Can food policy changes make America healthy again?

Shortly after Donald Trump because the only politician since Grover Cleveland to be re-elected to a non-consecutive second Presidential term, I discussed why Robert F. Kennedy, Jr.'s conspiracy-fueled positions on childhood vaccines and fluoridated drinking water make him unqualified to be the next Secretary of Health and Human Services (HHS). Now that the newly inaugurated President has withdrawn the U.S. from the World Health Organization, presumably paving the way for RFK Jr., if confirmed as HHS Secretary, to "go wild on health," it's time to examine the other side of "Make America Healthy Again": his more mainstream belief that overconsumption of ultra-processed food is the cause of a wide spectrum of chronic health problems.

A side note: medical historians have pointed out that the "again" part of the MAHA slogan, harkening back to a time in the past when our country was healthier than it is today, is nonsensical, as in no past era have Americans lived longer or had a better quality of life with less disability than today. The 19th century, for example?

It’s true that agriculture at the time was organic, food was locally produced and there were no ultraprocessed foods. But fresh fruits and vegetables were in short supply because they were difficult to ship and because growing seasons were so short. ... Common conditions, like hernias, were untreatable — men had hernias as big as grapefruits, held in by trusses. Nineteen percent of those soldiers had heart valve problems by the time they were 60, compared with about 8.5 percent today.

And of course, many thousands of people - mostly young children - died every year from infectious diseases like smallpox, polio, and measles, which have been eradicated or are completely preventable by vaccines that RFK Jr. claims are worse than the diseases. Has he ever seen an iron lung up close? But I digress.

The U.S. government has always had competing interests in food policy. As NYU nutrition professor Marion Nestle (whose engrossing autobiography "Slow Cooked: An Unexpected Life in Food Politics" I read over Christmas break) observed, having the Dietary Guidelines for Americans co-sponsored by HHS and the U.S. Department of Agriculture (whose missions are to help farmers profit from the products they bring to market and to prevent poor people from going hungry by subsidizing food purchases, not to support good health) means that scientifically obvious statements such as "eat less meat" or "drink less alcohol" rarely make it into the guidelines. And opposition from powerful food companies makes even modest changes such as the FDA updating criteria for labeling foods "healthy" and requiring food and beverage products to display amounts of fat, salt, and added sugar at a glance painfully slow.

So what's the evidence that ultra-processed foods lead to obesity and other chronic diseases? A recent systematic review of meta-analyses of observational studies found convincing or highly suggestive links between ultra-processed food exposure and cardiovascular disease, diabetes, anxiety, all-cause and cardiovascular deaths, depression, sleep problems, wheezing, and obesity. Observational studies are susceptible to selection bias, though - perhaps preferring inexpensive highly processed foods is associated with poverty, and poverty itself increases the risk of dying early and unhealthy behaviors, explaining these disease associations.

It's difficult, but not impossible, to randomize study participants to controlled diets; one research team managed to convince 20 adults to participate in a 28-day experiment at the National Institutes of Health that concluded that all other things being equal, people were more likely to consume excess calories and gain more weight on a diet of ultra-processed foods compared to an unprocessed diet. (For further reading, a recent New Yorker article went behind the scenes of this highly cited trial and the debate about its implications that continues to rage in food science circles.)

But the unqualified conclusion "ultra-processed food is less healthy than unprocessed food" is too simplistic, particularly when meat is involved. The plant-based Impossible Burger is clearly ultra-processed, but is it really less healthy than a minimally processed hamburger patty made from ground beef from cows raised on industrial farms? A review of plant-based meat alternatives (PBMAs) in the Canadian Journal of Cardiology found that their nutritional profiles were generally superior to the meats they replaced and improved cardiovascular disease risk factors in dietary trials. The authors concluded that "no currently available evidence suggests that the concerning aspects of PBMAs (food processing and high sodium content) negate the potential cardiovascular benefits."

Which leads me back to RFK Jr.'s crusade against ultra-processed foods. I think implementing this would be an uphill battle because making foods healthier will necessarily require creating more regulations in an administration committed to deregulation. If he's serious about asserting more control over our food production and distribution system to limit ultra-processed foods in the interest of improving Americans' health, RFK Jr. would do well to read Marion Nestle's aspirational agenda for regulating the food industry, which includes actions to take on dietary guidelines, mass media campaigns, taxes, warning labels, marketing restrictions, portion size restrictions, and farm subsidies.

Family physicians perform high-quality colonoscopies, but access is an issue

Most patients who choose colonoscopy as a screening test for colorectal cancer are referred from primary care to a gastroenterologist or other specialist who performs endoscopy. But that wasn’t the case for the estimated 1 in 15 US patients whose screening colonoscopies were performed by family physicians in 2021. A study of an insurance claims database found that family physicians are more likely to perform colonoscopies in older, male patients residing in more rural areas of the Midwest, South, and Western United States.

The American Academy of Family Physicians (AAFP) maintains that clinical privileges should be based on documented training and experience rather than the physician’s specialty. In 2000, American Family Physician published an AAFP position paper (an updated version currently resides on the AAFP website) emphasizing that “colonoscopy can be a natural extension of the total care provided by a well-trained family physician.” In 2008, a Society of Teachers of Family Medicine consensus statement classified colonoscopy as a core procedure that family medicine residents should not only be exposed to but also “have the opportunity to train to independent performance.”

A 2009 meta-analysis of 12 studies (n = 18,292) of screening colonoscopies performed by primary care physicians and a later study of faculty and residents at a single, university-affiliated family medicine center concluded that their performance on quality, safety, and efficacy indicators (reach-the-cecum rate, major complication rate, and adenoma detection rate) was comparable to those recommended by the major gastrointestinal endoscopy societies. In addition, a recent analysis of colonoscopy quality at two high-volume rural programs (University of Texas Southwestern and University of North Dakota) for family physicians, general surgeons, and gastroenterologists found no statistical differences in performance by provider type.

Data indicate that screening colonoscopies are overused and that a colonoscopy-first strategy may only be marginally better than sequential fecal immunochemical testing in reducing colorectal cancer mortality. Nonetheless, millions of US adults older than 50 years have never been screened for colorectal cancer and could potentially benefit from having access to family physician–performed colonoscopy services. Thus, the decline in endoscopic care (including flexible sigmoidoscopy) by family physicians in both urban and rural areas is cause for concern. From 2016 to 2021, the percentage of screening colonoscopies performed by family physicians decreased from 11.3% to 6.7%, and less than 2% of board-certified family physicians report performing colonoscopy in their practices.

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This post first appeared on the AFP Community Blog.

PSA screening: shared decision making is a flawed approach

In early 2020, I accepted an invitation to participate in a live debate with a nationally prominent academic urologist at the annual scientific meeting of the American Society for Men's Health. The topic: "The Great Debate of the 21st Century: To PSA screen or not to screen." Unfortunately, the COVID-19 pandemic caused the meeting to the canceled. By the time I was re-invited in 2021, my academic interests had drifted away from prostate cancer screening, so I declined. But over the past 5 years, I have watched with increasing dismay as family physicians and urologists (mis)interpreted the U.S. Preventive Services Task Force's more permissive stance on PSA screening as a license to start screening indiscriminately again without warning men about the adverse consequences of doing so. "We Should Be Doing Fewer PSA Tests, But We Are Doing More," I pleaded in a 2022 Medscape commentary for primary care physicians. I moved to Lancaster and was appalled when my program's residents received a lecture from a urologist chastising us for not ordering enough PSA tests because we apparently cared more about a few patients avoiding erectile dysfunction and urinary incontinence than the "millions" of lives that could be extended by screening. So I dove back into the evidence, read pretty much every paper on PSA screening published since the pandemic began, and concluded that our current approach to shared decision making is fatally flawed, and that we would be better off not using the PSA test for screening at all.

Then I wrote a paper about it. Here is my unfiltered conclusion:

Even though [the PSA] test's flaws, including poor accuracy and the cascade of interventions that follow a positive result, are well established, guideline developers have assumed that shared decision-making would limit the population of men being screened to those prepared to endure the lifelong monitoring and interventions that follow a positive PSA result. The preponderance of the evidence has not reflected this assumption. The net population benefit of prostate cancer screening is too small—particularly in men older than 70 years—to justify continuing this failed approach. Rather than treating PSA as an elective test and trying unsuccessfully to present “both sides” of the screening decision, primary care physicians should go back to discouraging its use.

You can read my full editorial on PSA screening in the January issue of American Family Physician.