False Dichotomies of Health Care - Part 1

A major flaw of the human mind is that it tends towards dichotomization - perceiving everything as two-sided: black vs white, hot vs cold, good vs evil, right vs wrong. The undesirable consequence is that we misperceive reality, which is extremely complex with many more than two sides. One only has to read the daily news to see the trouble this causes, but dichotomization also affects health care.

Scientists try to reveal complexity by looking at life in a carefully controlled manner – the scientific method – but scientists, too, fall prey to dichotomization. Most scientific debates are heated with “pro” vs “con” arguments about who’s right and who’s wrong (of course, a researcher’s career is a vested interest that fosters bias in his or her opinions).

Usually, a more enlightened perspective would be:

If datasets A, B and C are all valid and good quality, then how could it be that all must be true?

Such thinking can be overwhelmingly complex. To illustrate, let’s do a little exercise where we will consider a large body of research, and then apply that to a family who comes to your patient-centered medical home.

To start, consider key points (below) from a selected group of landmark research studies, as representative of general bodies of knowledge. Feel free to add on details that you know, as this is an exercise in generalities:

• Framingham Study - established the “traditional risk factors” for cardiovasular disease
• Seven Countries Study - revealed cardiovascular benefit of the “Mediterranean diet”
• PREDIMED Trial - confirmed that the Mediterranean diet prevents cardiovascular disease
• China Study - the optimal amount and sources of dietary protein may be lower than thought

• London Bus Study - physical activity prevents cardiovascular disease
• Aerobics Center Longitudinal Study - physical fitness confers strong benefit on all-cause and cardiovascular mortality, and it’s better to be fat and fit than to be lean and unfit

• Exercise & Diet for Weight Loss - under carefully controlled conditions, a calorie expended is equivalent to a calorie consumed (i.e., human weight follows the laws of thermodynamics), though this may have limited applicability in real life; more important, calorie expenditure through exercise is to reduce abdominal visceral obesity that confers high cardiovascular risk

• Trials of Supplements - A, E, D, Omega 3, folate - diets rich in these anti-oxidants and nutrients improves health, but taking them as supplements does not confer benefit and even does harm at high doses; one notable exception is that folate supplementation in very early pregnancy prevents neural tube defects (e.g., spina bifida)

• Umea Epigenetics Study - the likelihood of cardiovascular disease and diabetes are about 4x increased if one’s paternal grandfather was in his slow-growth pre-adolescent phase of life (~9-12 years old) during a period of food surfeit, but protected from cardiovascular disease and diabetes if the paternal grandfather’s slow-growth period occurred in a time of famine (wrap your mind around that!)

• Studies of Gut Microbiome - microbes living in the gastrointestinal tract are extremely highly associated between first-degree family members, particularly between mothers and their children with exquisitely strong P-value <0.00000000000001 (this strength of relationship is seen in particle physics, not biology); obesity is very highly associated with phylum-level shifts in gut microbes, and a genetic model of obesity (OB/OB rats) even suggests that gut microbes play an essential role in development of obesity

• ACE Study - the number of adverse childhood experiences (parental divorce, exposure to alcoholism/drugs, exposure to tobacco, financial stress, etc.) is very strongly associated with the burden of chronic disease when the child has become an adult

• CO2 Cost of Food - modern agriculture (particularly beef and pork farming) contributes heavily to greenhouse gas emission; shifting towards a plant- or poultry-based diet has the equivalent greenhouse gas benefit of converting from an SUV to a Toyota Prius

• Role of Fungi in Sapling Development - fungi in soil transfer energy (carbohydrate) from mature trees to saplings, facilitating the growth of young trees under the forest canopy and with poor access to sunlight for photosynthesis, in a plant & animal kingdom collaboration as astounding as the gut microbiome in humans

• Oceans Feeding Forest Life - 20-25% of the nitrogen in northern coastal flora comes from the ocean, because bears and avian predators (eagles) prey on mature salmon that return to spawn and the carcass proteins end up in trees and plants, creating a complex cycle where plants create the river microenvironments that the salmon use for spawning, bringing nutrients obtained from far in the ocean to nourish flora and fauna in northern forests

Before thinking about the family in your clinic, ponder these studies. There is no research that integrates all of this, so in putting it all together you’re on your own.

How you would prioritize them - importance, effect size, ability to modify the factors? How much interaction is there between findings? For instance, what unknown epigenetic and microbiome influences were there on the Seven Countries and Framingham studies? How much does that make you uncertain about something you thought was true? The ecological studies seem unrelated, but they show the interdependence of Life on Earth, putting the epigenetic and microbiome research in a different light and raising doubts about how much we know about these inter-relationships and health.


To complete this exercise, now consider how would you counsel a young couple. They come to your clinic looking for guidance on caring for her 87 year-old father, who has diabetes and lives with them, as well as on raising their 2 children (ages 4 and 7). However uncertain you are about what you think you know, this couple is asking for your advice right now.

They don’t have much money, and are a mixed-raced couple (he’s Latino, she’s African-American). He’s been a security guard since returning from the Iraq war, and she a special education teacher. He had difficulty with PTSD after returning from Iraq; she had excessive gestational weight gain and postpartum depression after her second child (9 lbs, 6 oz. at birth). Aside from his military duty, they have always lived in the New York City borough of Harlem, have never been in a forest or visited the coast other than summer trips to the Jersey shore.

• Should they eat beef and pork, or just poultry, or maybe go Mediterranean or vegan?

• If they eat salmon, should it be wild-caught or farm-raised?

• Should they be taking supplements? If so, which ones?

• What should they do for exercise, and how do they keep the kids physically active?

• What is the best lifestyle method to manage her father’s diabetes, and keep him as independent as possible? Should they get him a Fitbit?

• Should they sell the SUV and buy a Prius, or switch to bicycles and public transportation?

• What other views - biases - will you bring to the discussion?


Lastly, returning to the issue of dichotomies with one currently in vogue among health care reformers, your patient-centered medical home is charged with helping them change from being “unactivated” to being “activated”.

So what will you say, what counseling techniques will you use, what constructs will you invoke to motivate them, and what specific goals will you guide them towards in managing their family health and well-being?

Stay-tuned for Part 2.



Physical Activity / Fitness
JN Morris, JA Heady, PA Raffle, CG Roberts, JW Parks (1953). Coronary heart-disease and physical activity of work. Lancet 1953; 265(6795):1053–7. doi:10.1016/S0140-6736(53)90665-5.

M Wei, JB Kampert, CE Barlow, MZ Nichaman, LW Gibbons, RS Paffenbarger, Jr, SN Blair. Relationship Between Low Cardiorespiratory Fitness and Mortality in Normal-Weight, Overweight, and Obese Men. JAMA 1999; 282:1547-1553.

JM Helfield, RJ Naiman. Effects of salmon-derived nitrogen on riparian forest growth and implications for stream productivity. Ecology 2001; 82:2403-2409.

G Eshel, PA Martin. Diet, Energy, and Global Warming. Earth Interact 2006; 10:1-17.
doi: http://dx.doi.org/10.1175/EI167.1

S Lerat, R Gauci, JG Catford, H Vierheilig, Y Piché, L Lapointe. C14 transfer between the spring ephemeral Erthronium americanium and sugar maple saplings via arbuscular mycorrhizal fungi in natural stands. Oecologia 2002; 132: 181-187.

G Kaati, LO Bygren, S Edvinsson Cardiovascular and diabetes mortality determined by nutrition during parents’ and grandparents’ slow growth period. Eur J Human Genetics 2002; 10:682-688.

Social Factors
VJ Felitti, RF Anda, D Nordenberg, DF Williamson, AM Spitz, V Edwards, MP Koss, JS Marks. The relationship of adult health status to childhood abuse & household dysfunction. Am J Preventive Med 1998; 14(4):245-258.

PJ Turnbaugh, M Hamady, T Yatsunenko, BL Cantarel, A Duncan, RE Ley, ML Sogin, WJ Jones, BA Roe, JP Affourtit, M Egholm, B Henrissat, AC Heath, R Knight, JI Gordon. A core gut microbiome in obese and lean twins. Nature 2009; 457(7228): 480–484.

Cardiovascular Disease Epidemiology
A Keys, A Menotti, C Aravanis, H Blackburn, BS Djordevic, R Buzina, AS Dontas, F Fidanza, MJ Karvonen, N Kimura, et al. The seven countries study: 2,289 deaths in 15 years. Prev Med 1984; 13(2):141-54.

Gordon T, Kannel WB. Premature mortality from coronary heart disease. The Framingham study. JAMA 1971; 215(10):1617-25.

CT Campbell, J Chen, B Parpia. Diet, lifestyle, and the etiology of coronary artery disease: the Cornell China Study. Am J Cardiol 1998; 82(10, supplement 2):18–21.

Obesity & Exercise
R Ross, D Dagnone, PJH Jones, H Smith, A Paddags, R Hudson, I Janssen. Reduction in Obesity and Related Comorbid Conditions after Diet-Induced Weight Loss or Exercise-Induced Weight Loss in Men: A Randomized, Controlled Trial. Ann Intern Med 2000; 133:92-103.

R Ross, I Janssen, J Dawson, A-M Kungl, JL Kuk, SL Wong, T-B Nguyen-Duy, S Lee, K Kilpatrick, R Hudson. Exercise-induced reduction in obesity and insulin resistance in women: a randomized controlled trial. Obes Res 2004; 12:789 –798.

Diet, Nutrients & Supplements
A Sommer, KS Vyas. A global clinical view on vitamin A and carotenoids. Am J Clin Nutr 2012; 96(5):1204S-1206S. doi: 10.3945/ ajcn.112.034868

G Bjelakovic, D Nikolova, LL Gluud, RG Simonetti, C Gluud. Antioxidant supplements for prevention of mortality in healthy participants and patients with various diseases. Cochrane Database Syst Rev 2012; 3:CD007176. doi: 10.1002/14651858.CD007176.pub2.

JE Enns, A Yeganeh, R Zarychanski, AM Abou-Setta, C Friesen, P Zahradka, CG Taylor. The impact of omega-3 polyunsaturated fatty acid supplementation on the incidence of cardiovascular events and complications in peripheral arterial disease: a systematic review and meta-analysis. BMC Cardiovasc Disord 2014; 14:70. doi: 10.1186/1471-2261-14-70.

R Chowdhury, S Warnakula, S Kunutsor, F Crowe, HA Ward, L Johnson, OH Franco, AS Butterworth, NG Forouhi, SG Thompson, KT Khaw, D Mozaffarian, J Danesh, E Di Angelantonio. Association of dietary, circulating, and supplement fatty acids with coronary risk: a systematic review and meta-analysis. Ann Intern Med 2014; 160(6):398-406. doi: 10.7326/M13-1788.

R Estruch, R Emilio, J Salas-Salvadó, M-I Covas, D Corella, F Arós, E Gómez-Gracia, V Ruiz-Gutiérrez, M Fiol, J Lapetra, RM Lamuela-Raventos, L Serra-Majem, X Pintó, J Basora, MA Muñoz, JV Sorlí, JA Martínez, MA Martínez-González for the PREDIMED Study Investigators. Primary Prevention of Cardiovascular Disease with a Mediterranean Diet. N Engl J Med 2013; 368:1279-90. DOI: 10.1056/NEJMoa1200303