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?
No.

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?
Yes.

Which is different from “bad” fat.
Yes.

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?
Yes.

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?
No.

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?
No.

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.

Really?
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.

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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.

Indonesian Tsunami Was Powered by a Deadly Combo of Tectonics and Geography


The magnitude 7.5 earthquake that touched off the tsunami occurred amid a complex puzzle of tectonic plates.
Indonesian Tsunami Was Powered by a Deadly Combo of Tectonics and Geography
Rubble and debris lie around the ruins of a mosque following an earthquake, on October 02, 2018 in Palu, Indonesia.

Videos circulating on social media show an 18-foot wall of water advancing on the horizon.

The tremendous wave builds to a crescendo when it barrels ashore, submerging buildings already toppled by the deadly magnitude 7.5 earthquake that pummeled the northern part of Indonesia’s Sulawesi island last weekend (and triggered the inundation). The temblor and tsunami have killed well over a thousand people, with the toll expected to rise. The tsunami surprised the local population and, at first, some geologists, because the fault that ruptured was not the type typically associated with tsunamis.

Most big tsunamis, like the series of waves up to 100 feet high that killed more than 200,000 people around the Indian Ocean Basin in 2004, result from a sudden lurch of a subduction zone —a line where one of Earth’s tectonic plates is slowly diving beneath another. This heaving of the seafloor forces ocean water upward and outward. The tsunami that recently devastated the city of Palu on Sulawesi, however, was associated with a “strike-slip” fault, where two plates are sliding past each other. “It’s not something that you would’ve predicted,” says Jim Gaherty, a seismologist at Columbia University’s Lamont–Doherty Earth Observatory.

But strike-slip faults can also generate tsunamis through a couple different mechanisms that geologists have been evaluating for this event, in real time on Twitter and other social media platforms. The event, they say, speaks to the complex tectonic jumble that lies beneath Indonesia’s 14,000-plus islands.

Underwater Landslides

The earthquake’s shaking may have loosened sediment on a slope below the sea’s surface, triggering a submarine landslide that pushed water out of the way and sent it rocketing toward shore. Such occurrences have long been known to cause massive tsunamis; a rockslide triggered by a magnitude 7.8 earthquake set off the mega-tsunami in Lituya Bay, Alaska, in 1958. It sent water roaring up mountainsides to reach elevations of 1,700 feet, and remains the largest tsunami recorded in modern times.

Another possibility is the movement of the fault itself caused the tsunami. Although the fault moved horizontally and not vertically, the steep slopes and other unique features on the floor of Palu Bay could have pushed water in front of them as they moved during the earthquake. “It’s like pushing your hand through a bathtub,” says Chris Rowan, a geologist at Kent State University. Researchers at the Karlsruhe Institute of Technology in Germany have done a preliminary study with a tsunami model, and found the lateral movement of the fault and the topography of the bay would be enough to generate a tsunami the size of the one that hit Palu.

Neither possibility precludes the other. “I think the most likely [scenario] is there’s a combination of both going on,” says Austin Elliott, a geologist at the University of Oxford. Whatever the cause was, Palu’s location at the end of a narrow, V-shaped bay “is the worst place for a tsunami,” Elliott says, because the steadily narrowing channel funnels the water into an ever-narrower space, making the waves even higher.

Tectonic Jigsaw Puzzle

The Palu–Koro Fault Zone, the system that ruptured during this quake, is in the middle of a geologic tangle where multiple tectonic plates come together. Below western Indonesia the Indo–Australian Plate is shoved below the Eurasian Plate, occasionally creating the classic megathrust earthquakes that can generate huge tsunamis (just as the magnitude 9.1 temblor did in 2004). But in eastern Indonesia, where Sulawesi is located, the Indo–Australian Plate is topped by continental crust that does not subduct —so it is simply ramming headlong into the crust of the Eurasian Plate, fracturing it. “You’ve kind of got this jigsaw of little plates,” Rowan says, creating a complex environment with “lots of active, dangerous faults.”

Credit: Amanda Montañez; Source: USGS

The dangers of the Palu–Koro Fault have been known since the 1970s, Elliott says. Work in the 1990s and 2000s showed the plates on either side of the fault were moving in opposite directions “faster than the San Andreas Fault,” he says, meaning considerable stress was building up along the fault. A 2017 paper identified this fault as the most dangerous in the area, and suggested a future rupture was most likely to occur in the center of the valley where Palu is situated.

Being situated in this spot exacerbated the damage in Palu because the valley is filled with “flat, weak, soft, wet sediment,” says Robert Hall, a geologist at Royal Holloway, University of London who co-authored the 2017 paper. “Building on top of that is like building on jelly,” because this loose ground intensifies the shaking, he says. (The same thing occurred with the Mexico City earthquake of 1985.)

Surveys of the bay floor will need to be done to confirm the cause of the Sulawesi tsunami. They can look for signs of a landslide, and clues as to how much the fault moved. However it was triggered, the event makes it clear that coastal communities in seismically active regions should not only be worried about tsunamis from subduction zones —and this needs to be better communicated to local communities, Elliott and other experts say. The bottom line, he adds, is: “If you’re at the coast and you feel such a large earthquake, you just should assume there was a tsunami.”

Bill Gates thinks a coming disease could kill 30 million people within 6 months – and says we should prepare for it like we do for war


bill gates
  • The next deadly disease that will cause a global pandemic is coming, Bill Gates said at a discussion of epidemics on Friday.
  • We’re not ready.
  • A flu like the 1918 influenza pandemic could kill 30 million within six months, Gates said, and the next disease might not even be a flu, it might be something we’ve never seen.
  • The world should prepare like it does for war, according to Gates.

If there’s one thing that we know from history, a deadly new disease will arise that will spread around the globe.

That could happen easily within the next decade. And as Bill Gates reminded listeners while speaking at a discussion about epidemics hosted by the Massachusetts Medical Society and the New England Journal of Medicine on Friday, we’re not ready.

As Gates said, he’s usually the optimist in the room, reminding people that we’re lifting children out of poverty around the globe and getting better at eliminating diseases like polio and malaria.

But “there’s one area though where the world isn’t making much progress,” said Gates. “And that’s pandemic preparedness.”

The likelihood that such a disease appears continues to rise. New pathogens emerge all the time as the world gets more populous and humanity encroaches on wild environments. It’s becoming easier and easier for individuals or small groups to create weaponized diseases that could spread like wildfire around the globe. According to Gates, a small non-state actor could rebuild an even deadlier form of smallpox in a lab. And in our interconnected world, people constantly hop on planes, crossing from megacities on one continent to megacities on another in a matter of hours.

According to one simulation by the Institute for Disease Modeling presented by Gates, a new flu like the one that killed 50 million in the 1918 pandemic would most likely kill 30 million within just six months now. And the disease that next takes us by surprise will most likely be one that we see for the first time when the outbreak starts, like happened recently with SARS and MERS viruses.

If you were to tell the world’s governments that weapons were under construction right now that could kill 30 million people, there’d be a sense of urgency about preparing for the threat, said Gates.

“In the case of biological threats, that sense of urgency is lacking,” he said. “The world needs to prepare for pandemics in the same serious way it prepares for war.”

pandemic disease ebola

Stopping the next pandemic

The one time the military tried a sort of simulated wargame against a smallpox pandemic, the final score was “smallpox one, humanity zero,” according to Gates.

But as he said, he’s an optimist, and he thinks we could better prepare for the next viral or bacterial threat.

In some ways, we’re clearly better prepared now than we were for previous pandemics. We have antiviral drugs that can at least do something to improve survival rates in many cases. We have antibiotics that can treat secondary infections, like pneumonia associated with the flu.

We’re getting closer to a universal flu vaccine. During his talk, Gates announced that the Bill and Melinda Gates Foundation would be offering $12 million in grants to encourage the development of such a vaccine.

And we’re getting better at rapid diagnosis, too, something essential since the first step against a new disease is quarantine. Just yesterday, a new research paper in the journal Science announced the development of a way to use the gene-editing technology CRISPR to rapidly detect diseases and to identify them using the same sort of paper strip used in a home pregnancy test.

Yet we’re not good enough yet at rapidly identifying the threat from a disease and coordinating a response, as the recent global reaction to the last Ebola epidemic showed.

There needs to be better coordination and communication between military and government to help coordinate responses. And Gates thinks that government needs ways to quickly enlist the help of the private sector when it comes to developing technology and tools to fight against emerging deadly disease.

As Melinda Gates said recently, the threat from a global pandemic – whether one that emerges naturally or one that’s engineered – is perhaps the biggest risk humanity faces right now.

“Think of the number of people who leave New York City every day and go all over the world – we’re an interconnected world,” she said. Those connections make us all vulnerable.

Donald Trump Warns Flu Shots Are The Greatest ‘Scam’ In Medical History.


The flu shot is the greatest scam in medical history, created by Big Pharma to make money off vulnerable people and make them sick, warns President Donald Trump.
In an interview with Opie and Anthony on Sirius XM, Trump slammed flu shots as “totally ineffective” and declared that he has never had one. Donald Trump Warns Flu Shots Are The Greatest ‘Scam’ In Medical History “I’ve never had one. And thus far I’ve never had the flu. I don’t like the idea of injecting bad stuff into your body. And that’s basically what they do. And this one (latest flu vaccine) has not been very effective to start off with.
Donald Trump Warns Flu Shots Are The Greatest ‘Scam’ In Medical History
I have friends that religiously get the flu shot and then they get the flu. You know, that helps my thinking. I’ve seen a lot of reports that the last flu shot is virtually totally ineffective.” Trump is right on this – flu shots are the greatest medical fraud in history. They are full of “bad stuff” including formaldehyde and mercury – two powerful neurotoxins – and the vaccine industry even admits that laboratory tests prove the popular jab does not work.
Why is a toxic, medical hoax, backed by nothing but voodoo faith-based dogma and clever marketing, pushed on the whole population every year? Vaccines are the one medicine where no scientific evidence of safety or efficacy is required by anyone: not the FDA, not the CDC and not the media. Congress even passed a law protecting the vaccine industry with absolute legal immunity, even when they manufacture and sell defective products that injure and kill people. And vaccine manufacturers have been lying to us for years about toxic levels of mercury in flu shots. Everybody knows mercury is toxic to inject into the human body. That’s not debated except by irrational anti-science denialists. So why won’t manufacturers remove the mercury? And why does Big Pharma continue to push a product that the vaccine industry admits does not even work?
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Is there any real distinction between ‘high’ and ‘low’ pleasures?


<p>Ramen heaven. From Juzo Itami’s 1985 noodle-western <em>Tampopo. Courtesy Criterion Collection</em></p>

Ramen heaven. From Juzo Itami’s 1985 noodle-western Tampopo.

 

Parents often say that they don’t mind what their children do in life just as long as they are happy. Happiness and pleasure are almost universally seen as among the most precious human goods; only the most curmudgeonly would question whether benign enjoyment is anything other than a good thing. Disagreement soon creeps in, however, if you ask whether some forms of pleasure are better than others. Does it matter whether our pleasures are spiritual or carnal, intellectual or stupid? Or are all pleasures pretty much the same?

Utilitarianism, as a moral philosophy, puts pleasure at the centre of its concerns, arguing that actions are right to the extent that they increase happiness and decrease suffering, wrong to the extent that they cause the opposite. Yet even the early Utilitarians couldn’t agree about whether pleasures should be ranked. Jeremy Bentham believed that all sources of pleasure are of equal quality. ‘Prejudice apart,’ he wrote in The Rationale of Reward (1825), ‘the game of push-pin is of equal value with the arts and sciences of music and poetry.’ His protégé John Stuart Mill disagreed, arguing in Utilitarianism (1863) that: ‘It is better to be a human being dissatisfied than a pig satisfied; better to be Socrates dissatisfied than a fool satisfied.’

Mill argued for a distinction between ‘higher’ and lower pleasures. His distinction is difficult to pin down, but it more or less tracks the distinction between capacities thought to be unique to humans and those we share with other animals. Higher pleasures depend on distinctively human capacities, which have a more complex cognitive element, requiring abilities such as rational thought, self-awareness or language use. Lower pleasures, in contrast, require mere sentience. Humans and other animals alike enjoy basking in the sun, eating something tasty or having sex. Only humans engage in art, philosophy and so on.

Mill was certainly not the first to make this distinction. Aristotle among others thought that the senses of touch and taste were ‘servile and brutish’; the pleasures of eating were ‘as brutes also share in’ and so less valuable than those that used the more developed human mind. Yet many would continue to side with Bentham, arguing that we are really not so intellectual and high-minded as all that, and we might as well accept ourselves for the brutes that we are, shaped by biochemistry and animal drives.

The difficulty with resolving this disagreement about the kinds of pleasure is not that we struggle to agree on the right answer. It’s that we’re asking the wrong question. The entire debate assumes a clear divide between the intellectual and bodily, the human and the animal, which is no longer tenable. These days, few of us are card-carrying dualists who believe that we are made of immaterial minds and material bodies. We have plenty of scientific evidence for the importance of biochemistry and hormones in all that we do and think. Nonetheless, dualistic assumptions still inform our thinking. So, what happens if we take seriously the idea that the physical and the mental are inseparable, that we are fully embodied beings? What would it mean for our ideas about pleasure?

The dining table is a good place to start. Along with sex, food is usually considered to be the quintessential lower pleasure. All animals eat, using the senses of smell and taste. It doesn’t require any complex cognition to conclude that something is delicious. Philosophers have generally assumed that to take pleasure in eating is simply to sate a primitive desire. So, for instance, Plato believed that cookery could never be a form of art, because it ‘never regards either the nature or reason of that pleasure to which she devotes herself, but goes straight to her end’.

Plato and his successors, however, failed to appreciate something that the French food writer Jean Anthelme Brillat-Savarin captured pithily in The Physiology of Taste (1825): ‘Animals feed; man eats; only the man of intellect knows how to eat.’ Brillat-Savarin drew a distinction between mere animal feeding, which is the ingestion of food as fuel, and human eating, which can and should engage more than just our most basic carnal desires. Eating is a complex act. Simply gathering the ingredients takes thought, since what we buy not only requires planning but affects the wellbeing of growers, producers, animals and the planet. Cooking involves knowledge of ingredients, the application of skills, the balancing of different flavours and textures, considerations of nutrition, care for the ordering of courses or the place of the dish in the rhythm of the day. Eating, at its best, brings all these things together, adding an attentive aesthetic appreciation of the end result.

Eating illustrates how the difference between higher and lower pleasures is not what you enjoy but how you enjoy it. Wolfing down your food like a pig at a trough is a lower kind of pleasure. Preparing and eating it using the powers of reflection and attention that only a human being possesses turns it into a higher pleasure. This form of higher pleasure need not be intellectual in the academic sense. An accomplished chef might be judging the balance of flavours and textures intuitively; a home cook might simply be thinking about what his guests are most likely to enjoy. What makes the pleasure higher is that it engages our more complex human abilities. It expresses more than just the brute desire to satisfy a craving.

For every pleasure, it should not be difficult to see that the how matters more than the what. Furthermore, the highest pleasures do not merely use our distinctively human capacities, they use them for a valuable end. Someone who goes to the opera to be seen in a new dress is not experiencing the higher pleasures of music but indulging the lower pleasures of vanity. Someone who reads Dr Seuss with a careful ear for language gets a higher pleasure than someone who mechanically recites The Waste Land (1922) without any understanding of what T S Eliot was doing.

Even sex, perhaps the most primal human pleasure of all, can be appreciated in higher and lower ways. To adapt Brillat-Savarin, animals copulate, humans make love. In the intensity of sexual arousal and orgasm, it might not seem that our evolved human capacities are doing much work. But sex is highly contextual, and changes its nature depending on whether it is part and parcel of a genuine relationship between two human beings, however brief, or merely the satisfaction of a brute urge.

Mill was therefore right to believe that pleasures come in higher and lower forms but wrong to think that we could distinguish them on the basis of what we take pleasure in. What matters is how we enjoy them, which means that higher and lower pleasures are not two discrete categories but form a continuum. I think the persistence of the bogus form of the higher/lower pleasures distinction is a result of the fact that some things are more obviously amenable to richer appreciation than others. Art is typically enjoyed in mind-engaging ways, food all too often consumed in an animalistic one. This has led us to mistake association for identity.

The mistake also betrays a false view of human nature, which sees our intellectual or spiritual aspects as being what truly makes us human, and our bodies as embarrassing vehicles to carry them. When we learn how to take pleasure in bodily things in ways that engage our hearts and minds as well as our five senses, we give up the illusion that we are souls trapped in mortal coils, and we learn how to be fully human. We are neither angels above bodily pleasures nor crude beasts slavishly following them, but psychosomatic wholes who bring heart, mind, body and soul to everything we do.

Let’s bring back the Sabbath as a radical act against ‘total work’


<p><em>Bryan Mills/Flickr</em></p>

 

As a boy in late-1940s Memphis, my dad got a nickel every Friday evening to come by the home of a Russian Jewish immigrant named Harry Levenson and turn on his lights, since the Torah forbids lighting a fire in your home on the Sabbath. My father would wonder, however, if he were somehow sinning. The fourth commandment says that on the Sabbath ‘you shall not do any work – you, your son or your daughter, your male or female slave, your livestock, or the alien resident in your towns’. Was my dad Levenson’s slave? If so, how come he could turn on Levenson’s lights? Were they both going to hell?

‘Remember the Sabbath day, and keep it holy.’ The commandment smacks of obsolete puritanism – the shuttered liquor store, the cheque sitting in a darkened post office. We usually encounter the Sabbath as an inconvenience, or at best a nice idea increasingly at odds with reality. But observing this weekly day of rest can actually be a radical act. Indeed, what makes it so obsolete and impractical is precisely what makes it so dangerous.

When taken seriously, the Sabbath has the power to restructure not only the calendar but also the entire political economy. In place of an economy built upon the profit motive – the ever-present need for more, in fact the need for there to never be enough – the Sabbath puts forward an economy built upon the belief that there is enough. But few who observe the Sabbath are willing to consider its full implications, and therefore few who do not observe it have reason to find any value in it.

The Sabbath’s radicalism should be no surprise given the fact that it originated among a community of former slaves. The 10 commandments constituted a manifesto against the regime that they had recently escaped, and rebellion against that regime was at the heart of their god’s identity, as attested to in the first commandment: ‘I am the Lord your God, who brought you out of the land of Egypt, out of the house of slavery.’ When the ancient Israelites swore to worship only one god, they understood this to mean, in part, they owed no fealty to the pharaoh or any other emperor.

It is therefore instructive to read the fourth commandment in light of the pharaoh’s labour practices described earlier in the book of Exodus. He is depicted as a manager never satisfied with his slaves, especially those building the structures for storing surplus grain. The pharaoh orders that the slaves no longer be given straw with which to make bricks; they must now gather their own straw, while the daily quota for bricks would remain the same. When many fail to meet their quota, the pharaoh has them beaten and calls them lazy.

The fourth commandment presents a god who, rather than demanding ever more work, insists on rest. The weekly Sabbath placed a hard limit on how much work could be done and suggested that this was perfectly all right; enough work was done in the other six days. And whereas the pharaoh relaxed while his people toiled, Yahweh insisted that the people rest as Yahweh rested: ‘For in six days the Lord made heaven and earth, the sea, and all that is in them, but rested the seventh day; therefore the Lord blessed the Sabbath day and consecrated it.’

The Sabbath, as described in Exodus and other passages in the Torah, had a democratising effect. Yahweh’s example – not forcing others to labour while Yahweh rested – was one anybody in power was to imitate. It was not enough for you to rest; your children, slaves, livestock and even the ‘aliens’ in your towns were to rest as well. The Sabbath wasn’t just a time for personal reflection and rejuvenation. It wasn’t self-care. It was for everyone.

There was a reason the fourth commandment came where it did, bridging the commandments on how humans should relate to God with the commandments on how humans should relate to one another. As the Old Testament scholar Walter Brueggemann points out in his book Sabbath as Resistance (2014), a pharaonic economy driven by anxiety begets violence, dishonesty, jealousy, theft, the commodification of sex and familial alienation. None of these had a place in the Torahic economy, which was driven not by anxiety but by wholeness, enoughness. In such a society, there was no need to murder, covet, lie, commit adultery or dishonour one’s parents.

The Sabbath’s centrality to the Torahic economy was made clearer in other laws building upon the fourth commandment. Every seventh year, the Israelites were to let their fields ‘rest and lie fallow, so that the poor of your people may eat; and what they leave the wild animals may eat’. And every 50th year, they were to not only let their fields lie fallow, but forgive all debts; all slaves were to be freed and returned to their families, and all land returned to its original inhabitants. This was a far cry from the pharaonic regime where surplus grain was hoarded and parsed out to the poor only in exchange for work and loyalty. There were no strings attached; the goal wasn’t accumulating power but reconciling the community.

It is unknown if these radical commandments were ever followed to the letter. In any case, they are certainly not now. The Sabbath was desacralised into the weekend, and this desacralisation paved the way for the disappearance of the weekend altogether. The decline of good full-time work and the rise of the gig economy mean that we must relentlessly hustle and never rest. Why haven’t you answered that email? Couldn’t you be doing something more productive with your time? Bring your phone with you to the bathroom so you can at least keep busy.

We are expected to compete with each other for our own labour, so that we each become our own taskmaster, our own pharaoh. Offer your employer more and more work for the same amount of pay, so that you undercut your competition – more and more bricks, and you’ll even bring your own straw.

In our neo-pharaonic economy, we are worth no more than the labour we can perform, and the value of our labour is being ever devalued. We can never work enough. A profit-driven capitalist society depends on the anxious striving for more, and it would break down if there were ever enough.

The Sabbath has no place in such a society and indeed upends its most basic tenets. In a Sabbatarian economy, the right to rest – the right to do nothing of value to capital – is as holy as the right to work. We can give freely to the poor and open our homes to refugees without being worried that there will be nothing left for us. We can erase all debts from our records, because it is necessary for the community to be whole.

It is time for us, whatever our religious beliefs, to see the Sabbatarian laws of old not as backward and pharisaical, but rather as the liberatory statements they were meant to be. It is time to ask what our society would look like if it made room for a new Sabbath – or, to put it a different way, what our society would need to look like for the Sabbath to be possible.

Overlooked Biomarker May Predict Cancer Immunotherapy Response


Hi. I’m David Kerr, professor of cancer medicine from the University of Oxford.

As you know, I’ve believed for some time that ploidy (the number of sets of chromosomes in a cell) measurements have been largely overlooked in terms of the relative importance of prognostic markers for the whole range of different cancer types. One of my friends and colleagues, Prof Håvard Danielsen, from the University of Oslo, has established what I consider one of the best assays in the world for measuring ploidy and DNA content in tumors, and characterizing it from paraffin-embedded tissue. ‘It’s a very available system.

New Data on an Overlooked Biomarker

To this end, a really interesting study was recently reported in Science by Teresa Davoli and colleagues,[1] who looked at ploidy across a whole range of tumor types and tried to relate ploidy measurements to the hallmarks of cancer. A ploidy is also known as somatic copy number alterations (SCNAs), and [the authors] refined the definition of ploidy a little, into [SCNAs] that were predominantly focal or [SCNAs] that mainly correlated with whole-arm ploidy, or changes in DNA content in that way.

This was a fascinating study, in which they found that ploidy was indeed associated with prognosis, but also with signatures associated with proliferation, increased expression of the gene’s enzymes involved in control of proliferation and cell cycle—this was mainly for the focal SCNAs. The larger, long-arm, and chromosomal ploidy tended to be associated with reduced expression of immune signature and immune infiltration.

This is an important first step in showing that ploidy does correlate with drivers or hallmarks of cancer. There are some subtle differences that lead you toward increased proliferation or increased immune invasion, both of which work in terms of establishing the cancer.

The researchers then retrospectively analyzed ploidy levels in melanoma tumor specimens saved from two large trials using immune checkpoint inhibitors. What they showed was that aneuploid tumors (eg, elevated levels of SCNA) were indeed more resistant to immune blockade.

It’s a really fascinating new potential use of ploidy, which has been around for decades and has been much overlooked. Not only is it a prognostic marker and therefore gives us important information about the biological behavior of our patients’ tumors, but it may also be a predictive factor in that aneuploid tumors may be relatively resistant to immune checkpoint blockade.

[Because this study was conducted] retrospectively, there’s much work yet to be done. [However, it offers] a really interesting insight for a marker, which I think could be delivered relatively easily in a sophisticated way in every pathology lab in the world. It surprises me that we don’t measure ploidy more. [It is] another interesting insight—some beautiful basic science uncovering the subtle differences in ploidy, how it links to the different hallmarks of cancer, and how it may aid us in selecting patients who may benefit less from immune checkpoint inhibitors.

Thank you for listening. It will be really keen for you to have a look at the Science paper and post any comments that you may care to talk about. This is an unfinished story but one that must be followed up prospectively.

For all book lovers please visit my friend’s website.
URL: http://www.romancewithbooks.com

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