Roughly two weeks ago, the American Heart Association told the world that diet should be assessed routinely in clinical encounters, and that new tools were needed to make this possible.
The new tools should be quick, elegant, efficient, reliable, accurate, user friendly and economical. They should interface seamlessly with electronic health records, fit without friction into clinical work flow.
I don’t know whether to lead with “amen!” or… “what took you so long?”
Working with some of the world’s leading nutrition experts, associates and I began the development and testing of just such a tool about 5 years ago, and we have been deploying it for the past year. I left academic medicine after nearly 30 years to launch a company dedicated entirely to this value proposition.
You might wonder why diet should suddenly be treated as a vital sign, and the answer is as robust as the question is reasonable: diet quality is the number one predictor of premature mortality in the United States (and increasingly much of the modern world) today. That number one spot was held for some time by tobacco- but now that so many fewer of us smoke, while most of us still eat - diet is indisputably number one. How can the number one predictor of all-cause mortality be treated as anything less than a vital sign? Again, the question is not “why now?,” but… “what took so long?”
Diet is vital, but - why go to the trouble of measuring it? Well, because in medicine as in business…we don’t tend to manage what we fail to measure. Imagine acknowledging the profound importance of blood pressure to health, but never actually measuring anyone’s blood pressure. What hope would there be of managing hypertension?
Diet is vital to health; deserves to be a vital sign accordingly; and must be measured routinely to function as such. So, again I say to colleagues at the American Heart Association: amen. We have the exact tool we agree the world needs; come to DietID.com, and see for yourself.
But now, what about the timing? Is this declaration during the COVID pandemic opportune, inopportune, or simply impertinent? Does an emphasis on the vital importance of diet to health make timely sense given our current preoccupations?
It does. Because COVID makes the perennially vital influence of diet acute and urgent as well.
Other than age, the leading risk factors for adverse COVID outcomes are cardiometabolic derangements: type 2 diabetes, insulin resistance, and obesity; hypertension, dyslipidemia, and coronary disease. Diet is the leading cause of premature death in the United States because it is the leading cause of just such cardiometabolic liabilities. As famously evinced by McGinnis and Foege in 1993, the leading “causes” of death in America (and the world) that populate death certificates are actually effects of their own, underlying root causes. Among those, diet exerts the greatest singular influence.
And so, what follows ipso facto is true: improve diet, improve COVID related risk. Improve diet a lot, and that risk can go down very substantially. Much of the benefit is mediated via the amelioration of any established cardiometabolic malady, but there is a substantial direct impact of diet quality on immune system function as well. That benefit can begin with the immediacy of one well assembled meal, and burgeon greatly over time.
Diet is vital, but generally so in relatively slow motion. COVID makes that influence urgent. We thus have, as some with a bully pulpit have made clear, an opportunity in the crisis of COVID to defend ourselves immediately, while fortifying our health permanently. That latter enterprise is overdue.
My personal place in all this is rather interesting- to me, at least.
For some of you, I am simply a new acquaintance as a prominent voice on the COVID pandemic, speaking as a specialist in Preventive Medicine/Public Health. For others, I have long been familiar as a prominent voice on the topic of lifestyle medicine, in particular diet and health. Those in the latter camp seemingly want, and deserve to know: what’s the connection? Why the COVID commentary from someone preferentially focused until now on nutrition?
As a dual-board-certified physician, with 9 years of post-graduate training- I did not choose to focus on diet and nutrition and lifestyle because I like a good sandwich more than most people. Yes, I care about food, but who doesn’t?
I chose to focus on diet because it was, those nearly three decades ago when my career was launching, one of the several leading predictors of years in life (i.e., life expectancy) and life in years (i.e., quality adjusted life years free of chronic disease) in the United States and much of the modern world. Today, as noted, diet quality is the unrivaled number one such predictor.
So, the focus on diet was not because of preferential interest in diet; it was because of an interest in doing everything possible to add years to lives and life to years, and diet was and is, simply, the greatest available lever to apply to that resistant force. The career-long focus on diet issued from a predilection for the big picture; an interest in turning what we know into what we do; and an abiding devotion to public health pragmatism that always places epidemiology ahead of ideology.
For the moment, the pandemic is at the confluence of all that, and warrants our collective attention. Diet always has been there, and will be when the pandemic is conscribed to history. Even now, the annual death toll attributed to poor diet quality exceeds the toll of COVID in the United States by a multiple of three- and unlike the virus, diet exacts this toll of us every year. To reiterate: Even during the pandemic, poor diet quality is killing more of us than the virus. A food supply willfully engineered to mortgage our health for the sake of corporate profit siphons years from the lives and life from the years of those we love, every year- until we decide it must do so no longer.
Now, at the confluence of the vital and the urgent, the pandemic and the pernicious- seems an excellent time.
David L. Katz, MD, MPH, FACPM, FACP, FACLM, is the Founding Director (1998) of Yale University’s Yale-Griffin Prevention Research Center, and former President of the American College of Lifestyle Medicine. He has published roughly 200 scientific articles and textbook chapters, and 15 books to date, including multiple editions of leading textbooks in both preventive medicine, and nutrition. He has made important contributions in the areas of lifestyle interventions for health promotion; nutrient profiling; behavior modification; holistic care; and evidence-based medicine. David earned his BA degree from Dartmouth College (1984); his MD from the Albert Einstein College of Medicine (1988); and his MPH from the Yale University School of Public Health (1993). He completed sequential residency training in Internal Medicine, and Preventive Medicine/Public Health. He is a two-time diplomate of the American Board of Internal Medicine, and a board-certified specialist in Preventive Medicine/Public Health. He has received two Honorary Doctorates.