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Poor diet quality is the leading predictor of morbidity (i.e., chronic disease) and mortality (i.e., dying prematurely) in the modern world.
This is established epidemiologic fact, disputed, so far as I know, by nearly no one. Rather than yielding such a damning distinction during the COVID pandemic, the pernicious influences of “bad diet” simply extended to new ills: adverse COVID outcomes linked directly to low diet quality, and indirectly via the contributions of poor diet to pandemic obesity.
These are the facts of the indictment, but the eaters in question are largely innocent bystanders. Sure, we all own some personal responsibility for what adorns our forks daily, but then again- the choices each of us makes are always subordinate to the choices all of us have.
We have a cornucopia of bad choices, from a Farm Bill all about advancing agribusiness where a “Food Bill” all about sourcing sustainable, nourishing sustenance ought to be; to a food supply willfully engineered to undermine restraint by means of addiction or something indistinguishable from it; to the rampant distortions of marketing, fads, false promises, and gimmicks. Good luck out there.
Despite all this, I have generally renounced the notion of telling people- my patients included - how they “should” eat. As medicine incrementally evolves beyond its unfortunate, paternalistic legacies, “should” is something of a throwback, and a liability. To be healthy, the presumptive goal of all so-called “health care,” people arguably “should” eat well, and be active, and avoid tobacco, and so on. But then again- why “should” people be healthy in the first place?
I asked myself that question in the context of my clinical activities many years ago, as ever more cultural disdain positioned “should” at the end of an admonishing finger. Was health some kind of moral imperative? Was it my job to tell my patients that health was a kind of obligation, something “good” people achieved?
My answers to myself, to these and their assorted corollaries were emphatically: no. More than anything, health was a resource each patient could “spend”- during days, and months and years, and decades- as they saw fit. The value proposition of health was not the judgment of a physician, recognizing a moral achievement. The value proposition was simply this: healthy people have more fun. Other things being equal, your life will be better lived healthfully rather than not, and you will have more control over your options.
I settled on the Socratic method to advance that conviction; I started asking my patients why they cared about health, what they thought health was “for.” We generally arrived at an “aha moment” to share.
I am tempted to go with: but that was then, and this is now.
I still have an antipathy to “should,” in clinical context and perhaps in general, just as I do to the deafening bark of dogma. Listening ends where dogma and admonishments begin, and listening is the essential remedy now to so much of what ails us. The Homo sapien superpower is the capacity to share visions and stories; in effect, the art of listening that leads to understanding that leads to overcoming. We renounce that at our very great peril.
But even so, there are moral imperatives when our actions directly impact the health of others. If we are to respect that each of us is the master of personal fate, the captain of our native soul- we must respect the same in others, and honor the places where the bounds of autonomy collide. They meet routinely now in what we choose to eat.
Dietary patterns at odds with planetary health, practiced at the scale of billions of us, are a factor in rising seas that threaten homes; drying aquifers that propagate thirst; climbing temperatures that challenge the limits of human tolerance; and deforestation that devastates biodiversity while assaulting the very lungs of the planet. With these exigencies and more in mind, we are well beyond the boundaries of one another’s autonomy and opportunities for health, and thus well into the realm where “should” warrants reconsideration.
The immediate provocation for this column was a study just published in the Lancet Planetary Health highlighting the adverse mental health effects in children around the world of environmental degradation. We are ruining a planet our kids know they are going to need, and legions of them are looking on with a sense of helpless despair. If that’s not cause for a new look at “should” by us grownups, I can’t imagine what would be.
Remedies here are neither elusive nor abstruse. By itself, the global appetite for beef is a major contributor to environmental degradation of every kind and the single leading threat to biodiversity. Quite simply, we should- collectively- eat much less of it.
We are fortunate that what we "should" do about diet for our own health, and what we SHOULD do to alleviate our children's rightful anxiety about a habitable planet- are entirely concordant. It need not have been so, but it most decisively is.
Impacts of various foods on the environment (Y axis) and human mortality risk (X axis) via: https://www.pnas.org/content/116/46/23357
Those who note a parallel between eating as if the world depends on it- because it does- and vaccines to protect not just ourselves, but others- I can only say I am right there with you. But that’s a “should” topic for another day.
We still have dietary choices, albeit bounded by the common theme of feeding Homo sapiens well, and ever more constrained by the choices already devoured. We have long since passed a fork in the road and taken the tine that leads to new reasons for “should.” We should, I think, choose what we chew accordingly.
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.
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