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Food-As-Medicine trial ‘fails,’ Latest from the Diet-War Frontlines, and more.

Nina Teicholz and Gary Taubes Apr 13 ∙ Preview

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“Food-As-Medicine” Trial Fails to Improve Health

The current “Food As Medicine” movement harkens back to the adage “Let Food be Thy Medicine,” attributed to Hippocrates, yet maybe even the ancient Greeks sometimes wondered, ‘sure, but which foods?’ Fruits and vegetables, whole grains and lean proteins, aka, the cornerstone of the U.S. Dietary Guidelines, is now the usual answer, yet many experts believe that Americans, especially those of low socio-economic means, don’t have the knowledge or resources to follow this advice. For Food-As-Medicine advocates, one solution is to improve access, mainly to fruits and vegetables, by delivering free food— directly to people, in their homes.

The concept is championed by a powerhouse alliance of top-rank government, public health and industry actors. Rooted in a long history, the current movement started in about 2018, with a “Food As Medicine” working group on Capitol Hill. This led to a 2022 White House conference on Hunger, Nutrition & Health, resulting in a report recommending “food as medicine interventions for people with diet-related diseases.” In that same year, the Aspen Institute published its first “Food is Medicine” action plan, with a heady list of advisors. There’s also been “Food as Medicine” summits occurring nationwide since 2021. I (NT) have written with some skepticism about these efforts since the food industry has been central to virtually all of them.

From a scientific perspective, though, there’s the not-so-small problem that the Food-As-Medicine concept has barely been tested, and the few randomized, controlled clinical trials (RCTs) to date have yielded mixed results. This dearth of evidence was acknowledged in the 2022 Aspen report; An effort to get Congress in 2023 to spend $2 million on a “Food As Medicine” pilot program failed. 

Then, on December 26 2023 – the day after Christmas always being a good day to bury bad news – results from the latest RCT on the concept were published in JAMA Internal Medicine.  They were, to put it politely, not as expected. Five hundred “food insecure” adults with type 2 diabetes (HbA1c of 8.0% or higher) had been randomly assigned either to a control group that got “usual care” or an intervention group that received a year-long comprehensive program of dietitian consultations, nurse evaluations, health coaching, diabetes education and the delivery of “healthy” groceries for 10 meals per week for the entire household. 

The groceries included “whole grains, fruits, and vegetables (with an emphasis on fresh as opposed to canned and frozen), lean proteins and low-fat dairy products, as well as staple items including salad dressing, cereal, brown rice and bread that are tailored to patients’ needs in consultation with the dietitian.” The dieticians used the American Diabetes Association “plate method,” which advises that one quarter of the plate be starches (carbohydrates). 

If the food-is-medicine concept worked, the group getting free groceries along with the consultations and coaching should have seen their health improve noticeably. Yet they did not… at all. Their average blood sugar (the study’s primary outcome) remained no better than the controls; their LDL-cholesterol and HDL-cholesterol appeared, if anything, to worsen. 

The study authors – public policy researchers, not nutritionists – relied on the dietary approach recommended to them by the large healthcare system with which they partnered for the study. “We are interested in health delivery systems,” Joseph Doyle, a professor at the Sloan School of Management at MIT, stressed in an interview. “I was hoping we would show improved outcomes, but the way to make progress is to do well-randomized trials to find out what works.” We agree with Doyle, of course, and his experiment should put to rest some of the chatter that proper clinical trials in nutrition can’t be done.

Yet Doyle’s trial can’t inform public health strategies if its results are ignored. Despite a news item on the study in JAMA this week, the “null results” have had little noticeable effect so far on the Food-As-Medicine juggernaut. In February, the Department of Health and Human Services hosted its first “Food As Medicine” summit, with three public-private partnerships already in place, while a dozen projects are underway at the new, partially industry-funded Food Is Medicine Institute at Tufts University. 

Lamentably, until these programs better understand which foods are truly medicine, they will follow in the footsteps of other non-evidence-based programs, like listing calorie counts on menus, i.e., they’re very likely to fail…

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Adapted from BMJ 4 May 2024 Weights, resistance bands, and rest days are best for tendinopathy.

A systemic review and meta-analysis by Pavlova and Shim, published in the Journal of Sports Medicine 2023, indicates that planned exercise using weights or resistance bands with rest intervals gives better results than exercising every day, particularly with body weight exercises.

People with diabetes are considerably more prone to tendinopathy than the general population, so these findings may be helpful to them.

Tendinopathy is diagnosed when tendons become painful, stiff or swollen. It can affect both adults and children and tends to occur in the Achilles tendon at the heel, shoulder, elbow, knee and hip.

Although exercise is recommended it hasn’t been clear what specific exercises help the condition and what the training pattern should be to maximise effectiveness. Improving disability, function, pain, movement and quality of life are important for people who suffer from these conditions.

This study included 110 studies covering 4,000 people from Europe, Australia and the USA. Most of the exercise regimens had been prescribed or delivered by physiotherapists.

The study found that people improved more if they used dumbells, loaded backpacks or resistance bands rather than bodyweight only in resistance exercises. Also, rest days between sessions gave better results than daily exercises. The results were the same no matter the tendon damage site.

The authors suggest that at least one day of rest between the exercise sessions is necessary to maximise improvement. The number of repetitions and sets necessary did not become clear after the analysis.

My comment: So many people suffer from musculo-skeletal pain and research like this is very helpful. I’m a daily exerciser and I found that my chronic back pain got better by having more than one day between intense resistance workouts. Previously it had been alternate day resistance exercise alternating with either aerobic exercise or yoga/stretching. So many of us have the idea that more is better when really we would be better off doing less. Weights and resistance bands give more flexibility regarding the force exerted on the muscle and tendon so may lend themselves to progressive overload than body weight exercise.

Adapted from Statins: the risks and statistics by George Winter, Freelance writer and Fellow of the Institute of Biomedical Science. British Journal of Nursing 2023 Vol 32 No 20.

In a randomised trial of 3000 participants, Carling et al in 2009 concluded that when presented with the benefits of taking statins as a relative risk reduction, participants were more likely to accept treatment compared to when the absolute risk was given.

In a meta-analysis of 21 randomised controlled trials, Byrne et al in 2022 found reductions in AR of 0.8% for all cause mortality, 1.3% for myocardial infarction, 0.4% for stroke in those randomised for treatments with statins compared with control. The RR reduction for these were 9%, 29% and 14% respectively.

Diamond and Leaverton in 2023 consider that undue emphasis on RR reduction compared to AR reduction has led healthcare providers and the public to overestimate concerns about high cholesterol and to be misled as to the magnitude of the benefits of cholesterol lowering therapy.

Diamond and Leaverton re-evaluated the JUPITER trial of rosuvastatin. There were 18 thousand participants and there was a reported RR of 54% for fatal myocardial infarction. In absolute terms, the incidence of fatal MIs was 0.76% in the control group and 0.35% in the rosuvastatin treated group.

It would seem reasonable and good practice for both RR and AR to be discussed with patients when it comes to initiating treatments such as statins.

Does Exercise Prevent Cancer?

Why exercise is one of the best tools we have for cancer prevention.

Let’s start with the simple fact that a lot of cancer diagnoses are simply down to ‘bad luck’.

You can do everything right and still get cancer.

This is a somewhat depressing fact, given its leading position as a cause of death.

The other leading cause of death, cardiovascular disease, is mostly preventable.

Cancer – Less so.

But that does not mean you cannot tilt the odds in your favour.

And regular exercise, it seems, might be a good way of doing so.

Regular exercise and high levels of physical fitness have been consistently associated with longer lifespans and a substantially reduced risk of dying from any cause¹.

If exercise reduces all-cause mortality, it seems safe to say that it is reducing cardiovascular and cancer deaths.

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Let’s look at cancer specifically.

Over a 10-year period, those in the highest fitness levels had an 11% reduction in the risk of cancer².

But this 11% figure masks the fact that not all cancers are impacted equally.

Exercise has little effect on some cancers, while it has a much bigger effect on others.

While the risk of gastric/stomach cancer is reduced by only about 5%, the reductions in other cancer types are even greater.

• Breast Cancer – 13% Reduction
• Oesophageal Cancer – 18% Reduction
• Liver Cancer – 18% Reduction
• Lung Cancer – 25% Reduction
• Colorectal Cancer – 26% Reduction

The impact of exercise on cancer even extends beyond the original diagnosis and has been shown to reduce the likelihood of recurrence of cancer³.

Regular exercise in those who have already been diagnosed with cancer has been associated with:

• A reduced chance of dying from a breast cancer diagnosis by 40% compared to those with breast cancer who did not exercise regularly⁴.
• A reduced risk of death from colorectal cancer by 30%⁵.

The question is WHY exercise might be associated with such benefits with respect to cancer.

Regular exercise and high fitness levels are associated with lower rates of obesity.

Obesity is the second leading cause of preventable cancers after smoking⁶.

Please reread that line again.

It should hit you like a ton of bricks. If it doesn’t, you are not getting the magnitude of the problem that is preventable.

The likely driver of the cancer risk conferred by obesity is probably related to higher levels of insulin resistance and metabolic syndrome.

A diagnosis of metabolic syndrome significantly increases your risk of several leading cancers⁷:

• Postmenopausal Breast Cancer – 52% Increased Risk
• Hepatocellular Cancer – 81% Increased Risk
• Colorectal Cancer – 30-40% Increased Risk
• Pancreatic Cancer – 55% Increased Risk

But insulin resistance and metabolic syndrome are not the only drivers of risk.

Cancer As A Breakdown Of Immune Function

The hallmark of cancer is the uncontrolled replication of cells.

But the cells in your body are continually replicating.

The mechanisms of replication usually do an excellent job at producing exact copies of cells, but sometimes replication errors occur, which can lead to the development of cancer⁸.

The immune system’s job is to constantly search for these poorly replicated cells and destroy them.

In truth, we are probably creating very early cancerous cells throughout our lives, but because of our immune system, they do not get the opportunity to progress into fully formed cancers.

Natural Killer Cells are one of the key agents for targeting abnormal precancerous cells.

A properly functioning immune system then is essential for cancer protection.

Hereditary Cancers and The Role Of The Immune System

Lynch syndrome is a genetic colorectal cancer disorder where 60% of carriers go on to develop colorectal cancer over their lifetime⁹.

A recent study examined the question of whether regular exercise in such a high-risk group for cancer would impact the number of natural killer cells, which are important tools for destroying early cancer cells.

Those who did 45 minutes of high-intensity exercise three times per week for a year had significantly higher levels of natural killer cells¹⁰.

The higher levels of natural killer cells are likely to explain at least some of the protection regular exercise confers when it comes to cancer prevention.

Regular exercise also influences a variety of other cellular mechanisms that modulate cancer risk, including beneficial changes in¹¹:

• Cell Growth Regulators – IGF1 & IGFBP3.
• Suppression of RAS oncogenes.
• Higher levels of proteins involved in cellular repair.
• Enhanced activity of regulators of apoptosis and cellular growth.

Tilting Odds

The best way of not dying from cancer is to not get cancer.

Unfortunately, much of that risk is simply down to ‘Bad Luck’.

However, it is clear that regular exercise can play a crucial role in decreasing the odds of developing cancer, and the mechanisms by which it does so are becoming increasingly clear.

We need all the help we can get.

Keep the odds on your side.

1

Cardiorespiratory Fitness and Mortality Risk Across the Spectra of Age, Race, and Sex. J Am Coll Cardiol. 2022 Aug 9;80(6):598-609.

2

Association between physical activity and cancer risk among Chinese adults: a 10-year prospective study. Int J Behav Nutr Phys Act 19, 150 (2022).

3

Physical Activity Reduces the Risk of Recurrence and Mortality in Cancer Patients. Exerc Sport Sci Rev. 2020 Apr;48(2):67-73.

4

Physical activity in breast cancer survivors: A systematic review and meta-analysis on overall and breast cancer survival. Breast 2019; 44:144-152.

5

American College of Sports Medicine Roundtable Report on physical activity, sedentary behavior, and cancer prevention and control. Medicine and Science in Sports and Exercise 2019; 51(11):2391-2402

6

Cancer is a Preventable Disease that Requires Major Lifestyle Changes . Pharmaceutical Research, Vol. 25, No. 9, September 2008

7

Mendonça FM, et al, Metabolic syndrome and risk of cancer: Which link? Metabolism (2014),

8

Roles of the immune system in cancer: from tumor initiation to metastatic progression. Genes Dev. 2018 Oct 1;32(19-20):1267-1284.

9

Cancer risks by gene, age, and gender in 6350 carriers of pathogenic mismatch repair variants: findings from the Prospective Lynch Syndrome Database. Genet Med. 2020 Jan;22(1):15-25.

10

Exercise Training Reduces the Inflammatory Response and Promotes Intestinal Mucosa-Associated Immunity in Lynch Syndrome. Clin Cancer Res 1 November 2023; 29 (21): 4361–4372.

11

Why exercise has a crucial role in cancer prevention, risk reduction and improved outcomes, British Medical Bulletin, Volume 139, Issue 1, September 2021, Pages 100–119,

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As with all the material on this site it is not medical advice and is for general informational purposes only. None of the information provided constitutes the practice of medicine, or any professional healthcare services. No doctor patient relationship has been formed. Information contained on this platform is used at the readers own risk. Readers of this information should not delay or disregard in obtaining professional medical advice or treatment for any health related issue. The information presented is in no way a substitute for medical advice.

© 2023 Paddy Barrett
My Heart Health, Suite 3 Blackrock Clinic, Blackrock, Co Dublin, Ireland.

My comment: There is new research indicating that mitochondrial function greatly improves with exercise. It reduces the potential for DNA changes that can lead to cancer and in cellular degeneration. I didn’t write a specific blog about this as the scientific detail is overwhelming to me and I already keenly advocate exercise across all ages.

Adapted from Alzheimer’s and Dementia 15(2019) 625-634

A ketogenic drink improves brain energy and some measures
of cognition in mild cognitive impairment

Melanie Fortiera, *, Christian-Alexandre Castellanoa et al.

Research Center on Aging, CIUSSS de l’Estrie – CHUS, Sherbrooke, Quebec, Canada.

Abstract Introduction:

Unlike for glucose, uptake of the brain’s main alternative fuel, ketones, remains normal in mild cognitive impairment (MCI). Ketogenic medium chain triglycerides (kMCTs) could improve cognition in MCI by providing the brain with more fuel.

Methods: Fifty-two subjects with MCI were blindly randomized to 30 g/day of kMCT or matching placebo. Brain ketone and glucose metabolism (quantified by positron emission tomography; primary outcome) and cognitive performance (secondary outcome) were assessed at baseline and 6 months later.

Results: Brain ketone metabolism increased by 230% for subjects on the kMCT (P ,.001) whereas
brain glucose uptake remained unchanged.

Measures of episodic memory, language, executive function, and processing speed improved on the kMCT versus baseline. Increased brain ketone uptake was positively related to several cognitive measures. Seventy-five percent of participants completed the intervention.

Discussion: A dose of 30 g/day of kMCT taken for 6 months bypasses a significant part of the brain
glucose deficit and improves several cognitive outcomes in MCI.

2019 the Alzheimer’s Association. Published by Elsevier Inc. All rights reserved.

My comments: Providing a daily ketogenic drink seems to have been easy to implement and have a worthwhile positive effect on brain function in patients with early dementia. I would welcome more studies and information on how such drinks could be made commercially available out with the research setting.

From Open Verse

Adapted from IDDT Newsletter March 2024

What can patients do to help ensure a good consultation with their GP or specialist doctor?

This was the aim of a diabetes support group. They brainstormed what they wanted to achieve and then discussed the way to get this.

The first step is preparation for your appointment.

What is the point of the consultation? Is it a first meeting, a review of progress, a follow up from a previous meeting? Think, What do I want to get out of this consultation?

Have a clear understanding of your problem if possible. Rehearse what you intend to say.

If you have a complex or worrying problem you may wish take a partner or friend with you to listen so that important information is not forgotten.

Prepare a list of questions you have for the doctor. Give it to them. This way they can figure out best how to answer comprehensively on what they can answer and tell you what they can’t answer.

During the consultation

Try to sit so you can face the doctor either side on or in front of them.

Keep it simple if you can and let the doctor know you have questions to ask, and when is it a good time to ask them.

Maintain eye contact with the doctor, encourage a two way conversation and demonstrate a desire to build a working relationship with the doctor.

Briefly summarise your symptoms.

Ask clarifying questions if you have any uncertainty such as, Why do you advise me to take these medications? Ask if there are alternative treatments.

Answer questions honestly eg if you haven’t been taking your medication as prescribed.

Be positive.

What patients want in a consultation.

Patients want to feel welcomed into the consultation. They want a doctor who shows interest, care and respect for them. A sense of humour may be appropriate.

They want to have eye contact and not just have a doctor who looks at a computer.

They want to be treated in an intelligent adult to adult way. They want the doctor to listen and to have a two way exchange.

They need the doctor to have their notes and be familiar with them.

The patient’s carer also needs to be involved in the conversation.

They need TIME to allow a relevant discussion. Often more than one issue is involved. Test results need to be explained and some patients will want specific information other than “normal” or ” a bit low”. They want options to be discussed and involved in implementing a course of action.

Patients dislike being contradicted over their experience and treatment history. They want their doctor to be frank when the doctor doesn’t know something. They welcome referral or a doctor speaking to someone with more expertise when necessary.

Some patients are very keen to have copies of letters and summaries of the discussion and action plans.

My comment: This patient group has a good structure of the ideal consultation and is similar to the sort of thing that doctors also want. In my experience there are often impediments achieving this. Such things are lack of scheduled time, interruptions, lack of continuity of doctor-patient relationships, difficulty getting notes and getting computers to work. It also helps if patients are focussed on one or at most two main issues and don’t bring a shopping list of everything that bothers them. It is helpful to involve the team of health care professionals so that things that concern eg a podiatrist or a pharmacist can be dealt with separately to the GP or consultant.

Finland has been vaccinating children from rotavirus since 2009.

This has led to a 10 fold fall in the number of children getting a rotavirus infection by the age of 5.

There has also been a fall (they don’t say how much of a fall) in children being diagnosed with type one diabetes.

This supports the belief that rotavirus is a trigger for inducing islet cell autoimmunity.

Diabetes Care doi:10.2337/dc23-1203