people tell themselves a story about their lives, which may or may not add up to a pleasing tale. Yet, our day-to-day experiences yield positive feelings that may not advance that longer story, necessarily. Memory is enduring. Feelings pass. Many of our happiest moments aren’t preserved—they’re not all caught on camera but just happen. And then they’re gone.

Take going on vacation, for example. According to the psychologist, a person who knows they can go on a trip and have a good time but that their memories will be erased, and that they can’t take any photos, might choose not to go after all. The reason for this is that we do things in anticipation of creating satisfying memories to reflect on later. We’re somewhat less interested in actually having a good time.

This theory helps to explain our current social media-driven culture. To some extent, we care less about enjoying ourselves than presenting the appearance of an enviable existence. We’re preoccupied with quantifying friends and followers rather than spending time with people we like. And ultimately, this makes us miserable.

We feel happiness primarily in the company of others, Kahneman argues. However, the positive psychology movement that has arisen in part as a result of his work doesn’t emphasize spontaneity and relationships. Instead, it takes a longer view, considering what makes life meaningful, which is a concept that Kahneman claims eludes him.

Kahneman counts himself lucky and “fairly happy.” He says he’s led “an interesting life” because he’s spent much of his time working with people whose company he enjoyed. But he notes that there have been periods when he worked alone on writing that were “terrible,” when he felt “miserable.” He also says he doesn’t consider his existence meaningful, despite his notable academic accomplishments.

Indeed, although his contributions legitimized the emotion as an economic and social force and led to the creation of happiness indices worldwide, the psychologist abandoned the field of happiness research about five years ago. He’s now researching and writing about the concept of “noise,” or random data that interferes with wise decision-making.

Still, it’s worth asking if we want to be happy, to experience positive feelings, or simply wish to construct narratives that seems worth telling ourselves and others, but doesn’t necessarily yield pleasure. Meet a friend and talk it over with them—you might have a good time. 


Visions of a Better World

Noam Chomsky, Richard Dawkins, Martin Rees and others answer the question: What’s your utopia?

Visions of a Better World

Unless you are too stoned or enlightened to care, you are probably dissatisfied with the world as it is. In that case, you should have a vision of the world as you would like it to be. This better world is your utopia. That, at any rate, is the premise of a question I’ve been asking scientists and other thinkers lately: What’s your utopia?

I presented students’ responses to this question last year. This final column for 2018 (if aliens land in Central Park or CERN discovers a portal to a parallel universe, I’ll let major media handle it) offers responses from scientists and others I’ve interviewed lately. My hope is that these visions will cheer up readers bummed out by my previous post, “Dark Days.” See the end of the post for my utopia.

Noam Chomsky: I don’t have the talent to do more than to suggest what seem to me reasonable guidelines for a better future.  One might argue that Marx was too cautious in keeping to only a few general words about post-capitalist society, but he was right to recognize that it will have to be envisioned and developed by people who have liberated themselves from the bonds of illegitimate authority.

Richard Dawkins: My utopia is a world in which beliefs are based on evidence and morality is based on intelligent design—design by intelligent humans (or robots!). Neither beliefs nor morals should be based on gut feelings, or on ancient books, private revelations or priestly traditions.

Sheldon Solomon: Staying alive long enough to see that my children are relatively settled and economically secure and knowing that there’s a decent chance that the earth will not be reduced to a festering heap long before the sun explodes!

Sabine Hossenfelder: That we finally use scientific methods to restructure political and economic systems. The representative democracies that we have right now are entirely outdated and unable to cope with the complex problems which we must solve. We need new systems that better incorporate specialized knowledge and widely distributed information, and that better aggregate opinions. (I wrote about this in detail here.) It pains me a lot to think that my children will have to live through a phase of economic regress because we were too stupid and too slow to get our act together.

Scott Aaronson: Since I hang out with Singularity people so much, part of me reflexively responds: “utopia” could only mean an infinite number of sentient beings living in simulated paradises of their own choosing, racking up an infinite amount of utility.  If such a being wants challenge and adventure, then challenge and adventure is what it gets; if nonstop sex, then nonstop sex; if a proof of P≠NP, then a proof of P≠NP.  (Or the being could choose all three: it’s utopia, after all!)

Over a shorter time horizon, though, maybe the best I can do is talk about what I love and what I hate.  I love when the human race gains new knowledge, in math or history or anything else.  I love when important decisions fall into the hands of people who constantly second-guess themselves and worry that their own ‘tribe’ might be mistaken, who are curious about science and have a sense of the ironic and absurd.  I love when society’s outcasts, like Alan Turing or Michael Burry (who predicted the subprime mortgage crisis), force everyone else to pay attention to them by being inconveniently right.  And whenever I read yet another thinkpiece about the problems with “narrow-minded STEM nerds”—how we’re basically narcissistic children, lacking empathy and social skills, etc. etc.—I think to myself, “then let everyone else be as narrow and narcissistic as most of the STEM nerds I know; I have no further wish for the human race.”

On the other side, I hate the irreversible loss of anything—whether that means the deaths of individuals, the burning of the Library of Alexandria, genocides, the flooding of coastal cities as the earth warms, or the extinction of species.  I hate when the people in power are ones who just go with their gut, or their faith, or their tribe, or their dialectical materialism, and who don’t even feel self-conscious about the lack of error-correcting machinery in their methods for learning about the world.  I hate when kids with a passion for some topic have that passion beaten out of them in school, and then when they succeed anyway in pursuing the passion, they’re called stuck-up, privileged elitists.  I hate the “macro” version of the same schoolyard phenomenon, which recurs throughout cultures and history: the one where some minority is spat on and despised, manages to succeed anyway at something the world values, and is then despised even more because of its success.

So, until the Singularity arrives, I suppose my vision of utopia is simply more of what I love and less of what I hate!

David Deutsch: Of course I’m opposed to utopianism. Progress comes only through piecemeal, tentative improvements. I think the world will never be perfected, even when everything we think of as problematic today has been eliminated. We shall always be at the beginning of infinity. Never satisfied.

Stephen Wolfram: If you mean: what do I personally want to do all day?  Well, I’ve been fortunate that I’ve been able to set up my life to let me spend a large fraction of my time doing what I want to be doing, which usually means creating things and figuring things out.  I like building large, elegant, useful, intellectual and practical structures—which is what I hope I’ve done over a long period of time, for example, with Wolfram Language.

If you’re asking what I see as being the best ultimate outcome for our whole species—well, that’s a much more difficult question, though I’ve certainly thought about it.  Yes, there are things we want now—but how what we want will evolve after we’ve got those things is, I think, almost impossible for us to understand.  Look at what people see as goals today, and think how difficult it would be to explain many of them to someone even a few centuries ago.  Human goals will certainly evolve, and the things people will think are the best possible things to do in the future may well be things we don’t even have words for yet.

Peter Woit: Besides the peace, love and understanding thing, in my utopia everyone else would have as few problems and as much to enjoy about life as I currently do.

Martin Rees: A utopian society would, at the very least, require trust between individuals and their institutions. I worry that we are moving further from this ideal. Two trends are reducing interpersonal trust: firstly, the remoteness and globalization of those we routinely have to deal with; and secondly, the vulnerability of modern life to disruption –- the realization that “hackers” or dissidents can trigger incidents that cascade globally. Such trends necessitate burgeoning security measures. These are already irritants in our everyday life – security guards, elaborate passwords, airport searches and so forth — but they are likely to become ever more vexatious. Innovations like blockchain could offer protocols that render the entire Internet more secure. But their current applications – allowing an economy based on crypto-currencies to function independently of traditional financial institutions –seem damaging rather than benign. It’s depressing to realize how much of the economy is dedicated to activities that would be superfluous if we felt we could trust each other. (It would be a worthwhile exercise if some economist could quantify this.)

And the world is so interconnected that no utopia could exist on the scale of one nation-state.  Harmonious geopolitics would require a global distribution of wealth that’s perceived as fair– with far less inequality between rich and poor nations. And even without being utopian it’s surely a moral imperative (as well as in the self-interest of fortunate nations) to push towards this goal. Sadly, we downplay what’s happening even now in far-away countries and the plight of the “bottom billion.” And we discount too heavily the problems we’ll leave for new generations. Governments need to prioritize projects that are long-term in a political perspective, even if a mere instant in the history of our planet.

Tim Maudlin: In the utopian tradition that goes back to Plato (again!) utopias are not supposed to be real places. In Republic, Socrates says that it does not matter whether the ideal state actually exists: it is a pattern by reference to which one can judge the present situation and how it can be improved. There is a reason why Butler’s Erewhon is about a place called “Erewhon”. But as it happens my present not-yet-in-full-existence utopia is well on its way to full-blown reality. It is called the John Bell Institute for the Foundations of Physics, a non-profit institute formed to promote the study, teaching and investigation of the foundations of physics. So far we have our Faculty and Honorary Fellows and Bell Fellows and regular Fellows, and we have identified where our European campus will be (in Bojanić Bad, Hvar, Croatia) and are seeking an American campus in the Rockies. This is putting my views about utopia to the acid test.

Robin Hanson: My personal utopia would be an intellectual world where we actually lived up to most of the intellectual ideals we espouse. Where work is judged mainly on the long term benefit it gives the world, and arguments are accepted no matter how unpalatable their conclusions, or whose ox is gored. I actually think we know a lot about how to construct such a utopia if we wanted – see my work on futarchy and idea futures. The main problem seems to be that most of us don’t actually want my “utopia.”

Tyler Volk: John, having this opportunity to focus for a spell on your great questions: this is it!

Jim Holt: My utopia is a society that consists in its entirety of Tim and Vishnya Maudlin, David Albert, Jenann Ismael, Shelly Goldstein, Barry Loewer, Carlo Rovelli, Hartry Field, Trevor Teitel, and me, all arguing eternally about gauge theory while beautiful girls and comely boys peel grapes for us.

Nick Herbert: In sociology, I am utterly ignorant. My favorite poet Robinson Jeffers (“Shine, Perishing Republic”) held a dim view of human progress. Perhaps we are now living in the Last Golden Age before the Decline of the West. Whatever the case, Nick offers these words as a guide to rightly living in this odd complexity:

Love this well

ere it perish.

And thank you

for your mystery

which I almost entirely

do not understand.

John Horgan: As I argue in Mind-Body Problems, my free, online book, many of us are already living in pretty good utopias, democracies that give us unprecedented freedom to be who we want to be. But things could be—will be!–a lot better. We will recognize how stupid and wrong war is and end it once and for all. With the money we save from demilitarizing we will end poverty, too, improve education and health care for all, and solve the conundrum of climate change. And we will keep giving ourselves more freedom, more choices. Our children and their children will find new ways to be human, to live good, meaningful lives, ways we can’t even imagine now. This weird, wonderful human adventure will never, ever end. Happy Holidays!

The Inventor of the Genetically Modified Potato Comes Clean

How many years did you spend working on creating GM potatoes? Was this all lab-based work or did you get out to see the farms that were growing the potatoes?

During my 26 years as a genetic engineer, I created hundreds of thousands of different GM potatoes at a direct cost of about $50 million. I started my work at universities in Amsterdam and Berkeley, continued at Monsanto, and then worked for many years at J. R. Simplot Company, which is one of the largest potato processors in the world.

I had my potatoes tested in greenhouses or the field, but I rarely left the laboratory to visit the farms or experimental stations. Indeed, I believed that my theoretical knowledge about potatoes was sufficient to improve potatoes. This was one of my biggest mistakes.

Have the GM potatoes you helped create been approved by the FDA and EPA in the U.S. or indeed elsewhere in the world?

It is amazing that the USDA and FDA approved the GM potatoes by only evaluating our own data. How can the regulatory agencies assume there is no bias? When I was at J.R. Simplot, I truly believed that my GM potatoes were perfect, just like a parent believes his or her children are perfect.

I was biased and all genetic engineers are biased. It is not just an emotional bias. We need the GM crops to be approved. There is a tremendous amount of pressure to succeed, to justify our existence by developing modifications that create hundreds of millions of dollars in value. We test our GM crops to confirm their safety, not to question their safety.

The regulatory petitions for deregulation are full with meaningless data but hardly include any attempts to reveal the unintended effects. For instance, the petitions describe the insertion site of the transgene, but they don’t mention the numerous random mutations that occurred during the tissue culture manipulations. And the petitions provide data on compounds that are safe and don’t matter, such as the regular amino acids and sugars, but hardly give any measurements on the levels of potential toxins or allergens.

The Canadian and Japanese agencies approved our GMO potatoes as well, and approvals are currently considered in China, South Korea, Taiwan, Malaysia, Singapore, Mexico, and the Philippines.

What was your role at Monsanto and J.R. Simplot?

I led a small team of 15 scientists at Monsanto, and I directed the entire biotech R&D effort at Simplot (up to 50 scientists). My initial focus was on disease control but I eventually considered all traits with commercial value. I published hundreds of patents and scientific studies on the various aspects of my work.

Why did you leave firstly Monsanto and then later J.R. Simplot?

I left Monsanto to start an independent biotech program at J.R. Simplot, and I left J.R. Simplot when my ‘pro-biotech’ filter was wearing thin and began to shatter; when I discovered the first mistakes. These first mistakes were minor but made me feel uncomfortable. I realized there had to be bigger mistakes still hidden from my view.

Why have you decided to reveal information about the failings of GM potatoes after spending many years creating them?

I dedicated many years of my life to the creation of GMO potatoes, and I initially believed that my potatoes were perfect but then I began to doubt. It again took me many years to take a step back from my work, reconsider it, and discover the mistakes. Looking back at myself and my colleagues, I believe now that we were all brainwashed; that we all brainwashed ourselves.

We believed that the essence of life was a dead molecule, DNA, and that we could improve life by changing this molecule in the lab. We also assumed that theoretical knowledge was all we needed to succeed, and that a single genetic change would always have one intentional effect only.

We were supposed to understand DNA and to make valuable modifications, but the fact of the matter was that we knew as little about DNA as the average American knows about the Sanskrit version of the Bhagavad Gita. We just knew enough to be dangerous, especially when combined with our bias and narrowmindedness.

We focused on short-term benefits (in the laboratory) without considering the long-term deficits (in the field). It was the same kind of thinking that produced DDT, PCBs, Agent Orange, recombinant bovine growth hormone, and so on. I believe that it is important for people to understand how little genetic engineers know, how biased they are, and how wrong they can be. My story is just an example.

Ask the Expert: Breast Cancer, Diet and Exercise

Cancer Connect

CancerConnect partnered with Dana-Farber to engage with breast cancer expert, Jennifer A. Ligibel, MD, of the Susan F. Smith Center for Women’s Cancers at Dana-Farber. Dr. Ligibel guest-moderated a question-and-answer session on “Breast Cancer, Diet and Exercise.”

Dr. Ligibel has authored several papers on the role of lifestyle factors and breast cancer, including a recent study on the impact of exercise on reducing drug-related joint pain. She is also an assistant professor of medicine at Dana-Farber.

Join us in the Breast Cancer Community on CancerConnect to view the entire Ask the Expert session with Dr. Ligibel.

Question about lifestyle factors, breast cancer and depression: Are there any ‘lifestyle’ type of factors—diet/nutrition, that might help with anxiety, depression (I didn’t seem to have these issues until after my breast cancer diagnosis)?

Dr. Ligibel:There are many studies that show that exercise has a positive impact on anxiety and depression. Studies suggest that fairly modest amounts of exercise can improve mood. We generally recommend that women start slowly and check with their physicians before starting an exercise program, but research suggests that moderate physical activity, such as walking, is safe for most breast cancer survivors and can have many positive health effects.

Although information is more limited in cancer survivors, there is also evidence that weight loss can have a positive effect on depression in women.

Question about health benefits of green tea or tumeric: What do you think of the health benefits of green tea, specifically Matcha green tea? Also, what about tumeric?

Dr. Ligibel:There is a lot of interest in the health benefits of specific supplements, but not much evidence that these products have any benefits for cancer survivors. Green tea has been studied as a potential nausea-preventing intervention, but the results of these studies have been mixed. Some preliminary results from animal studies have suggested health benefits of turmeric, but it is too early to know whether either of these supplements will eventually be shown to be beneficial for cancer survivors.

It is important to note that green tea and turmeric are foods rather than medications, like most supplements. This means that they are not regulated by the FDA. Companies that produce them can make all kinds of health claims, as long as they include the statement that the claims are not supported by the FDA. This can be confusing for patients, as many of these products are marketed as “cancer-fighting”.

Question about Optimal Types of Fat: I’m a 9-year breast cancer survivor. I’ve seen studies which favor a low fat diet to reduce the risk of breast cancer and recurrence. These studies do not specify types of fat. Do they look at or compare trans fats, fat from meat, dairy and processed foods, fats from nuts, seeds, olive oil, coconut oil, etc? I am mostly vegetarian and my diet is actually fairly high in fat since my protein comes from nuts, seeds and some eggs. What is your sense about high fat vs low fat and if the types of fats consumed contribute to higher or lower risk? I’d like to believe that healthy fats are not risk factors! Thank you.

Dr. Ligibel:The study that showed that eating a low fat diet reduced the risk of breast cancer recurrence, called the Women’s Interventional Nutrition Study or “WINS”, was largely conducted in the 1990’s, when there was not as much of a focus on different types of fat. Thus there is unfortunately not a lot of evidence to provide an answer for your question about the impact of different types of fat on breast cancer recurrence rates. However, in the years since the WINS study was conducted, research in other disease such as heart disease, has shown that all fats are not equal in terms of the impact that they have on a person’s risk of developing different diseases. There is also evidence from population studies that suggest that individuals who consume healthy fats seem to be at lower risk of some kinds of cancers, although we can’t determine if there is a cause and effect relationship between the types of fats a person eats and their risk of cancer from this kind of study.

A number of on-going studies are looking at whether there is a “best” diet for breast cancer survivors, but evidence is not conclusive at this point. Some evidence suggests that keeping weight in a good range might be more important than specific dietary ingredients. The National Heart, Lung and Blood Institute, a group that prepares many of the recommendations about weight and diet for the US population, currently supports the use of a number of diets to maintain a healthy weight.

Thus there is no simple answer to your question, but if your diet is successful in keeping your weight in a good range, it is likely a reasonable plan for you to continuing following.

Question about Exercise and Health Benefits: I have a very physically demanding job where I move at a great clip outdoors for at least 3-4 hours each day. When I am done work I have no energy for formal exercise, especially since BC treatment and Tamoxifen, just stretching or a little Yoga. Is this enough?

Dr. Ligibel:Studies have shown that physical activity, no matter how it is achieved is linked to better outcomes in breast cancer. Sometimes it is hard to know how much activity a person is doing as part of a work day, so one way to make sure that you are doing enough exercise is to wear a pedometer to track the distance you walk each day as part of your job and during your leisure time. You should aim for 10,000 steps per day. If you are accomplishing this much walking during your average work day, you are likely achieving enough physical activity to provide health benefits.

Question about Weight Loss: I am taking Anastrozole. It is very difficult to lose weight. Do you have any suggestions as to offsetting the effects of this medication on weight loss? What should the majority of the diet include and what should be omitted in order to lose weight?

Dr. Ligibel:There are many reasons why woman with breast cancer gain weight or have difficulty in losing it after breast cancer diagnosis. Some women go through menopause as a result of chemotherapy or other cancer treatments. The average women who undergoes a “normal” menopausal (not due to cancer treatment) will gain 5-10 pounds in the years after her menstrual cycles stop. This weight gain can be even greater when it occurs suddenly as a result of breast cancer treatment. Many women also feel fatigued as a result of their breast cancer therapy and become less physical active. Studies have shown that weight gain is not increased in women taking tamoxifen or anastrozole, but it is harder to study the effects of these drugs on a woman’s ability to lose weight.

Regardless of the reasons for weight gain, weight loss requires calorie reduction. This can be accomplished in many ways. A diet that is low in fat and high in fruits and vegetables has been a standard for weight loss for many years, but low carbohydrate, vegetarian, low glycemic index and Mediterranean diets can also be used to lose weight. Many people find keeping a journal of what you eat and drink as a first step to understanding your eating patterns. You might be surprised by “hidden” calories you are consuming. Some people also find a structured meal plan to be helpful when starting a weight loss program. Commercial programs can also be useful to teach you how to recognize where your calories re coming from and create new eating patterns.

Question about Diet/Exercise Resources: Do you have any recommendations for books or resources that would be a good guide to helping with navigating the best things to do for nutrition/exercise after breast cancer?

Dr. Ligibel:The American Cancer Society has developed a set of diet and nutrition guidelines for cancer survivors that is available on its web site.

The American Society of Clinical Oncology has also made Obesity and Cancer one of its primary initiatives this year and will be releasing a set of materials about weight, nutrition, and diet for cancer survivors in the next few weeks. This materials will be available in print and online through the Cancer.net website.

Question about Neuropathy: Can diet or exercise help neuropathy from chemo?

Dr. Ligibel:There is not a lot of evidence that diet or exercise can help neuropathy from chemotherapy. There are studies looking at glutamine, a supplement, but this product seems to work best while an individual is receiving chemotherapy treatments. On-going studies are looking at acupuncture as a potential treatment for chemotherapy-induced neuropathy.

Question about Prevention: What should we tell our daughters, sisters, mothers, wives, girlfriends about diet/exercise to help them prevent breast cancer?

Dr. Ligibel:There is a lot of evidence that a “healthy” lifestyle—keeping your weight in a healthy range, exercising regularly, and consuming a diet that is higher in fruits and vegetables and lower in fat—could reduce the risk of developing breast and other cancers. This doesn’t mean that these behaviors are 100% effective in preventing breast cancer or that people who don’t do any of these things will necessarily develop breast cancer, but the evidence does suggest that maintaining a healthy lifestyle should be part of a cancer prevention strategy.

General nutrition and physical activity recommendations from the American Cancer Society for Cancer Prevention include the following:

1. Stay Active: perform at least 150 minutes of moderate-intensity aerobic exercise each week, such as walking at a brisk pace

2. Consume a healthy diet that is low in fat and high in fruits, vegetables and fiber

3. Maintain your weight in a healthy range and attempt weight loss if you are overweight or obese

4. Limit alcohol to no more than 1 drink per day for women and 2 drinks per day for men

Question about Immune System: My questions are three-fold: First- does boosting the immune system help prevent breast cancer? Second, Is there a diet that boosts the immune system (I am a vegetarian)? And, lastIy, I just read something about a study showing that a vegetarian diet is linked to poor health—what does this mean to me as a breast cancer survivor?

Dr. Ligibel:There is a lot that we do not know about the biology that links nutrition and exercise to breast cancer. Some scientists have hypothesized that the immune system may play a role in this connection, but there is little conclusive evidence. Similarly there is not much known about how specific foods or supplements affect the immune system, so I would not recommend a particular diet to enhance the immune system.

Finally, vegetarian diets can be very healthy, as long as they contain a good balance of essential nutrients. It can be hard to consume enough protein, for example, for individuals who maintain a vegetarian diet. As long as you ensure that you consume a balanced diet, there is no reason why a vegetarian diet would be unhealthy. If you have specific concerns regarding your diet, I would recommend meeting with an oncology nutrition specialist.

Question about Diet/Exercise to help with fatigue: I have metastatic breast cancer—been on multiple treatments for what seems like forever. I am grateful to be alive but am beginning to feel what I assume are the cumulative effects of all of my treatments. Are there any recommendations for food or exercise that might help with my fatigue?

Dr. Ligibel:There is unfortunately very little information about the role of diet and exercise in patients with advanced breast cancer. However, exercise has been shown to be an effective way to reduce fatigue in many studies performed in women with early-stage cancer undergoing chemotherapy. There have been a few small studies of moderate-intensity exercise in women with advanced cancer that suggest that exercise is safe and may have benefits. I would recommend asking your doctor about starting an exercise program. As long as he or she is supportive of this, I would recommend slowing starting to exercise. It is important to set reasonable goals, and begin slowly. If you have not been exercising at all, even just walking around the block once per day can be a good start. Build up the time that you spend exercise each week, and you will likely begin to see some benefits in terms of your energy level.

Question about Weight Loss: I was diagnosed with Stage 4 Inflammatory Breast Cancer last July at the age of 31. I am currently on maintenance treatment and need to lose about 40-50 pounds. I lost a lot of my strength during treatment and I am a pretty picker eater who hates to cook. The thought of having to lose that much weight is so overwhelming even though I know it will help to decrease recurrence. Can you tell me what 2 or 3 things (whether nutrition or exercise related or both) that I can start with?

Dr. Ligibel:It can be daunting to know where to figure out where to start when you would like to lose a lot of weight. We find that people are most successful when they start with an attainable goal. Studies have shown that smaller amount of weight loss, 5-10% of your starting body weight, can have many benefits, even if people can’t lose 50 pounds.

I would recommend that you start with keeping track of what you eat for a week. Look for “hidden” calories like soft drinks, alcoholic beverages or juices, which are high in calories and not filling. Processed foods and sweets are also very high in calories with less nutritional value. Try to limit the amount of these you consume.

Start slowly with exercise if you have not been active. Make a plan to start with walking at a moderate pace for 10-15 minutes three times per week and gradually increase to every day, and then for longer periods of time.

Joining a group program (like Weight Watchers) can also be helpful for some people, or working with a weight loss “buddy”, a person with whom you can explore low calorie recipes and exercise, works for some people.

Question about Maca: I am taking Femara for ER & PR + stage III breast cancer. Is it safe to take Maca to help manage side effects of the AI?

Dr. Ligibel:There is unfortunately no safety data for this supplement for women with breast cancer.

Question about Soy: My question concerns tamoxifen, nutrition and products that contain soy. I was diagnosed 1/19/12 with invasive ductal carcinoma PR+ ER+ HER2+ and received bilateral lumpectomies, No lymph node involvement either side, 16 taxol/herception weekly infusions, 33 radiation rounds, 4 A/C, and the year’s course of Herceptin. I have been taking tamoxifen for the last year and a half and have read conflicting information about soy products. Although my hot flashes have subsided a bit, they do keep wake me up at night. I realized that many protein rich yogurts and nutrition bars have traces of soy in them. I considered soy as a supplement initially but decided against it, since the research appeared to be “”out”” on the final word (soy mimics estrogen but does it tend to promote my type of estrogen-driven cancer?). What are your thoughts on how much soy is “”good”” or harmful in contributing to recurrence? I appreciate your opinion. ”

Dr. Ligibel:There is a lot that we do not know about the relationship between soy and estrogen-driven breast cancers. Early studies showed that high doses of soy led to breast cancer formation in lab experiments, but it is not clear whether this amount of soy was remotely similar to what a woman could consume through diet. A number of recent reports looking at diet patterns in women in Asia and the US suggested that the risk of breast cancer recurrence was not increased by soy intake. Although there are some difficulties in using this information to completely conclude that soy intake is “safe” for breast cancer survivors, most experts at this point feel fairly confident that some soy intake in the diet is unlikely to be dangerous for breast cancer survivors. This means that it is likely not necessary to be reading food labels to avoid products containing soy, but I would personally stop short of endorsing soy as a supplement for a breast cancer survivor.

Question about Foods to Avoid: Are there any specific foods we should stay away from specifically if you are positive to estrogen?

Dr. Ligibel:There is a lot of debate regarding the use of soy products in women with an estrogen-positive breast cancer (please refer to the prior question regarding soy). Other foods also contain phytoestrogens, which are plant-based substances that are similar in structure to hormonal estrogen but come from plant sources. There is not a lot of definitive evidence about the risks or benefits of any of these products in women with breast cancer, but as a general rule, the moderate amounts of most of these substances in foods are considered safe.

Therefore, I would not say that there is good evidence that any food needs to be avoided for women with breast cancer, but soy products, flax seed, and alcoholic beverages (which also increase estrogen in some situations) should be taken in moderation.

Would Human Extinction Be a Tragedy?

Our species possesses inherent value, but we are devastating the earth and causing unimaginable animal suffering.

An overgrown lot along Highway 13 near the town of Haleyville, Ala.CreditWilliam Widmer for The New York Times.
An overgrown lot along Highway 13 near the town of Haleyville, Ala.CreditCreditWilliam Widmer for The New York Times

There are stirrings of discussion these days in philosophical circles about the prospect of human extinction. This should not be surprising, given the increasingly threatening predations of climate change. In reflecting on this question, I want to suggest an answer to a single question, one that hardly covers the whole philosophical territory but is an important aspect of it. Would human extinction be a tragedy?

To get a bead on this question, let me distinguish it from a couple of other related questions. I’m not asking whether the experience of humans coming to an end would be a bad thing. (In these pages, Samuel Scheffler has given us an important reason to think that it would be.) I am also not asking whether human beings as a species deserve to die out. That is an important question, but would involve different considerations. Those questions, and others like them, need to be addressed if we are to come to a full moral assessment of the prospect of our demise. Yet what I am asking here is simply whether it would be a tragedy if the planet no longer contained human beings. And the answer I am going to give might seem puzzling at first. I want to suggest, at least tentatively, both that it would be a tragedy and that it might just be a good thing.

To make that claim less puzzling, let me say a word about tragedy. In theater, the tragic character is often someone who commits a wrong, usually a significant one, but with whom we feel sympathy in their descent. Here Sophocles’s Oedipus, Shakespeare’s Lear, and Arthur Miller’s Willy Loman might stand as examples. In this case, the tragic character is humanity. It is humanity that is committing a wrong, a wrong whose elimination would likely require the elimination of the species, but with whom we might be sympathetic nonetheless for reasons I discuss in a moment.

To make that case, let me start with a claim that I think will be at once depressing and, upon reflection, uncontroversial. Human beings are destroying large parts of the inhabitable earth and causing unimaginable suffering to many of the animals that inhabit it. This is happening through at least three means. First, human contribution to climate change is devastating ecosystems, as the recent article on Yellowstone Park in The Times exemplifies. Second, increasing human population is encroaching on ecosystems that would otherwise be intact. Third, factory farming fosters the creation of millions upon millions of animals for whom it offers nothing but suffering and misery before slaughtering them in often barbaric ways. There is no reason to think that those practices are going to diminish any time soon. Quite the opposite.

Humanity, then, is the source of devastation of the lives of conscious animals on a scale that is difficult to comprehend.

To be sure, nature itself is hardly a Valhalla of peace and harmony. Animals kill other animals regularly, often in ways that we (although not they) would consider cruel. But there is no other creature in nature whose predatory behavior is remotely as deep or as widespread as the behavior we display toward what the philosopher Christine Korsgaard aptly calls “our fellow creatures” in a sensitive book of the same name.

If this were all to the story there would be no tragedy. The elimination of the human species would be a good thing, full stop. But there is more to the story. Human beings bring things to the planet that other animals cannot. For example, we bring an advanced level of reason that can experience wonder at the world in a way that is foreign to most if not all other animals. We create art of various kinds: literature, music and painting among them. We engage in sciences that seek to understand the universe and our place in it. Were our species to go extinct, all of that would be lost.

Now there might be those on the more jaded side who would argue that if we went extinct there would be no loss, because there would be no one for whom it would be a loss not to have access to those things. I think this objection misunderstands our relation to these practices. We appreciate and often participate in such practices because we believe they are good to be involved in, because we find them to be worthwhile. It is the goodness of the practices and the experiences that draw us. Therefore, it would be a loss to the world if those practices and experiences ceased to exist.

One could press the objection here by saying that it would only be a loss from a human viewpoint, and that that viewpoint would no longer exist if we went extinct. This is true. But this entire set of reflections is taking place from a human viewpoint. We cannot ask the questions we are asking here without situating them within the human practice of philosophy. Even to ask the question of whether it would be a tragedy if humans were to disappear from the face of the planet requires a normative framework that is restricted to human beings.

Let’s turn, then, and take the question from the other side, the side of those who think that human extinction would be both a tragedy and overall a bad thing. Doesn’t the existence of those practices outweigh the harm we bring to the environment and the animals within it? Don’t they justify the continued existence of our species, even granting the suffering we bring to so many nonhuman lives?

To address that question, let us ask another one. How many human lives would it be worth sacrificing to preserve the existence of Shakespeare’s works? If we were required to engage in human sacrifice in order to save his works from eradication, how many humans would be too many? For my own part, I think the answer is one. One human life would be too many (or, to prevent quibbling, one innocent human life), at least to my mind. Whatever the number, though, it is going to be quite low.

Or suppose a terrorist planted a bomb in the Louvre and the first responders had to choose between saving several people in the museum and saving the art. How many of us would seriously consider saving the art?

So, then, how much suffering and death of nonhuman life would we be willing to countenance to save Shakespeare, our sciences and so forth? Unless we believe there is such a profound moral gap between the status of human and nonhuman animals, whatever reasonable answer we come up with will be well surpassed by the harm and suffering we inflict upon animals. There is just too much torment wreaked upon too many animals and too certain a prospect that this is going to continue and probably increase; it would overwhelm anything we might place on the other side of the ledger. Moreover, those among us who believe that there is such a gap should perhaps become more familiar with the richness of lives of many of our conscious fellow creatures. Our own science is revealing that richness to us, ironically giving us a reason to eliminate it along with our own continued existence.

One might ask here whether, given this view, it would also be a good thing for those of us who are currently here to end our lives in order to prevent further animal suffering. Although I do not have a final answer to this question, we should recognize that the case of future humans is very different from the case of currently existing humans. To demand of currently existing humans that they should end their lives would introduce significant suffering among those who have much to lose by dying. In contrast, preventing future humans from existing does not introduce such suffering, since those human beings will not exist and therefore not have lives to sacrifice. The two situations, then, are not analogous.

It may well be, then, that the extinction of humanity would make the world better off and yet would be a tragedy. I don’t want to say this for sure, since the issue is quite complex. But it certainly seems a live possibility, and that by itself disturbs me.

There is one more tragic aspect to all of this. In many dramatic tragedies, the suffering of the protagonist is brought about through his or her own actions. It is Oedipus’s killing of his father that starts the train of events that leads to his tragic realization; and it is Lear’s highhandedness toward his daughter Cordelia that leads to his demise. It may also turn out that it is through our own actions that we human beings bring about our extinction, or at least something near it, contributing through our practices to our own tragic end.

Cardiologists and Airline Pilots: Mark Nicholls Speaks to Interventional Cardiologist Dr Bill Lombardi About What the Profession Can Learn From the Airline Industry

Every time a commercial pilot encounters a complication, the airline involved conducts an immediate root-cause analysis and shares the findings throughout the industry with the focus on the problem and the appropriate response, rather than blame. Pilots, argues interventional cardiologist Dr Bill Lombardi, welcome the process as it keeps their skills sharp. However, no such feedback-improvement loop exists for interventional cardiologists, he notes, despite performing their role with similar life-or-death consequences.

Bill Lombardi believes a culture change is required to prise cardiologists ‘out of a too-cautious posture’ and enable them to have the confidence and skill sets to perform more challenging procedures for the benefit of patients without the fear of litigation or criminal investigation. At present, he suggests, fear of potential complications often results in cardiologists declining to perform procedures in complex cases or readily share data when complications occur. With interventional cardiologists, the norm is to quietly review and learn without sharing the information, and perhaps deciding not to take on such riskier cases in the future, Lombardi says.

The son of an airline pilot, he suggests, this is ultimately counter-productive and that interventional cardiologists should follow the example of his father’s profession and adopt the commercial airlines’ ‘feedback improvement loop’.

Lombardi, who directs Complex Coronary Artery Disease Therapies at UW Medicine—the health system of the University of Washington—outlined his views at a ‘learning from complications’ symposium in Seattle in August, one focus of which was how cardiologists could improve by sharing information about mistakes or unforeseen complications to learn from them and avoid repeating them.

Lombardi said: ‘Instead of hiding complications and being fearful of describing complications, or being somewhat protectionist and having a heavy emphasis on avoidance rather than learning from them, what we want to try and do is discuss the challenges of our profession in doing more complex procedures. How do we develop a better way to share global experience in a way that others can learn from other’s mistakes rather than having to repeat them or learn them on their own?’

In aviation, accident scenarios can arise out of a minor technical malfunction, but escalate because of hurried subsequent decisions. This is mitigated through communication and regular training. He advocates the development of a structured work process for cardiologists with checklists and educational updates, so that when a complication occurs, it is a learning opportunity for all practitioners.

For instance, the famous landing of US Airways flight on the Hudson River—as portrayed by Tom Hanks in the film ‘Sully’—was possible because the commercial pilot had rehearsed the scenario of multiple engine failures as part of ongoing training and was able to calmly respond. And after a catastrophic engine failure caused the 1989 crash of a DC-10—the aircraft type his father flew—all DC-10 pilots were mandated to fly the crash and the appropriate response on a simulator. ‘The impetus of the symposium and was to bring some of that sensibility to our profession’, said Lombardi, a specialist in cardiac catheterisation and interventional cardiology.

At present, he says many interventional cardiologists differ significantly from commercial pilots when they encounter a complication. ‘There is a lot of risk-avoidance’, he suggests, ‘of avoiding therapies that would have benefit to patients but are avoided because of lack of competency and lack of understanding of how to manage the consequences of a poor decision’. It would be like saying an airline pilot is only going to fly when the weather is beautiful. ‘That is because we don’t fundamentally train the minimum competences of interventional cardiologists to the level of a pilot. The minimum competency to do interventional cardiology is more analogous to flying a Cessna, a little single-engine plane, in beautiful weather, rather than the competency required of a commercial or military pilot’.

Lombardi thinks the hierarchical structure of cardiology contributes to this culture with a top-down, rather than horizontal, education process. He also expressed concern about communication practices, in which the senior physician dictates what happens during procedures and other points of view are not encouraged. ‘In contrast, cockpit communication is very horizontal between pilot, flight attendants, and air traffic control. That certainly is not nurtured and developed within our profession’.

And when a complication does occur, few mechanisms exist to share and broadly learn from it. There is more of a culture of blame, he said. The lack of such a feedback-improvement loop for interventional cardiologists may stem from fear of malpractice litigation, which encourages practitioners to shy away from an open dialogue.

Lombardi advocates minimum competencies that practitioners must acquire and demonstrate in a more structured way. That, he says, would require hospitals and healthcare systems to send interventionalists to annual courses of case simulation and didactics, updates on potential complications, treatment and new data. People would be forced to maintain a minimum competency—exactly the same as the airline profession. Once you have built that kind of culture, you can look at a complication with a central resource data set. It can be reviewed by a panel and yield learning objectives that go back to the institution and the operator. Ultimately, it can be among the annual educational updates for the profession.

‘In an ideal world, that is what we would get to’, he said ‘It would not be litigation and criminal justice to help doctors learn but the value of education and competency’.

Lombardi suggests this reluctance to learn from mishaps is a global issue across healthcare more generally, not specifically interventional cardiology. ‘I speak of interventional cardiology because it is what I know, but I think it is a wider problem. Patients might assume that every doctor with similar training has the same skills, but because we lack measurable competencies, that is not actually true’.

He is convinced that if practitioners had better minimum competencies and a better understanding of potential consequences of decisions, patients would receive better care. ‘If you work in an objective way to improve management of complications and reduce not just the number of complications but the consequences of those complications, that actually saves healthcare systems and hospitals tremendous amounts of money as well as helping patients. In the long term, it would give patients more trust that when they are getting treated, the person treating them actually has the skill sets to take good care of them’.

Such a transformation could take a decade to bring about tangible improvements.

‘If we can start to build a constructive discussion and construct, one that is not going to offend but one that is going to actually highlight the benefits, then we have an opportunity to start changing the culture, which should then help improve patient care’.

The Last Conversation You’ll Ever Need to Have About Eating Right

Mark Bittman and doctor David L. Katz patiently answer pretty much every question we could think of about healthy food.

Raw tomatoes or cooked tomatoes? Our metabolism can more easily access the antioxidant that makes tomatoes red when they’re cooked than when they’re raw. Photo: Bobby Doherty

It’s beyond strange that so many humans are clueless about how they should feed themselves. Every wild species on the planet knows how to do it; presumably ours did, too, before our oversized brains found new ways to complicate things. Now, we’re the only species that can be baffled about the “right” way to eat.

Really, we know how we should eat, but that understanding is continually undermined by hyperbolic headlines, internet echo chambers, and predatory profiteers all too happy to peddle purposefully addictive junk food and nutrition-limiting fad diets. Eating well remains difficult not because it’s complicated but because the choices are hard even when they’re clear.

With that in mind, we offered friends, readers, and anyone else we encountered one simple request: Ask us anything at all about diet and nutrition and we will give you an answer that is grounded in real scientific consensus, with no “healthy-ish” chit-chat, nary a mention of “wellness,” and no goal other than to cut through all the noise and help everyone see how simple it is to eat well.

Here, then, are the exhaustively assembled, thoroughly researched, meticulously detailed answers to any and all of your dietary questions.

Just tell me. Ethical concerns aside, which diet is the best: vegan, vegetarian, or omnivorous?
We don’t know, because the study to prove that any one diet is “best” for human health hasn’t been done, and probably can’t be. So, for our health, the “best” diet is a theme: an emphasis on vegetables, fruits, whole grains, beans, lentils, nuts, seeds, and plain water for thirst. That can be with or without seafood; with or without dairy; with or without eggs; with or without some meat; high or low in total fat.

Okay, well what about the “diets” I keep trying? I just started the paleo diet. Will it change my life?
A genuine paleo diet is almost certainly good for human health, since it’s a diet to which we are adapted. But what is a true paleo diet?

It’s, you know, eating paleo. Like meat. And fruit. And eggs? And bacon!
It is certainly not a blanket license to eat bacon. And it’s not a good reason to give up whole grains, either. Nor do you need to eat eggs, or even meat.

What about burgers or pepperoni? They’re paleo, right?
There were no Paleolithic burgers, or pepperoni. There was also no paleolithic bacon.

So what can I eat?
This is a good place to start because the real experts in Stone Age nutrition think our ancestors — who, by the way, were foragers — consumed a wide variety of ever-changing plant foods that gave them up to 100 grams of fiber daily. We, on the other hand, eat an average of 15 grams of daily fiber. Our forebears are thought to have eaten lots of insects, too. (Few people espousing the virtues of “Paleo” seem inclined to try that out.) They probably ate grains, with some evidence they did so 100,000 years or more ago. And, of course, they ate the meat of only wild animals, since there were no domesticated animals in the Stone Age, with the possible exception of the wolf-to-dog transition.

In any event, the diet to which we are adapted is almost certainly much better for health, and reversing illness, than the prevailing modern diet. There is abundant evidence of disease-reversal with diets of whole, minimally processed food; plant-predominant diets; and even plant-exclusive diets.

So plants are good. Maybe I’ll just do a juice cleanse instead. Wait — are juice cleanses dangerous?
Generally not, depending on your health at the start, but neither are they useful.

Don’t they cleanse your body?
The general claim is that they actually do “cleanse” you — but of what?

Um, toxins?
The body detoxifies itself daily; that’s a primary job of the liver and the kidneys, and they are really good at it. (The intestines, spleen, and immune system are in on it, too.) So, you want to take good care of your liver and kidneys, gut, and immune system. That’s a far better “cleanse” than any juice. How do you take good care of all your detoxifying organ systems? By taking good care of yourself, of course. That means eating well, not smoking, exercising, sleeping enough, managing your stress, and so on.

My friend is always talking about “inducing ketosis.” What is he babbling on about?
A ketogenic diet is one diet that starves the body of glucose sources so that it’s forced to burn ketone bodies — products of fat metabolism — as fuel.

Is that … healthy?
There is no evidence that such diets are conducive to good health in the long run, and no evidence they are better than other, more sustainable diets at health transformation or weight loss in the short run.

But he’s losing weight.
Not everything that causes weight loss or apparent metabolic improvement in the short term is a good idea. Cholera, for instance, causes weight, blood sugar, and blood lipids to come down — that doesn’t mean you want it! The only use of a ketogenic diet that is clearly medically justified is to treat refractory seizures in select cases, mostly in children.

Which is better: a plant-based diet with carbs, or a low-carb diet with meat?
The evidence of every variety overwhelmingly highlights the benefits of plant-predominant diets for the health outcomes that matter most: years in life, and life in years; longevity, and vitality. Forget about “carbs,” and think instead in terms of the foods that are best for you.

If there’s one thing I know for sure, it’s that carbs are evil.
This is probably the silliest of all the silly, pop-culture propaganda about diet and health. All plant foods are carbohydrate sources.

Yeah, but: Carbs are evil.
Everything from lentils to lollipops, pinto beans to jelly beans, tree nuts to doughnuts, is a carbohydrate source. Most plant foods are mostly carbohydrate. So if “all carbs” are evil, then so are vegetables, fruits, whole grains, beans, lentils, nuts, and seeds.

Sure, but, I should still avoid carbs, right?
Exactly the opposite is true. You cannot have a complete or healthful diet without carbohydrate sources.

Why have I been led to believe that carbs are evil?
Highly processed grains and added sugar are bad, not because they are carbohydrate, but because they’ve been robbed of nutrients, they raise insulin levels, and they’re often high in added fats, sodium, and weird ingredients. Carbs are not evil; junk food is evil.

What about gluten? It seems like everyone is kind of gluten-intolerant now.
On the contrary: Statistically, a small percentage of the population is gluten intolerant. About one percent of people have celiac disease, and perhaps 10 percent have lesser forms of sensitivity, which may be related to other factors, like a disrupted microbiome. But still, 90 percent of people have no problem digesting gluten.

So if you’re not gluten intolerant, and if you don’t have celiac disease, is bread really that bad for you?

Should I eat whole-grain bread?
There’s a big difference between white bread and whole-grain bread, and you certainly don’t need to eat bread to have an optimal diet. But an optimal diet leaves room for good bread — whole grain especially — and we think good bread is one of life’s great pleasures. Eat it for that reason.

I want to lose weight. Is diet really more important than exercise?
Yes. It is much easier to outeat running than to outrun all of the tempting calories that modern marketing encourages us to cram in. Both diet and exercise are important to health, and exercise is important in weight maintenance. But to lose weight, the preferential focus needs to be on controlling calories in, more than calories out.

I keep hearing that lectins are toxic and make weight loss harder. What’s the deal?
The deal with lectins is that making them into a bogeyman was a great way to sell yet another fad diet book. Lectins are distributed across almost the entire expanse of foods consumed by humans, and concentrated in some of the foods most decisively linked to health benefits, such as beans and lentils, along with many fruits and vegetables.

Oh yeah, and what’s up with beans? I’ve heard they’re low in fat, high in protein, and high in fiber. However, I also read that they are digestive irritants and slightly toxic due to the lectin content.
The single most salient commonality among all the Blue Zone diets — the diets around the world associated with longevity and vitality — is beans. Beans are really, really, really good for us. Identifying compounds in beans that are potentially “toxic” is like noting that air contains oxygen, which can be toxic.

But also: Beans make me fart.
Some people have a hard time digesting beans, and might benefit from enzyme support, such as Beano. All beans should be cooked; they are nearly impossible for any of us to digest when raw. Despite all the nonsense, the bottom line is that beans are among the most beneficial foods for human health, and offer enormous environmental benefits as well.

Given the prevalence of heart disease associated with poor diets in the U.S., we say bring on the beans! (And, as far as farting is concerned, anecdotally at least, the more frequently you eat beans the better your gut tolerates them.)

Since we’re already talking about farts: I’m all for eating foods like whole grains, nuts, legumes, fruits, and vegetables, but they sometimes — okay, often — make me gassy and bloated. That doesn’t happen when I eat “less healthy” foods.
This could be a food allergy or sensitivity, irritable bowel syndrome, or a problem with your microbiome. All of these can be addressed, but you need a clear diagnosis first. So this is an issue you should take to a doctor who can evaluate you, specifically. You should be able to have a healthful diet, and alleviate these symptoms, too.

Do I have to eat grains if I want to be healthy?
No, but optimizing your diet, and thus your health, is harder if you exclude whole grains, which are highly nutritious. Among their virtues: they are rich in fiber, which tends to be very deficient in the typical American diet — that 15 grams we all tend to eat is half the daily recommended intake. So, if cutting out whole grains lowers your already-low fiber intake further, that’s no good!

My friend never eats fruits and vegetables and is quite proud of that. Is it possible to be healthy without eating fruits and vegetables?
A qualified “no.” Although nuts and seeds are really fruits, and beans and legumes and grains are really vegetables of a sort, we will go the other way and say they are separate. So, you could, in principle, have a diet rich in beans, lentils, chickpeas, whole grains, nuts, seeds, and perhaps fish and seafood, and it would almost certainly be better than the prevailing modern diets of fast food, processed meat, and junk. But as good as the same diet with vegetables and fruits? No way.

If I want to lose weight, should I eat less? And if I eat less, will my metabolism really slow down?
If you starve yourself, yes. And if you lose weight, yes, because a smaller body burns fewer calories than a larger one. The effects tend to be modest, however, unless the weight loss is extreme. You can compensate with exercise, and building some muscle, both of which increase your metabolic rate.

What kinds of foods do you think will help support weight loss?
Wholesome, whole, unprocessed plant foods in particular. And, any food you eat while riding in the Tour de France.

What should I care about on nutrition labels? Calories, fat grams, or sugar grams?
The best foods don’t even have labels, because they are just one ingredient: avocado, lentils, blueberries, broccoli, almonds, etc.

Okay, sure. But what about the ones with labels?
When foods do have labels, look for a short ingredient list of things you recognize as actual food. If the ingredients are wholesome, the nutrient profile will be fine. If the ingredient list is dubious — chemicals, various kinds of added sugar, questionable oils, sodium, and so on — the nutrient profile will be, too. It is really the overall nutritional quality of the food, rather than any one nutrient, that matters. For help getting it right, that even an 8-year-old can use, see here.

Cut through the hype: Cold-pressed coconut oil is neither “good” nor “bad,” but olive oil is a better choice; carbs are not evil, and an optimal diet allows for whole-grain bread. Photo: Bobby Doherty/New York Magazine

What about intermittent fasting? Is that actually effective for better gut health and energy levels?
It’s “effective” relative to doing nothing.

I can eat how I want and then just occasionally fast to “reset” my diet?
No. Fasting is not more effective than limiting calorie intake every day. Fasting is a way to control average, daily food intake — but not the only way. If it works for you, it’s a reasonable option, but it does not involve any magic.

Can I just eat the same thing every day?
Yes, that’s quite reasonable. Variety over time is important to the quality of a diet, but that can be concentrated at dinner if you prefer. So, for instance, how about whole grains (hot or cold), mixed fruits, and nuts for breakfast — every day? Then, how about a salad, soup, or stew of mixed vegetables and beans or lentils for lunch? And then for dinner, a wholesome variety of choices.

Is there really such a thing as a superfood?
If the idea is that a superfood will do super things, then no.

Yeah, except for quinoa, right? Which is magical or something.
No single food, separate from the overall quality and pattern of diet, exerts a major health effect. If your diet is excellent, no single food will be responsible for the benefits. If your diet is terrible, no single food will compensate.

If “super” means the nutrient profile rather than the effects of a food, then … okay: A food that has an especially high ratio of many valuable nutrients relative to calories, and a very low amount of any detrimental nutrients like sugar or saturated fat could be called “super.” But this would not just pertain to exotic berries from neighboring solar systems. This would apply to foods like spinach, broccoli, blueberries, chickpeas, pinto beans, lentils, kale, peaches, or walnuts.

What about avocados? Are they bad for you or good for you? Everyone says they’re full of fat, but that it’s “good” fat.
Think of avocados as you do nuts: They’re “good for you” but with limits. One a day is certainly fine. Their nutrient profile is great, with fat that’s a lot like the fat in olives.

Which is good fat?

Which is different from “bad” fat.

So what’s the difference between good fat and bad fat? I’ve heard I need to avoid saturated fat.
In the diet, what really matters most is balance. Saturated fat, for instance, is bad not because it is “bad” — there is some in even highly nutritious foods — but because we get too much of it. And too much is bad.

How do I get that fat balance?
To get the right balance of fats in our diet, with an emphasis on a mix of polyunsaturated fats, omega-6, omega-3, and monounsaturated fats, we need a balance of foods. Get the “right” fats from nuts, seeds, olives, avocado, and seafood, and use the best cooking oils: extra virgin olive oil tops that list. To avoid an excess, limit the intake of foods high in saturated fat. That includes most meats, and full-fat dairy. And all junk food is suspect for all sorts of reasons.

What about animal fats like lard or tallow? They’re natural so they must be good, right?
All fat sources are a mix of different fatty acids; almost all fats and oils contain a mix of fat varieties: saturated, polyunsaturated, and monounsaturated. Lard is almost 40 percent saturated fat; and tallow is more than 50 percent saturated. That’s a lot.

Since the world’s best diets consistently derive 10 percent or less of their calories from saturated fat, raising the average amount of saturated fat in your diet makes no sense. And there are other factors: Unlike oils that are predominantly unsaturated, such as olive oil, there is no evidence of a health benefit from lard or tallow.

Olive oil. Got it. That one I knew. What about coconut oil? First I heard it’s good for me. Then I heard it’s bad for me.
There’s certainly no evidence it’s “good” for you, but organic, cold-pressed varieties are probably not “bad” for you, either. But olive oil and cold-pressed canola oil are better choices.

Organic, obviously. Even I know that organic is better. Right? It’s certainly more expensive. Tell me it’s better.
Yes. Unquestionably. For many reasons, including that organic farming protects farmworkers from harmful pesticides. There are also clear environmental and ethical benefits.

But … is it healthier?
Proving specific health benefits for organic food is nearly impossible: Imagine a randomized trial comparing only organic food to no organic food, but exactly matched in every other way.

Okay, I’ll stick with organic. Should I take probiotics?
We know pretty reliably that bad microbiomes are common, and that the “right” gut microbes foster good digestion, robust immunity, better sleep, and even weight control —

Okay, sounds good, but — what about probiotics?
In order to foster a healthy microbiome —

Yes, okay, but — what is the microbiome?
Your microbiome is the ecosystem of diverse bacteria that flourishes, quite naturally, in your digestive system. It’s a part of you; as you get healthier, so does it — and quickly. Whole foods, minimally processed, mostly plants, and plain water are good places to start.

One of the current gimmicks — which helps to sell books — is the idea that you have to eat to feed your microbiome. But let’s face it: every wild species on the planet knows what to eat, and none of them know anything about their microbiota. They eat the foods to which they are adapted, and the bugs adapted to live inside them thrive as they do. There’s a lesson for us there: fixing what’s broken is good, and probiotics may be one way of doing it. A balanced diet is a near-certain way.

Okay — so what are probiotics again?
Probiotics are supplements that encourage the repopulation of a healthy microbiome. Think of it like putting high-quality grass seed on a distressed lawn.

Can you “overdose” on probiotics?
In theory, an overdose could result in something called a “dysbiosis,” where the gut is overgrown with an imbalance of organisms. But it must be very hard to do, since we’re not aware of any cases.

What happens if I eat too much yogurt?
We have no idea. Probably you get full.

Fruits and vegetables that are flash-frozen are likely to retain more nutrients than “fresh” fruits and vegetables imported from far away. Photo: Bobby Doherty

What about vegetables? I’ve heard frozen can be healthier than fresh — is that possibly true?
There are instances of frozen vegetables being of higher quality and higher nutritional content than “fresh” vegetables. This is particularly true when produce is “flash frozen,” meaning frozen quickly at very low temperature right after harvesting. Age is everything, and freezing retards aging. So, “fresh” produce that comes from far away is likely to lose some of its nutrient value during the transit time, whereas frozen produce is more likely to preserve the nutrients it had at the start of its journey. The best vegetables are likely to be fresh and locally sourced, but flash frozen is nearly as good, and those “fresh” vegetables that spend a long time in storage or transit are probably the least nutritious.

Does cooking food make it less healthy?
Yes and no: Heat can damage some antioxidants, so raw berries are more nutritious than cooked. But cooking can make some food more nutritious: We can’t even eat (let alone digest) dried beans and lentils without cooking them; but cooked, they’re among the most nutritious and health-promoting of all foods. The antioxidant that makes tomatoes red, lycopene, is more “bioavailable” (our metabolism can access it more easily) when cooked than when tomatoes are eaten raw. Cabbage and other brassicas — including broccoli and most dark, leafy greens — are more readily digested with gentle cooking as well.

What about soy? Is soy good or bad for me?
Soy foods come in many varieties, and many are highly processed, so suffer the same liabilities of all highly processed foods; they’re high in refined starches, heated oils, added sugar and salt, and low in nutrients and fiber.

So what kind of soy should I eat?
Traditional soy foods such as tofu and tempeh are good for you, largely because they provide sound nutrition and because they usually displace meat. Soy as a supplement is less clearly a good idea.

I heard that processed soy products are linked to cancer.
The estrogen-like compounds in soy can promote cancer growth in animals in labs, but the net effect of eating foods like tofu and tempeh is less cancer, not more.

Here’s a stumper. I always hear I should eat more fish for lean protein. But then I also always hear that too much fish exposes me to toxins like mercury. Which is it?
Fish is unquestionably the healthiest animal protein to eat. However: There are huge sustainability issues, and some fish — especially large, predatory fish, like big species of tuna and mackerel, and swordfish and shark — concentrate mercury by eating smaller fish.

That doesn’t really answer my question.
Like anything else, fish shouldn’t be eaten three times a day. Should it be eaten once a day? If it’s your only animal product, and it’s sustainable and not otherwise tainted, yeah. Smaller fish are far less likely to contain mercury than big ones.

How can I find out if it’s otherwise tainted?
There are good online sources about such matters: Here’s one, and here’s another.

Maybe I should just skip the fish and take fish oil supplements instead.
Many high-quality fish oil supplements are tested to be contaminant free. However, sustainability of fish or even krill to produce fish oil is a concern, so if you want a supplement, think about getting omega-3s from those produced using algae.

Algae supplements?

Speaking of supplements, how am I supposed to get my vitamin D when it’s winter and the sun has disappeared and I’m sad?
Stand-alone supplements of vitamin D3 are safe, effective, and inexpensive. Many foods, and most milk, are vitamin D–fortified as well.

How about a drink? The antioxidants from the skins of grapes may confer unique health benefits, but don’t drink because you think it’s “healthy.” Juice cleanses, meanwhile, are neither dangerous nor are they particularly beneficial. Photo: Bobby Doherty

What if I hate lettuce? Do I really needs to eat my greens?
Greens are all good, and one of the few foods you can eat pretty much without limit. These plants are all very low in calories and highly concentrated in diverse nutrients: antioxidants, fiber, vitamins, and minerals.

What are the best antioxidants to take and what are easy ways to get them in our diet?
Eat a variety of vegetables and fruits and you’ll get all the antioxidants you need. There is no good evidence that antioxidant supplements confer the benefits of a diet rich in antioxidants. Other good sources include coffee, tea (especially white and green), dark chocolate and cocoa, whole grains, legumes, nuts and red wine.

Wine! I’ve heard moderate alcohol consumption is good.
Alcohol is the quintessential double-edged sword: There’s a chance for some benefit, but there are risks as well. There’s the relaxation factor, which is immeasurable, and the consensus, which is pretty clear, is that “moderate” consumption may be beneficial and, even more likely, isn’t harmful. “Moderate” means two glasses per day for men; one for women. (Men have higher levels of alcohol dehydrogenase than women, and thus metabolize alcohol more efficiently than women.) There is an association of almost any level of alcohol intake with increased cancer risk, including breast cancer in women and of course liver cancer.

So what is the healthiest alcohol? Is tequila as clean as the hype? Should I aim for low carbs or low calories?
If you think you are drinking alcohol for health, stop now. If you’re drinking it for pleasure, keep your intake moderate and don’t worry about the form, as long as it’s not — for example — paint thinner. If your question is about calories, spirits are the most efficient alcohol in terms of bang for buck; beer is the least. Of course if you take your spirits with ginger ale, it’s a different story.

What about the theory that red wine is good for you?
The antioxidants from the skins of grapes may confer unique health benefits, which would suggest red wine is the best form of alcohol. Again, don’t drink because you think it’s the healthy thing to do.

What about coffee? Please don’t take away my coffee! Caffeine has positive effects, right?
Positive and negative.

What are the positive effects?
Positive: alertness, slightly enhanced cognition.

I’m going to regret asking this but — what are the negative effects?
Negative: potential increases in heart rate, blood pressure, jitteriness, and insomnia.

Not cancer?

I love lattes, but which milk should I use? Are nut milks just flavored water?
No. But nut milks aren’t nutritional powerhouses, either. (Of course, like dairy milk, many such products are nutrient fortified.)

What about oat milk? How do you milk an oat?
Oat milk is made by soaking oats in water, then grinding and straining.

So that is basically oat-flavored water?
Well, with some of the nutrients featured in oats.

Do I need to drink milk at all?
Only if you were born yesterday. Literally.

I thought I needed the calcium. How much calcium does an adult need?
How much calcium we need to eat daily varies with factors such as our activity level, dietary pattern, protein intake, acid load (from foods and medications), life stage (e.g., pregnancy, lactation, senescence), and so on. The closest thing to a one-size-fits-all amount is: roughly 1,000 mg per day.

What are non-dairy sources of calcium?
Kale and other dark leafy greens, beans, soy. Calcium is actually quite widely distributed in the food supply.

But really, in 2018, I’m all about inflammation, which is bad and causes diseases. I’m sure I read that somewhere.
Inflammation is not bad; we need “inflammatory” responses to defend ourselves against germs, and the rogue cells that can cause cancer.

Okay, but it’s sometimes bad. Right?
What is bad is imbalance, and we tend to have an excess of inflammatory exposures and a deficiency of anti-inflammatory exposures. So, for instance, refined carbohydrate and added sugar tend to be inflammatory because they drive up insulin levels and insulin triggers inflammatory responses. We tend to get more saturated and omega-6 fat than we should (from processed foods and many of the oils used in them), and these are inflammatory. Omega-3 fat (from fish, seafood, walnuts, certain seeds) and monounsaturated fat (from olive oil, avocado, nuts and seeds) are anti-inflammatory.

Wait, wait, wait. You lost me at “monounsaturated.” Can you make this simpler?
Water instead of soda: good.

Whole grains instead of refined grains: good.

Nuts, seeds, olive oil, avocado: good.

Fish and seafood in the place of meat: good.

In other words, an “anti-inflammatory” diet is a good diet, one that avoids highly processed foods, lots of meat, lots of full-fat dairy, refined carbs and added sugar, and is instead made up mostly of vegetables, fruits, beans, lentils, whole grains, nuts, seeds, and plain water.

But not seltzer water.
Plain seltzer is fine for generally healthy people, and a far better choice than any of the popular sugary drinks.

Doesn’t seltzer water decalcify your bones?

I’m pretty sure I heard that it does.
It does not.

That’s good, because I like seltzer with a snack. Is snacking okay, or should I stick to three square meals?
There is some evidence suggesting a benefit from smaller meals spaced close together, in terms of total insulin requirements. There is also some evidence that eating earlier in the day is beneficial relative to packing in calories close to bedtime. But these matters are much less important than total daily diet quality, and quantity. Get those right, and almost any timing will be okay, although timing might make a good diet even better. Get quantity and/or quality wrong, and no time is a good time. What you eat matters more than when you eat it.

Many protein bars are as nutritious as candy bars — and you probably don’t need the protein anyway. If you’d like something sweet, dark chocolate is smarter. Photo: Bobby Doherty

Listen, I am a very busy New Yorker and sometimes I eat the occasional PowerBar for lunch. Is that bad?
Many power bars have nutritional profiles similar to Snickers. Generally, power bars are closer to junk than to real food.

But they’re made of protein!
One of the great myths of modern diet is we all need more protein, but in this country almost all of us get more than we need. The satiety that comes from a concentrated protein source could come from a protein bar, or an egg, or a can of tuna, or yogurt, or nuts.

Okay, sure, but again: busy New Yorker. If I don’t have a can of tuna on hand, which protein bar should I eat?
If the bar, it should have a short list of recognizable ingredients; in other words, it should be made of real food. But try hard-boiling some eggs and keeping them handy; or a can of sardines. And stop obsessing about protein: We guarantee you’re getting more than enough.

What is the final verdict on eggs? Are high-cholesterol foods cleared to eat?
Yes. Most levels of high blood cholesterol are not from dietary cholesterol but from saturated and trans fats. Moderation is key. The average person gets most of her or his daily recommended cholesterol by eating just one egg a day.

We got this a bit wrong 30 years ago or so, because saturated fat and cholesterol go together in most foods. But we didn’t get it entirely wrong: The new thinking is that cholesterol is not a nutrient of concern for the typical American. That doesn’t mean it has been entirely exonerated, just that we are already eating it within the recommended range for the most part, and have more pressing concerns, like saturated fat, added sugars, high sodium, and all the rest.

How much protein do I actually need?
We need less than most of us get. A dose of about 1 gram of protein daily per kilogram (2.2 lbs) body weight is already generous in terms of the formal DRIs (Dietary Reference Intakes). So that would mean a man of almost 200 pounds would get more than enough protein from 90 grams daily. Just 3.5 ounces of salmon has nearly 30 grams, and a cup of cooked lentils has about 18 grams. That 200-pound man could easily eat twice that much, or more, in a single meal. So, getting enough protein is easy, which is why there is virtually no such thing as protein deficiency in the USA outside of hospital wards (where it is an effect, not a cause, of serious illness).

Do you have to take protein supplements to build muscle? They are gross, and I’d rather eat real food. But I also want to look like Wonder Woman.
(a) No. (b) Get a fancy bracelet. (c) Good luck! (Have you seen Gal Gadot?)

While we’re on the subject of Wonder Woman: What’s the best thing to eat before and after working out to lose weight and build muscle?
If your diet is wholesome and balanced overall, it almost certainly doesn’t matter. That said, for extremely long or intense workouts, there may be advantages to carbohydrate and protein prior, concentrated antioxidants after to help with muscle recovery. But none of this is relevant for a trip to the gym; this is for the Tour de France or a marathon. Otherwise, eat well over the course of each day, and distribute that eating around your workouts any way you like.

Which is a healthier diet: protein-rich, fat-rich, or fat-free?
They’re not mutually exclusive. You want moderate amounts of protein and fat in your diet. You want carbohydrates, too, which are in most foods but especially fruits, vegetables, grains, and legumes. What you don’t want is hyperprocessed food or a lot of animal products.

What about GMOs? I’ve heard foods with GMOs are really bad.
The foods themselves, no.

Genetic modification is just a method of producing something new, like an assembly line. The answer to whether assembly lines cause health problems is: “It depends what they’re making.” So, too, with GMO foods. It’s the foods that matter, not the process that produced them.

So I can just eat GMO food and not worry?
No. The chemicals used in growing them are a real concern. Glyphosate, the herbicide in Roundup, is likely carcinogenic and harmful in other ways. Furthermore, almost all of the foods currently produced using genetic engineering are useless at best and harmful at worst: “GMOs” are mostly present in junk food, which you want to avoid anyway.

So I should worry.
Since 1996, use of glyphosate has increased 15 times over; there’s a high probability of it showing up in our food.

Now the big question: Which foods will give me cancer?
Processed and cured meats are classified by the International Agency for Research on Cancer as a Group 1 carcinogenic. This doesn’t mean they’re as bad as tobacco, but it means the evidence about a link is comparably clear. Red meat is classified as Group 2A, which means it is “probably” carcinogenic. Needless to say this is a work in progress, but in general almost everyone in the United States would be better off eating less meat.

What if I barbecue it? That seems natural.
Charring food, meat especially, produces carcinogens; so does cooking carbohydrate at high temperature, which happens in the making of chips and some cereals.

This seems like bad news.
These are carcinogenic exposures, but then again, so is sunlight.

So it will kill me? Won’t kill me? Might kill me?
In general, the carcinogens in a reasonable diet make a very modest contribution to overall cancer risk, and don’t compare to something like smoking. A 2017 study by American Cancer Society researchers estimated that 40 percent of all cancer cases could be preventable, and nearly 20 percent of all cases are related to diet and physical inactivity.

Other studies put those figures even higher, but no matter what, if an optimal diet can prevent as many as one of every five cancer cases, and a crummy diet displaces the optimal diet, then the case could be made that a crummy diet of highly processed foods is highly carcinogenic. Our recommendation is: Don’t focus on specific carcinogens. Get your overall dietary pattern right, and your cancer risk will fall.

It sounds like cold cuts and hot dogs are really bad.
As is always the case with food being “bad” for you, it’s partly because of what you are eating, and partly because of what you aren’t eating. People who eat more processed meat are, presumably, eating fewer beans, fewer veggies. It is the overall dietary pattern that matters. But when you add in effects on the environment, and what it means to the animals involved, yeah, you don’t want to eat that too often.

How often is often?
We would go with … once or twice a month, not more. That said, if hot dogs are occasional; and pepperoni pizza is occasional; and cheeseburgers are occasional; and bacon is occasional … well, you get the idea. When all of the “occasionals” add up to more than occasional, then it no longer qualifies as occasional.

What about the “no-nitrate” meats? Are those healthier?
Nitrates have been identified as carcinogenic, and no-nitrate products should be nitrate free. Furthermore: Any product that comes with health claims should not be trusted. What’s not in a product matters, but what is in a product also matters. Sugar is “cholesterol free”! Trans fat is “sugar free”! So what?

Will we ever get lab-grown meat that’s good for us, and also won’t suck to cook and eat?
There are obvious ethical and environmental benefits of raising meat in a lab rather than the body of a living animal. It’s still early to know if there will be any nutritional benefits (or liabilities), and it’s also too early to know about resource use. Suppose lab-raised meat uses more water or food than “regular” meat? And, of course, it’s too early to say much about taste. What is true, is that we can be eating less meat, and better-raised meat, right now.

Is it really that horrible to have too much sodium? We need salt, right?
Too much salt is certainly bad for us, and most Americans eat too much salt. But here’s the thing: 70 percent of our salt comes to us in processed foods and restaurant meals that tend to be bad for us for many reasons. They are high in refined carbohydrate; added sugars; saturated fats; omega-6 oils; food chemicals, as well as sodium. By reducing intake of highly processed foods, and eating more whole, minimally processed foods, mostly plants, your sodium intake will go way down without focusing on sodium at all.

What about sugar? Is it bad for me if I eat it in moderation?
Sugar provides calories with no other nutrients — “empty” calories. It also goes quickly into the blood as blood sugar, where it triggers an insulin release. High levels of insulin help foster weight gain, and particularly fat around the middle, where it does the most harm. Perhaps more important, sugar and sweetness trigger appetite, so we simply tend to eat more when sugar is added to an ingredient list. The food industry knows this very well and routinely puts sugar into formulations to stimulate our appetites, and make us all eat more than we should. So, for many reasons, limiting intake of added sugar is very important to weight control.

How would you define sugar “moderation”?
Limit processed foods; and don’t eat foods with added sugar unless they are a dessert. Look out for sugar added to pasta sauce, salad dressings, even salty snacks. Calories from added sugar should be less than 10 percent of your daily total, and ideally, less than 5 percent.

What about sugar substitutes and artificial sweeteners?
Probably better than sugar, but almost certainly worse than a wholesome diet of foods naturally low in sugar, which then leaves room for a bit of sugar when something sweet is a treat.

Can I keep drinking diet soda? Is it terrible for me?
There’s no real evidence that it’s terrible, but no evidence it’s of any benefit either; it’s not even clear that it helps with weight control. Some recent evidence that artificial sweeteners may disrupt the microbiome and contribute to insulin resistance is reason for concern, and another argument to drink mostly water.

I feel smarter, but what happens when new information comes out, like, tomorrow? How can I stay up to date? It seems like the conventional wisdom on healthy diets changes all the time.
It doesn’t, and the definition of a healthy diet has been clear for some time. In fact, the basic theme of optimal eating — a diet made up mostly of whole, wholesome plant foods — has been clear to nutrition experts for generations. What does change all the time is the fads, fashions, marketing gimmicks, and hucksterism. How do you avoid the pitfalls of all that? Focus on foods, not nutrients. A diet may be higher or lower in total fat, or total carbohydrate, or total protein, and still be optimal. But a diet cannot be optimal if it is not made up mostly of some balanced combination of vegetables, fruits, whole grains, beans, legumes, nuts, seeds, and water. If you get the foods right, the nutrients sort themselves out. But if you focus on nutrients rather than foods, you quickly learn that there is more than one way to eat badly, and we Americans seem all too eager to try them all.

Bear in mind that humans evolved to eat a wide variety of diets, all over the world, from the Arctic to the tropics, desert, plains, mountains, all of which offer wildly different kinds of foods. But none of them “naturally” offer junk food or industrially produced animal products. If you bear that in mind, and eat a balanced diet of real food, you don’t have to worry about much else. It’s really quite simple.

Physicians Are Steering the Conversation About Gun Violence

The NRA’s response in November to the American College of Physicians’ newly published position paper on reducing firearm injuries and deaths—tweeted just hours before a gunman killed 12 people at a California country music bar—was blunt:

Image description not available.

“Someone should tell self-important anti-gun doctors to stay in their lane.”

That tweet galvanized the medical community. The hashtags #ThisIsMyLane and #ThisIsOurLane began to trend on Twitter. And less than a month after the Twitter feed @ThisIsOurLane was created, it had more than 27 000 followers.

Megan Ranney, MD, MPH, is one of the leading voices in the “This Is Our Lane” movement, whose supporters emphasize the need for scientists, physicians, and other health care professionals to tackle gun violence the way they would any other deadly epidemic: with well-funded, thoughtful research to assess its magnitude, identify risk factors, and improve prevention and treatment.

Dr Ranney, an emergency physician and researcher at Brown University, is the chief research officer for AFFIRM, the American Foundation for Firearm Injury Reduction in Medicine, a new nonprofit supported by a number of medical professional organizations, including the American Medical Association.

She spoke with JAMA about why firearm violence is a public health problem and how physicians can be a part of the solution. The following is an edited version of that conversation.

JAMA:Gun violence, including some highly publicized mass shootings, has been a problem in the United States for decades, but that NRA tweet November 7 seems to have galvanized the medical community. Why?

Dr Ranney:Gun violence is an American epidemic, and it’s been an issue that many of us have been working on behind the scenes for years. I think what we saw after the NRA tweet was partly a response to the outrageousness of the assertion, but it also reflected the hard work that a lot of folks have been doing over the years to try to develop a coherent public health approach to this issue.

JAMA:How much has the current political climate been a factor in galvanizing physicians?

Dr Ranney:One of the things that strikes me most about the physician response to this topic is how nonpolitical it is. For most physicians and other health care professionals, gun violence is not an issue of politics. It’s an issue of human lives. What I’ve seen in the response in our community is an insistence that this needs to come back to the patients’ stories.

JAMA:How has gun violence affected your work as an emergency medicine physician?

Dr Ranney:I think for every emergency physician across the country, unfortunately, treating victims of gun violence is something that is part of our—for lack of a better word—bread-and-butter. It is an integral part of every residency program, and almost every hospital across the country sees victims of gun violence. It is something that affects us, both in terms of the number of resources that are needed to respond to a trauma and in terms of the emotional aftermath. Many of us carry the kind of long-term memories and sadness about patients we took care of that we wish we could’ve saved.

JAMA:You’ve noted that gun violence victims are the hardest patients to save. How has that motivated you?

Dr Ranney:I think there are 2 things. One is that the mortality rate from gunshots is so much higher than that of other injuries. There was a great research letter in JAMA looking at the fatality rate of trauma cases in Denver, and the fatality rate from gunshot wounds is increasing. It’s well over 35%, and that’s for folks who make it to the hospital. We know that 90% of suicide attempts with a gun die, and most of them never make it through the doors of the emergency department. When you compare it to the mortality rate from car crashes or falls or even stabbings, the difference is staggering.

We, as researchers and health care professionals, are used to not just treating victims of epidemics but also preventing those injuries and illnesses from happening. Look at our response to HIV or opioid overdoses or Ebola: We identified a problem, and we did something about it.

JAMA:An editorial accompanying the ACP’s position paper suggested that the document missed the mark because it ignored the importance of policing gun violence as a preventive measure. What is your take on that?

Dr Ranney:We all know that laws are useless if they’re not followed, and we do need enforcement. However, a true prevention strategy for gun violence, just like the prevention strategy for car crash deaths, is more than just about the criminal justice space. It’s about changing the upstream factors that lead to gun violence in the first place. When I say violence, I’m talking about mass shootings, but I’m also talking about homicide and about suicide, which is two-thirds of the gun deaths in this country, as well as unintentional injuries, a small but particularly tragic subset of gun deaths.

JAMA:The NRA has questioned the quality of the evidence that the ACP used to support its recommendations. Some physicians blame a lack of federal funding for the shortage of strong evidence. Do you agree?

Dr Ranney:I agree with the NRA tweet that the strength of the evidence is low. The state of the research on firearm injury, or gun violence prevention, is more or less where it was back in 1996, when the Dickey Amendment was passed. Imagine if we were still doing the same thing for sepsis or cancer that we were doing in 1996.

I also agree that a large reason for that deficit in research quality is the lack of funding. A paper that was published in JAMA in January 2017 looked at the amount of funding for various injury and disease conditions compared to the mortality burden. Firearm injury has approximately the same mortality rate, around 10 or 11 per 100 000, as sepsis. And yet, it receives less than 0.8% of the funding that sepsis research does.

Does the funding need to be federal? I think that’s ideal, but we can make a lot of progress with nonfederal funding. You look at what the Gates Foundation is doing for malaria. You look at what the American Cancer Society did back in the 1940s to fund the very first trials on chemo, before the National Cancer Institute was created at the NIH.

There is a role for federal funding, there is a role for state funding, and there is a huge role for private foundation funding. That’s where organizations like AFFIRM are poised to step in. Rather than continuing to wait on politicians and government to act, we felt that it was time to do something ourselves. We know that we need better answers. We need more funding to create those answers, but the source of the funding is not as important, and the rigor of selection and conduct of studies is critical.

JAMA:The editorial author also argues that regardless of the research budget, there are inherent statistical challenges that would preclude scientific certainty with respect to many policies related to firearm violence. What are those challenges?

Dr Ranney:The first and foremost challenge is that we don’t have accurate measurements of the number of injuries and deaths across categories. Obviously, deaths are easy to measure in general, but we don’t have standard methods for medical examiners across the country to decide whether a gun violence death should be categorized as unintentional, vs suicide, vs homicide.

Worse is the measurement of injuries. For that we depend largely on hospital billing codes, with some supplementary data sources like the National Trauma Data Bank, but those are not designed for accurate surveillance. One of the big roles that we [as physicians] can play is trying to get that first data to measure outcomes. When you look at some of the critiques of the early research around guns, a limitation is how accurate do we think we are in measuring whether there’s a gun in the home? There’s a lot of stuff that we could do better by collaborating with gun owners in making this truly a nonpartisan issue. We’re all interested in increasing safety.

JAMA:Is the hope that “This Is Our Lane” will lead to increased funding? Or is the goal mainly to raise awareness of firearm violence as a public health problem?

Dr Ranney:One of the neatest things about “This Is Our Lane” is that it is this beautiful, organic movement that grew from the work many of us had been doing for years. I think we will figure out in the weeks and months to come what the next steps are, but I think our biggest goal is to save lives and prevent injuries.

For some people, it’s about continuing to keep this public health issue in the public eye. For some, it is about federal funding or nonfederal funding, with private-sector funding being a really critical part of the solution. Certainly, right now, and possibly forever, it’s going to be about education of physicians and patients. It’s going to be about improving care for survivors.

We don’t need to approach gun violence as a political problem, and with the other folks involved with “This Is Our Lane,” as well as various collaborators across the country, ranging from AFFIRM to folks at the University of Michigan involved with the FACTS group, to folks at University of California Davis with the “What You Can Do” initiative, to a group of med students called SAFE, there are a lot of us working together to try to move the needle and make some real progress in reversing this epidemic.

JAMA:You mentioned FACTS, the Firearm Safety Among Children and Teens Consortium. The Eunice Kennedy Shriver National Institute of Child Health and Human Development recently awarded a $5 million, 5-year grant for FACTS. Could you talk about the consortium’s goals and your role in it?

Dr Ranney:The big goal of FACTS is to really restart the science of pediatric firearm injury prevention. To achieve that, they’ve assembled a terrific collective of researchers from across the country. We’ve done literature reviews and we’ll be starting some pilot projects. I am leading the work group on secondary prevention and longitudinal consequences, looking at what happens to kids and their communities after a firearm injury, whether it be a suicide attempt or a mass shooting. What can we do to prevent those consequences and to prevent future injury? There’s a lot in the news about PTSD [posttraumatic stress disorder] and anxiety after mass shootings. We think it’s important to not just talk about that, but also to do something.

JAMA:Do you think “This Is Our Lane” will encourage more people to study firearm violence prevention?

Dr Ranney:That’s really the goal behind AFFIRM. We just released our first grant opportunity for young researchers. When I first started doing this—I’ve been a violence prevention researcher for over a decade now—I was explicitly told not to research or talk about gun violence because it would be impossible to create a career with that focus. I’m seeing a lot of folks across the country pop up and say, “This is important to me, and I want to be able to research it in a really thoughtful manner so that the quality of evidence can be better.” For that to happen, there needs to be funding. That’s a large part of the purpose behind AFFIRM. I think groups like FACTS, which are pairing senior researchers with junior researchers, will be critical. We’re starting to see a grassroots network of collaboration and funding that will help to grow the field so that folks who are coming out of residency and PhD programs and fellowships today don’t get the same advice that I got 10 years ago.

JAMA:Why didn’t that advice discourage you?

Dr Ranney:Initially, it did. I didn’t explicitly look at this issue for the first few years. Two things changed my approach. One was a series of clinical experiences with patients that were absolutely tragic, preventable deaths. One patient I took care of had shot himself in the head and did not survive. It really highlighted for me how firearm injury is different: If that person had attempted suicide by taking a handful of pills, I would have saved him.

The other thing was Sandy Hook. For many of us, the images of seeing those kindergartners walk out of that school, and then the images of the parents whose kids never made it out, will remain in our brains forever. I know that there are ways that we can stop this epidemic without infringing on folks’ rights. Our country can solve thorny issues, and I know we can solve this one, too.

Physicians’ Voices on Gun Violence and Other Important Public Health Issues

Physicians have long lent their voices to issues of concern to the health of the public, many of which were politically and socially controversial at the time. Physician organizations were instrumental in formulating recommendations that led to policies around alcohol and driving. Such policies are normative in much of the world today, contributing to reductions in motor vehicle–related morbidity and mortality and resulting in one of the greatest public health triumphs of the 20th century.1 Physicians have been deeply involved in advocacy around tobacco control, resulting in comprehensive tobacco legislation that has contributed to substantial declines in tobacco-related morbidity and mortality over the past decades.1

Physicians have also been engaged in what is perhaps one of the most pressing and contentious issues of the present moment: gun violence. Physician organizations here have led the way. The American College of Physicians, the largest medical specialty group in the United States, has long advocated for a policy-based approach to address firearm morbidity and mortality in the United States, culminating in a set of recommendations published in 2014 about approaches to reduce the effects of gun violence.2 The following year, the American College of Physicians joined a group of 52 organizations in a call to action to consider gun violence as a threat to the health of the public.3 The American Medical Association, the largest physician organization in the country, endorsed a variety of gun control measures in 2018.

Individual physicians have capitalized on more modern means of communication to engage on the issue of gun violence. Galvanized, perhaps ironically, by a tweet from the National Rifle Association that urged physicians to “stay in their lane” and away from the issue of guns, thousands of physicians tweeted their experience of treating those who have experienced gun violence, appropriating the hashtag #thisismylane, and arguing that physicians had a unique perspective on the consequences of gun violence, and, as such, that their voices matter in the broader societal debate about gun safety.4

Yet, this picture of physician involvement in public health issues of consequence omits complexity around this same physician engagement. Gun violence has been essentially endemic in the United States for the past 20 years, long before physician groups endorsed policy efforts that may mitigate the consequences of guns. The new wave of physician voices about guns trails the public conversation that has been raging since the Sandy Hook massacre in 2012. Physician voices have been weak on a range of other issues that occupy the present public health moment, including, for example, the roles of racism and income inequality in shaping health.5,6

Physicians’ Hesitation to Lend Their Voices

Several factors may contribute to physicians’ hesitation when considering engagement with issues of public health consequences.

First, the physician’s role centers on the individual patient-physician relationship. This is canonical in medical school training, inculcated in physicians from the first day of medical school. Much about the role of physicians flows from this orientation. At core, physicians see their responsibility as being to the patient in front of them and, as such, are concerned with the determinants of health of the individual. These determinants, it turns out, are often quite different than the determinants of health of populations.5,6 While comprehensive efforts to limit unfettered access to guns may be essential for reducing the burden of gun violence, such policies are not particularly relevant to the health of an individual patient for whom depression may be a much more important risk factor for potential suicidal ideation. Therefore, the physician’s focus on individual health requires physicians to focus on causes that differ than those that preoccupy population health scientists.

Second, physicians are protective of the integrity of the patient-physician relationship. This leads to appropriate caution about creating barriers between physicians and their patients. At a mundane level, this extends to issues of physician dress and manner.7 Physicians are trained to behave in a way that makes the patient comfortable so that patients may be forthcoming in their conversations. It is not unreasonable to imagine that a patient will be reluctant to discuss safe gun storage with the physician if the physician is well known to have voiced perspectives about gun safety. Ultimately, the need of the physician to be seen by patients as a welcome listener on all aspects of concern to the patient may be at odds with a public presence on contentious issues.

Third, physicians have traditionally not been trained or prepared to lend voices to issues that extend beyond the clinical interaction. Medical journals are replete with articles about the clinical encounter, and physician scholarship has predominantly been concerned with the foundational role of physicians as healers. Although some innovative programs around the country have aspired to train a new generation of physicians in broader advocacy and public engagement, these remain few and far between. Physicians may then be neither prepared for, nor comfortable with, lending their voices to issues that are drawing substantial attention and controversy in very public debates about their merit. The democratization of communication via digital media adds weight to this concern. Physicians are all too aware of the perils of leaving a long digital footprint, in formats that may lull the user to make extemporaneous statements, that then may label a physician in perpetuity.

Why Physicians Should Lend Their Voices

These 3 forces suggest caution for physicians weighing public engagement around issues of public health concern and may explain the relative slowness with which physicians have engaged such issues over the past few decades. However, there are equally important countervailing forces that urge that physicians do lend their voices to the public debate and that, indeed, physicians may have little choice but to do so.

First, and most centrally, physicians continue to be seen as the keeper of the public’s health. While medical professionals recognize the distinction between the clinical encounter, the role of the physician, and the role of the public health practitioner, this distinction is largely lost on the general public, including on policy makers and politicians. Leaders of chief health departments and agencies remain predominantly physicians and the surgeon general is charged with leading the Public Health Service; hence, the silence of physicians on issues of public health consequences is not value neutral. Although the medical profession may have its reasons for not engaging around issues of gun safety, the absence of physician involvement is seen in the broader public as a marker that the issue is not of health concern. In the context of guns, for example, it suggests that guns are primarily a criminal justice issue and not a public health issue, substantially impeding efforts to create a policy framework that can mitigate the consequences of gun violence.

Second, physicians have unique access to the population. It is the role of physicians to engage in conversations with individuals from all walks of life around issues that may harm their health. While public health professionals may create campaigns to sway the public conversation and influence legislation, ultimately, physicians have access to people that no other profession has. By way of analogy, while public health efforts may resemble advertisements for a candidate for political office, the patient-physician interaction may resemble the door-to-door canvassing that is well-recognized to be key to the election of any candidate. In other words, it is inaccurate to see the role of physicians as separate from the role of public health professionals. Insofar as efforts to improve population health require policy actions that rest on individual implementation, little will be achieved without physicians’ engagement.

Third, and building on the latter, physicians have an important moral responsibility to engage around issues that produce health. As former Surgeon General David Satcher said on the issue of gun violence, “If it isn’t a health problem, then why are all these people dying from it?”8 Ultimately, physicians have an important responsibility to engage around issues that harm health and there is no substitute for physicians lending their voices to these issues, no matter how difficult or controversial they may be.

Bringing Physician Voices to Issues of Contemporary Public Health Concern

The observations that physicians have valid reasons for hesitating before lending their voices to issues of public health concern and that these issues need physicians’ engagement present a challenge to the medical profession. It is, however, a challenge that may be long overdue. Widespread availability of digital communication has made public communication faster and more immediate for a much larger portion of the population. This puts pressure on the physician community to come to terms with their engagement with pressing issues of concern faster than they may have had the luxury of doing so in previous decades. Grappling with this tension, ie, between the challenges inherent in lending physicians’ voices to issues and the need to do so, shall require an honest reappraisal of the role of physicians now and during the third decade of the 21st century. This would extend from teaching medical students, through the role of the individual physician in day-to-day practice, to the responsiveness and engagement of professional societies. This will require some time and discussion. It will be time and discussion well spent.

Rethinking medicine

There’s something going on out there

Modern medicine is one of humanity’s great achievements. It improves, prolongs, and saves lives by applying the biomedical and clinical sciences to the diagnosis and treatment of disease. Its strength lies in its clarity and focus, making it an easy model to explain, understand, and put into practice. People have found it powerful, beguiling, seductive even. It is not surprising that the medical model is proving so popular: it serves society well.

But there’s something going on out there. Increasing numbers of doctors and patients are questioning whether medicine has overstretched itself,1 whether it is always as effective as proponents claim, and whether there are instances when the side effects and unintended consequences outweigh the benefits. This critique is not new,23 but it has recently found a common voice in initiatives that transcend health systems and national borders, such as minimally disruptive medicine,4 high integrity care,5 and rethink health.6

In the United Kingdom unease with the medical model may be contributing to doctors’ low morale and to problems with the recruitment and retention of the medical workforce. But the unease is also being expressed in how doctors are thinking about and practising medicine. Some doctors are expressing concern about overdiagnosis and overtreatment and the attendant potential for harm and waste,7 particularly among people with multiple conditions and those who are frail or at the end of their lives. Others are concerned about the limited effectiveness of what they have to offer in the face of the wider social determinants of health such as poor education, unemployment, and the unequal distribution of wealth.8 They are increasingly prescribing social interventions9 and are mobilising the established collective strengths that exist within many local communities to improve health and wellbeing.10

Shifting focus

Some doctors are trying to change their relationships with patients, to listen more carefully to their narratives and work alongside them, sharing information about diagnoses and options for treatment and offering more personalised care and support.11 Others are focusing on helping schoolchildren to understand and manage their health and wellbeing and to understand where doctors do and do not add value.12 Still others are attempting to improve the context within which clinical medicine is provided, drawing on organisational and systems perspectives and on approaches to quality improvement originating from the manufacturing sector.13

These evolving activities in which doctors are choosing to focus their energies are connected. Underlying them is an awareness that some things doctors do are effective for some clinical problems but that different approaches are required to respond to an increasing number of the challenges that doctors face. Rather than becoming entrenched in traditional ways of working, doctors are searching for different ways to make clinical practice more effective and more doable.

Some initiatives are being developed at a national level to support this process. “Prudent healthcare” in Wales14 and “realistic medicine” in Scotland1 represent concerted efforts to create a new set of principles and activities to guide clinical practice, and a narrative which builds on the ground-up energy for change. Early evidence suggests that this work is engaging clinicians who want to have greater impact, patients who want to be listened to, and policy makers who want to optimise value from the healthcare spend. Similar work is starting in England, led by the Academy of Medical Royal Colleges.15

We believe that the process of rethinking medicine is a necessary challenge. We need to define more clearly where the application of a disease focused medical model adds value and where it doesn’t, to help doctors actively develop more productive relationships with patients, and to help them incorporate social interventions into the more traditional armoury of biological and psychological interventions. This will require radical changes to undergraduate and postgraduate training curriculums and the content of continuing professional education. It will require a strong focus on personalised care, community and population health, and the skills required to develop new ways of working with people in local government, the voluntary sector, and local communities.

In 1974, Richard Smith, then an idealistic medical student who was later to become an editor of The BMJ, attended a lecture by Illych entitled, “Limits to medicine.” The lecture gave voice to Smith’s deep but poorly formed concerns about medicine, and he immediately decided to drop out of medical school. Three days later, uncertain what else to do, he dropped back in.16 Forty years on, a growing number of doctors with similar concerns are experimenting with alternatives to ceasing clinical practice. Medicine is being rethought, and doctors have an opportunity to contribute to the wider initiatives taking place in the UK and elsewhere or to incorporate the different elements of these initiatives into their clinical practice. Doing so is likely to revitalise what it means to be a doctor and transform our relationships with patients.

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