Bernard M. Jaffe, Professor of Surgery, Department of Surgery, Tulane University School of Medicine, New Orleans, LA
Bernard M. Jaffe, MD
Professor of Surgery
Department of Surgery
School of Medicine
New Orleans, LA
I hate carrots! I've hated carrots as long as I can remember. I don't think it's because my mother forced me to eat them, because she didn't. I had no good explanation for this absolute aversion until my daughter sent me this e-mail, which explains it all:
"Warning: Carrots Can Kill!!!
? Nearly all sick people have carrots. Obviously, the side effects are cumulative.
? An estimated 99.9% of all people who die from cancer have eaten carrots.
? Another 99.9% of people involved in auto accidents ate carrots within 60 days before the accident.
? Some 93.1% of juvenile delinquents come from homes where carrots are served frequently.
? Among people born in 1893 who later dined on carrots, there has been a 100% incidence of fewer teeth and failing eyesight."
Nothing we consume is safe anymore. Each passing day brings a new warning about a food we eat or a pharmaceutical agent we prescribe. In 1977, Moore and Palmer wrote an article entitled "Money causes cancer," based on a study in which newly minted coins proved carcinogenic when placed subcutaneously in rodents.* Recently, interest in diet has escalated greatly. Restaurants are bulging at their seams, but even those that serve haute cuisine feature a number of entrees labeled "heart healthy." There is no better evidence for the focus on diets than the profusion of media for weight-loss clinics and the phenomenal number of gastric bypasses performed annually in our country. With the heightened interest in nutrition, dietitians have escaped my literary attention, until now.
Before I get into much trouble, let me stress at the outset that I respect the concept and the scientific field of dietetics. However, I do have major concerns. First and foremost is the record of productivity. It's important to point out that although the major recent advances in nutrition have been made by surgeons, dietitians seem to expect a lot of the credit and claim the bulk of the responsibility. Now, in particular, it's necessary to emphasize and reemphasize that nutrition is an important component of care provided by surgeons.
One of my biggest concerns about dietetics is the lack of consistency. When red wine in moderation was deemed to be cardioprotective (because of its antioxidants), the same kudos were not granted to white wine. But, of course, that has changed and both elixirs now have the same designation. Another example is dietary fat. For years, the advantages of a low-fat diet have been promulgated, yet at the time this editorial was written, three articles appeared in documenting that low-fat diets do not protect women against vascular disease or cancer. Millions of Americans have lowered their taste thresholds based on that false premise. But, not to worry, there is already a new restriction. Now it's not the quantity of fat you eat that matters, it's the nature of the fat that counts. You can pretty much bet that will change in the future.
Obesity is clearly epidemic in our country, and for many of us with fat genes, weight loss poses an extraordinary challenge. I have just lost a substantial amount of weight using the Katrina diet (no food for several days followed by very little food since). Yet despite the simplicity of the calorie-restrictive approach, a large number of complex and varied diets have been formulated to avoid or modify the basic premise. First it's high carbs, then it's low carbs, then it's low glycemic index, etc. Propriety diets have made a number of people very wealthy. Perhaps I missed the boat by failing to perfect the anticarrot diet for people like me who hate carrots. The premise is simple: lose weight by avoiding carrots.
With all the publicity and media attention to weight loss, I would have expected dietitians to lead the charge and slenderize America. But, as a purveyor of gastric bypass for the morbidly obese who have failed all conservative means of weight reduction, I can tell you that hasn't happened. In fact, dietitians have been relatively ineffective. In all the diet histories I have taken, few, if any, patients have lauded the support or accomplishments of dietitians, even though virtually all have used their services. One might argue that my assessment is unfair since I see only the failures, but based on the number of morbidly obese patients, that criticism is not likely to be valid.
I wish surgeons had the same public relations success as dietitians. Despite dietitians' relative ineffectiveness in aiding weight control, virtually all insurers require a dietary consultation before approving gastric bypass. And although there are few good data to support their postoperative bypass diets (a dribble of this, a dram of that), the dietitians' recommendations are widely accepted and followed.
The role of dietitians in hospital care is also greatly exaggerated. As a matter of process, dietary notes are automatically written in the charts of virtually all inpatients, even without requests for consultation. I have never understood the rationale, but I guess I must be in the minority. The fact that it unnecessarily increases the cost of hospital care has somehow been overlooked. I don't know how many of you actually read the dietitian's notes, but if you haven't, I urge you to do so. Their notes are a potential source of enormous liability and canabet malpractice cases. I was recently involved in defending a surgeon in a malpractice trial who had clearly not only met but exceeded the standard, yet the trial ended with a hung jury, based largely on a single misleading comment in a dietitian's note. I wish I had a dollar for every incorrect dietary note written in my patients' charts. For example, I am tired of "inadequate oral intake" in postoperative patients with nasogastric tubes. Based on such nonsense, I have forbidden hospital dietitians from seeing my patients on multiple occasions. But that hasn't worked either.
Despite my protestations about the current situation, there is a real need for dietetics and dietitians. Think of that every time you eat a carrot.
*Moore GE, Palmer WN. Money causes cancer: ban it. JAMA. 1977;238(5):397.