Christopher D'Adamo, PhD, is the Director of the Center for Integrative Medicine (CIM) at University of Maryland School of Medicine, Baltimore, Maryland. Dr. D'Adamo is an epidemiologist who has served as Principal Investigator on a wide range of studies evaluating the effects of nutrition and other healthy lifestyle practices on human health and wellness.
Robert Rountree: I've seen you wear a lot of different hats over the years. How do you think of yourself professionally—a professor, an epidemiologist, a functional medicine specialist? How would you describe yourself to our readers?
Christopher D'Adamo: Well, that's a great question. I would describe myself as an epidemiologist by training who has applied that approach and skill set and methodology to the fields of integrative, functional, and lifestyle medicine. So that's obviously three broad areas, but I've taken that approach to looking at health with applications to integrative medical care, with the functional medicine operating system, and in healthy lifestyle promotion, more generally. That's taken many different forms and many different studies and educational endeavors over the years, but if I had to do it in an elevator pitch, that would be it.
Dr. Rountree: When you were growing up, did you have a dream of becoming an epidemiologist with a special interest in lifestyle medicine? Or did you follow a circuitous path to get here?
Dr. D'Adamo: It's definitely been circuitous, to say the least, and I feel like the conglomeration of the different experiences and influences I've had around me have led me to where I am now and where I hope to go. I was a math/premed undergrad, and received a summer undergraduate fellowship at Johns Hopkins in surgery, which is what I initially wanted to do. I had always been an athlete and into my own personal health and nutrition and so on, and I saw so little health promotion in the setting that I was exposed to there and just said, “You know what? I don't think I really want to do this.” So I began my career in the health care management consulting field and did that for a number of years. We did some challenging work, but really I felt like at the end of the day it was kind of like: “Well, we're helping our hospital client A take market share from competing hospital B,” and I didn't really feel that great about it. At that point in time I was doing some personal exercise training and nutrition consulting with clients on the side, just to tap more into my interest in health. Ultimately, my grandfather (former President and CEO of Muzak) was my biggest professional influence. He asked whether I liked what I was doing and if I was blending my vocation and avocation. I wasn't. That's where I just thought to myself: I've got this quantitative background. I love health. I had this long-standing interest in medicine. Let me give epidemiology a go. So I left my career after about seven years in health care management consulting, went and did a PhD in epidemiology, and that was the best professional decision I ever made.
Dr. Rountree: What was your understanding of the field of epidemiology? What did you believe that you were going to end up doing with that type of training?
Dr. D'Adamo: At that point in time, I had the classic view of infectious disease epidemiologists. I knew there was chronic disease epidemiology, which drew me in more, and I was awarded an epidemiology of aging fellowship, where I did work with exercise and nutrition and aging. This was influenced by my grandfather who I mentioned earlier, who lived to be over 100 years old, and much of that was, he felt, due to the fact that he ate a nutrient-dense diet, was lifting weights into his 90s, and incredibly physically active. I think people are capable of much more than going to a nursing home when they're in their 80s, and there's the capability to thrive physically and mentally much deeper into life if we take care of ourselves. So that's what I got into with the epidemiology of aging, the study of modifiable lifestyle factors at the population level, and ultimately applied this approach across the lifespan.
Dr. Rountree: What I hear you saying is that your appreciation of the value of lifestyle practices, eating a good diet, regular exercise, and athleticism was a guiding force in your professional life. You had an intrinsic belief that living a healthy life is fundamentally important. Some people are brought up thinking that exercise or eating a healthy diet are not worth the effort, or they just aren't interested. But for you, that was a core driver.
Dr. D'Adamo: Absolutely. It's one of those things where I had lived it, I had been around it, I knew that there was research on it, too. But at the same time, it took a back seat in the medical practice that I had been exposed to at that point in time. I hadn't really been exposed to integrative, functional, and lifestyle medicine at that point. But yes, it's something that I knew was powerful but overlooked in many ways.
Dr. Rountree: When you were going through your training in epidemiology, did you develop a sense of the strengths and weaknesses of the field? I know that's a very general question, but I'm wondering if there were certain concepts, tools, or methodologies that you found to be more reliable or useful than others?
Dr. D'Adamo: When you get into data analysis and you have a data set in front of you and you've got these tools, I realized that epidemiology is an incredibly useful tool for hypothesis-generating. Epidemiology can help draw causal inference, but you'd better be darn careful doing it. Let's take nutritional epidemiology, for example, which is a field that's come under quite a bit of heat recently, and rightfully so. It has come front and center in a lot of ways in what we could call “the diet wars.” And what I saw with the data sets I had in front of me was that: What's my hypothesis? And what would you want to be the villain in this story from a dietary perspective? The reality is that there isn't a single dietary villain. It isn't red meat, it isn't carbohydrates, it isn't fat. One of the examples I use when I'm teaching students is the “Extra Value Meal” example. You could erroneously conclude that the red meat is the threat to health if you don't adjust for the refined carbohydrates in the bun, the hydrogenated oils in the fries, or the high fructose corn syrup in the soda. However, if you did the nutritional epidemiology properly, you would conclude that it is a processed food eating pattern that is causing the detrimental impact on health more than any single dietary component.
So I think what we're seeing too often in nutritional epidemiology is that we have painted with too broad of a brush in making dietary conclusions. This goes back a long way to the demonization of dietary fat in the 1980s, and we didn't realize that many fats are actually health-promoting. Some are not: the hydrogenated oils, and trans fats, and some of those. But when we painted with a broad brush, we were led astray. I think the same thing happens with red meat for example, which was largely exonerated as a causal risk factor for disease when we looked at the totality of the evidence across dozens of studies and hundreds of thousands of participants in a series of meta-analyses published in the Annals of Internal Medicine. Sadly, the diet wars have taken on such fervor—largely fueled by poorly designed nutritional epidemiology and dietary ideology that goes beyond science—that these well done studies using GRADE methodology (to evaluate the quality of the evidence) were attempted to be retracted by advocacy groups. Fortunately, these efforts failed and the science stood. This isn't just about red meat though, as I think you could say the same for sugar, which has become a big villain in recent years. Are we talking about sugar from soda? Are we talking about sugar from blueberries? These cannot be lumped together in one category. I think that nutritional epidemiology can be an incredibly valuable tool if we're painting with a fine brush as opposed to broad strokes, and that requires some reform with better adjustment for confounding and accurate reporting on the clinical relevance of statistically-significant associations in large datasets. John Ioannidis articulated the need for reform very nicely in a recent JAMA paper.
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Dr. Rountree: As a practitioner who, for the last four decades, has repeatedly been on the receiving end of the recommendations from government-appointed nutrition committees, it's been amazing to me how the experts don't seem to be able to answer even the most basic questions about what the right diet is for most people. Not even questions as seemingly simple as: Chicken eggs—are they good for you, or are they harmful? Is dietary fat good for you or bad; or is the problem only with saturated fat, while polyunsaturated fat is healthy? Is salt harmless for some people and dangerous for others? There are people on both sides of the fence for every single one of those questions. You've got Michael Pollan, PhD, saying, “Eat food. Not too much. Mostly plants,”
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but then you've Dr. Steven Gundry warning us about the hidden dangers in some healthy fruits and vegetables. Or there's the carnivore diet with advocates like Dr. Paul Saladino, who claim that, “We don't need to eat plants, we can get all the nutrients we need from eating eggs, milk, fish and meat.”
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I think the public right now is feeling crazy about all this. The result is that people are throwing their hands up in the air and not knowing which authority to trust. What do you see as the answer to all that contradictory advice? I'm partly saying all this as a leading question, because I know that you are teaching culinary medicine to medical students and residents.
Dr. D'Adamo: Sure. The reality is that there is supportive evidence for many different ways of eating… Mediterranean, low-fat, low-carb, paleolithic, plant-based, and animal-based diets. Those who claim nutrition is “one size fits all” and that there is one dietary approach that is best for everyone are mistaken and doing more harm than good. When any of these diets are done well, they're done with a whole-food philosophy that minimizes processed food. Whether that's keto, paleo, plant-based, animal-based, Mediterranean, you name it, the commonalities they have is that when done well, they are done with a real-food approach, and not a bunch of processed stuff. And I think that one of the key tenets that we've emphasized in our culinary medicine is that we see that there are these really vociferously defended ideological positions on these diets—that take on partisan political or religious fervor—that we should probably avoid for the most part. We provide much more latitude to our patients for expression of what resonates with them when we abandon the strict ideologies in favor of a more versatile approach that emphasizes whole foods. We've tried to bridge the divide between these different approaches so that people are less ideological with it. We've published data on culinary medicine training as part of a core curriculum at the University of Maryland School of Medicine,
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and we've shown that you can actually give your patients more latitude with this important topic. We teach medical students about the different diets, here's how you do them well; here are some of the misconceptions about the diets, and here are the commonalities with other popular diets. Each class features evidence-based lecture, we cook a meal together based on the tenets of the lecture, and then we eat together and discuss application to clinical care and the students' personal lives.
Dr. Rountree: You can be both vegetarian and paleo.
Dr. D'Adamo: Absolutely. One of the meals we cooked together was both paleo and vegan, actually. One of our goals was to break down the ideological barriers to reveal what's common among all these diets: nutrient density through whole foods. If you want to eat meat, great. There are good reasons to do so. If you don't, great. Here's ways you can do that, and maybe you think about supplementing with B12, creatine, etc. So we just gave some of the finer print that gets missed in a lot of sensationalism, as in “everyone needs to eat diet A or B or C.” It's highly personalized, which ties into the functional medicine operating system. And there's probably some genetic component to that. There's probably some microbiota sort of component to that. There are varying health needs and there's also personal preference. We need to be aware of all these different factors that are going to influence long-term compliance. It's been a lot of fun, and I think we've helped open people's eyes, broaden their perspectives across the board, had some really engaging discussions about how we can use food as medicine, how cooking can engage people in healthy behaviors, and how we can break down these dietary ideologies that are tough, because people bounce from diet A to diet B to diet C, never really understanding how to eat but just following whatever the popular diet du jour is, and we think there's a better way.
Dr. Rountree: It's interesting that you use that phrase, “dietary ideologies,” because it suggests that the way people think about diet has more to do with their belief system than the data. The overarching issue that I keep coming back to is that some lifestyle practices we're doing—or not doing—are having a negative impact on public health. We've got an obesity epidemic, especially in kids. We've got an epidemic of non-alcoholic fatty liver disease—the incidence is skyrocketing in modern societies. We've had a viral pandemic that disproportionately affects people with metabolic disorders. And yet I've heard respected nutrition researchers say, “There's no evidence that diet really makes a difference, and the only solution to obesity is bariatric surgery and diet.” To me, that conclusion defies common sense. Perhaps one can poke holes in the idea that what we call common sense means anything in the long run. But still, how do we respond to critics that say, “There isn't any evidence that anything we're doing, anything we're eating, is really making a difference,” because the whole energy model of obesity—the idea that weight is a result of calories in minus calories out—doesn't really hold up in court.
Dr. D'Adamo: Yes. We could really go down the rabbit hole of this one.
Dr. Rountree: It's a deep rabbit hole.
Dr. D'Adamo: It is, with many different vested interests that are contributing to it. First, I think there is a preponderance of data that shows that what we eat influences our weight, and even with well-done isocaloric studies that have been done with different types of diets—so it's not just the quantity, it's the quality of food. That's pretty clear at this point. Different macronutrients have different effects on satiety and thermogenesis, we know that. Micronutrients have an incredibly important impact on a wide variety of physiological processes. And micronutrients don't have calories at all! So it's not just a calorie thing.
Dr. Rountree: And that's not included in a lot of the studies. They don't really talk about the micronutrients or the secondary nutrients, the secondary metabolites.
Dr. D'Adamo: Yes. And that's even more interesting. How do we absorb and assimilate the micronutrients we consume? What does our body do with them? Then there are aspects like our microbiota and the impact that they may have on metabolism. It's fascinating. The calories in, calories out energy balance is an oversimplification of the impact of food on human health. We need to think about quality as much as we do quantity. We need to think about things like timing of our food intake, it's become of great interest these days with time-restricted eating and fasting. There are many different factors there that influence our weight and metabolic function beyond this overly simplistic calories in, calories out. There's quite a bit of nuance to this. I think clinicians know that from their own practice. But I think policy isn't hitting these big areas yet. So I'm glad to be doing work in this area to try to get a little more personalization there.
Dr. Rountree: One of the more specific criticisms I've read is that a lot of epidemiologic studies rely on food (or dietary supplement) frequency questionnaires. When I read that a study was based on a single questionnaire done at the beginning of the trial after which the cohort was followed for 10 years, that data seems to be a bit of a sieve. How is that kind of data supposed to hold water?
Dr. D'Adamo: Dietary assessment is a matter of looking at what's the best house in a bad neighborhood, for the most part. You've got food frequency questionnaires, you've got 24-hour dietary recalls, you've got food diaries. All of these have strengths and limitations. There are other novel ways, though. These include more engaging apps and a wide variety of biomarkers. My team and I have looked at biomarkers of certain dietary components such as vitamins, carotenoids, flavonoids, and polyphenols. I think there have been some false flags or red herrings that have been picked up with these methods along the way, but I don't think we want to throw the baby out with the bath water, because there are better methods—let's say we were to complement a food frequency questionnaire with some biomarker of, let's say carotenoids. Again, we've done work with that in our nutrigenetics research.
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There is no endogenous carotenoid production, so if someone says that they're eating tomatoes, and you look at lycopene, we can match that up. Now, there's going to be some variance there due to genetics and other factors, but there are ways that we can improve the accuracy of our food frequency questionnaires.
And it's not just nutritional epidemiology, though, because it's nutritional science in general. It gets down to this whole efficacy vs. effectiveness question. Efficacy is what happens under ideal conditions, like in a metabolic ward, for example. You can have your meals delivered to you, you eat them, they measure and know exactly what and how much you ate. So that answers a good question: If someone is perfectly compliant with this diet, then what happens? And some may say, well, that's the real answer. But is it really? Because in freestanding people who are working and have families, are busy, and have other challenges, they may not have that perfect compliance, so there's the effectiveness end of the research spectrum, which answers what happens in the real world. That would be methods such as you provide participants with education, and then let them go from there, because that's what people usually do in the real world. I don't know many people who have access to a metabolic ward where all of their meals are given to them for free. It would be nice! So I think in that instance, too, assuming you have a nicely done clinical trial, yes, that may give us a nice answer of what happens in some populations under ideal conditions, but does that actually translate to the real world? So that's where I think there's this false dichotomy that clinical trials tell us the right answer and nutritional epidemiology cannot. So there's much that we need to look at, different kinds of research and clinical observation to consider.
Dr. Rountree: I should point out to our readers that you have published a lot of excellent papers that have addressed the very issues we are touching on.
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But for you it's also about clinical applications since you're using this same information to provide community-based health interventions and then study the impact of those interventions. For example, I know that you've done research in Baltimore with adolescents, and schoolteachers, and underserved populations. What have you learned from trying to apply all these principles, given that government authorities keep changing the guidelines while you are tasked with going out into the community and optimal nutrition. Ultimately, you have to ask, “Where does the rubber meet the road?” How do you put it all together?
Dr. D'Adamo: Yes. It's a great question. I'm from Baltimore originally, so it's been some of the most rewarding work that I've done. Baltimore has a preponderance of food deserts, there are extreme socioeconomic challenges, and there's a lack of health literacy in many of these populations And I think working with these populations, predominantly of underserved high school students in Baltimore, we've learned a couple of things. We realize that if you're talking to a 14-year-old, his or her risk of hypertension 30 years down the road is not high on their priority list. So one of the things we really emphasize is: How can we engage these young people in positive nutritional and other health behavior changes that are engaging? So we use cooking quite a bit. We engage them where they get to create their own recipes. We've used spices and herbs as a vehicle for healthy nutrition changes. These strategies have been effective in engaging the children and adolescents such that they actually want to make the healthy behavior changes.
Dr. Rountree: Is that the Spice MyPlate initiative?
Dr. D'Adamo: Spice MyPlate was one of our first studies in this area. This was a school-based nutrition education intervention that focused on promoting healthy nutritional changes through experiential education with spices and herbs. We showed that we can improve diet quality from a relatively brief school-based intervention. It was less than 10 hours in total, and thus was able to be implemented in other settings. The next step in this line of research was to see if we can actually improve vegetable intake at school in the National School Lunch Program with spices and herbs with direct dietary modification. We changed the recipes. We worked with our partners at the Nova Institute for Health, led by Brian Berman, MD, professor emeritus of family medicine at the University of Maryland School of Medicine, where he founded the Center for Integrative Medicine, and also the Founder and President of the Institute for Integrative Health, now known as the Nova Institute for Health. After over a year of stakeholder engagement at Cristo Rey Jesuit High School in Baltimore, featuring extensive sensory testing and really getting to know the students, cafeteria staff, etc., we showed that by adding spices and herbs, we could improve vegetable intake from very paltry levels at baseline. The recipes were otherwise identical with the exception of spices and herbs. We were pleased with the results.
Dr. Rountree: A common belief is that kids won't eat anything else besides comfort food, so if you give them salads they will turn up their noses. You're saying that's a misconception.
Dr. D'Adamo: Yes. You know what? That may be so if you don't have any focus on flavor with that. Yes, they're probably not going to eat the plain, boiled-to-oblivion Brussels sprouts. Yes, that's true. But broccoli was actually the vegetable that had the largest increase when flavored with spices and herbs.
Dr. Rountree: Really? Broccoli?
Dr. D'Adamo: Yes, broccoli. Surprisingly, dill and garlic powder were the herbs and spices used in the recipe. We published two papers out of this study. The first one was on the sensory combinations of spices and herbs that these teenagers found palatable. So we actually looked at a smaller group of students in this paper, and we came up with different flavor combinations that were well-liked. We know you can change behavior at young ages, but this was a slightly older population of teenagers who were predominantly African-American and economically-underserved at increased risk of suffering from diabetes, obesity, hypertension, and so on. So we were really happy with that work.
Dr. Rountree: Some people think integrative medicine is only about combining healing modalities such as acupuncture or Traditional Chinese Medicine, massage, and mind/body therapies. This is an entirely different definition.
Dr. D'Adamo: Yes. We've done a lot of that kind of work over the years, too. Dr. Berman led some of the seminal research in acupuncture. We've also done quite a bit of work with mindfulness, and we published work on a multi-modality summer program for high school students in Baltimore called Mission Thrive Summer, where they did mindfulness, yoga, and farming—actually on an urban farm. They did cooking and combining many of these integrative modalities, and we showed that they basically had much better health behaviors during the summer, because that's the time when both learning and health behaviors tend to regress in young people in cities like Baltimore.
Dr. Rountree: Do you see this kind of approach—working with underserved kids and teaching them about healthy lifestyles—as something that should be a fundamental part of medical school training? Or should it be more in the realm of public health specialists? What is the best avenue for this to become a more standard practice in healthcare delivery?
Dr. D'Adamo: I'll tell you, Bob, it's interesting, because during the core medical student curriculum in culinary medicine, the questions that always came up would be: “Well, this is all well and good. But how can our patients in Baltimore afford this, or have access to these foods?” This engendered some interesting discussion on buying frozen foods, buying in bulk, mobile farmers markets, and other cost-containment and access strategies for people in underserved areas of cities like Baltimore. Unfortunately, there are some real access barriers and unhealthy foods are generally federally-subsidized more than healthy foods, making eating healthy more expensive. We discuss strategies to do the best we can with these patients and their families.
Dr. Rountree: Exactly.
Dr. D'Adamo: These questions come up constantly about access, so we actually developed a session as part of our core curriculum now about these interventions that we've done in underserved communities in Baltimore, the health promotion and integrative health interventions that we've done in Baltimore, and what are some of the lessons learned that can be applied to clinical care. I actually give a medical student core curriculum lecture on integrative health interventions in underserved communities now to prepare students for what they will encounter in this respect in clinical care. You're not going to have two hours to go through all of these things at the point of clinical care, but what are some basic stress management techniques you can offer, some basic food, movement, and sleep strategies that you can briefly teach (or point to online resources) to people that live in these really challenging situations, just to get them started with it. What are some things that you can do in five minutes or less, brief tips to give, because it's going to help. I think there's a role for it in both public health and in primary care.
Dr. Rountree: Something I'm learning from listening to you and from reading your papers is that these seemingly simple interventions—getting kids involved in programs over the summer, teaching them about spices and eating fresh foods that are prepared in a healthy way—can make a huge difference in the long run, right? It's not just a pipe dream, it's really impactful.
Dr. D'Adamo: Definitely. And I think if we can give the kids a sense of ownership and engagement in this, so it's not just something they did for a study, but rather something that they enjoyed doing, and that it was theirs… we've been really intentional about that. For example, the physical activities that we did—getting back to my background as a personal trainer—but we didn't make them do burpees and deadlifts as this was not of interest to them. We personalized to their interests and had them play games, sports, dancing, etc. We would let the students know “You know, when you were playing this sport, dancing, etc., you actually took 5,000 steps.” We measured physical activity using the “gold standard” of accelerometry. So I do think that these interventions, when positioned accordingly, can inspire lifelong behaviors that they bring in to their lives. We haven't done 30-year longitudinal studies yet, but we do know that the behaviors have persisted even at our follow-up points, and we're hopeful that they carry them with them later into their lives.
Dr. Rountree: What we're seeing here is that these basic lifestyle interventions are a great start, and the longitudinal evidence of their benefits is growing. Unfortunately, you still have to deal with pushback from skeptics who ask, “Where is the evidence this works?” For people with obesity, the same pundits will say “just give them medication or do bariatric surgery, but don't bother trying to get healthy grocery stores into food deserts or underserved neighborhoods.” Then the next level of pushback is around dietary supplements. As you know, the mainstream media bashes supplements left and right. The headlines repeatedly shout, “There's no evidence that supplements help for any health condition; and they are probably harmful.” This is typically the result of a negative confirmation bias that allows reporters to completely misinterpret research findings and ignore any data that contradicts their position. I know you've published numerous studies showing that certain micronutrients can support healthy aging. You've also given lectures on the potential utility of dietary supplements such as vitamin D for preventing viral infections like SARS-CoV2. How do you address this negative confirmation bias that is so rampant among reporters? It's hard enough just to get the mainstream convinced that eating healthier diets may prevent obesity, but now we're talking about something on an even higher and more complex level.
Dr. D'Adamo: Yes. We share frustration about the way the media seems to discourage dietary supplements whenever they get a chance. And I think any time you hear something like “there's no evidence whatsoever for dietary supplements,” you need to immediately question anything else that source is saying, because there are thousands of supportive studies for a wide variety of dietary supplements. Dietary supplements are not a panacea for everything, but I think once again, with these broad “all or nothing” strokes, it's really detrimental to trust in media. So the ways that we're trying to help resolve this is by offering sessions in the core medical student curriculum on dietary supplements, and I've been doing that for almost 10 years now. I commend the University of Maryland School of Medicine for their openness and recognition that over half of Americans take a dietary supplement and physicians need to be prepared to address dietary supplementation at the point of clinical care. In light of the limited amount of time that we have in the session, I address the ways that physicians can develop a discriminating eye in dietary supplement quality and help their patients do the same. Here's what you look for in transparency in labeling. The efficacy of ingredients. We'll go through examine.com, which I think is a great resource. So we go through the website together in the class and look at curcumin and they'll say “Wow, there's 600 references here! I guess there is some evidence for this after all.” I also talk about product quality and purity so resources like labdoor.com, ConsumerLab.com and others are part of the instruction. We go through the different resources that are out there and show them that there are evidence-informed resources and there actually is a wealth of evidence for dietary supplements. So that's one of the ways that we've done that. In addition, we've done a number of clinical trials on commercially-available dietary supplements at our center as well, thereby contributing to the ever-expanding evidence base. I also present regularly at conferences such as the Scripps Natural Supplements Conference, where you and I have been together for many years.
And so I think the more we can get factual information on dietary supplements out there, the better. During COVID, I was able to do a few media opportunities to deliver overlooked information that could help people on modifiable lifestyle factors, including dietary supplementation. While this information was generally suppressed, I was able to convey that there was pretty good data for vitamin D, vitamin C, zinc, quercetin, melatonin, and some other supplements to use as adjuvants in our approach to COVID. I think it's been rewarding to get some information out there, that there is utility for dietary supplements in promoting optimal health. We need to make good choices and choose brands that have supportive research, that have third-party lab verification, that have traceable lot numbers, etc. We also need to convey that while they're certainly not all terrible, they're also not all great, but if you look at these types of parameters you can make good choices that will help your patients.
Dr. Rountree: I can't tell you how many times I get frustrated when one of my clients calls me and says, “Well, I just saw an article that says vitamin D is worthless and therefore all dietary supplements are worthless.” After reading that article—which had appeared in a major newspaper—my first impression is: This isn't very good journalism. And the reason it isn't good journalism is because it doesn't include both sides of the story. If the authors of a new meta-analysis conclude that vitamin D supplements don't help for a certain condition, then don't the principles of good journalism require that you interview somebody who has a different perspective? Could there be potential flaws in the study? How would you know that unless you asked someone who wasn't directly involved in the research? Why not call the vitamin D Council and ask if there is an expert who can provide a response to the conclusions? That seems like just basic journalism to me.
Dr. D'Adamo: I agree. It's challenging, and what I feel is encouraging is that I think many people are developing a discriminating eye in where to find their medical information in general, and it's probably not going to be from some of the major periodicals or legacy media channels. I think people are starting to realize that these legacy media sources rarely present differing opinions on a subject in an equal light, so that the reader or viewer can make their own determination. So I think societally there's a lot going on there, but yes, I think people need to dig a little bit deeper when it comes to these sensationalistic all-or-nothing types of claims about dietary supplements and other aspects related to health.
Dr. Rountree: Another example is the many calls I got from doctors who read the headline, “Fish oil supplements will give you prostate cancer.” And then, more recently, there's the papers that suggest fish oil could increase the relative risk of atrial fibrillation. The biggest red flag here is the overgeneralization that “fish oil didn't work or caused problems in this particular study, so omega-3 fatty acid supplements are worthless and dangerous,” instead of taking a more nuanced approach that includes pros and cons about the study design, the dosage or form of the supplement used, etc. It's not unusual for one meta-analysis to come out with its set of conclusions, and then the next week another meta-analysis has a completely different finding. So practitioners don't know what to believe. What they really want to know is where they can get a solid source of information behind the headlines, so they can come up with a credible response to the inevitable questions from their patients. It would be great to have a reliable resource that one could go to for a consistently thoughtful discussion of the facts around some of these nutritional controversies. Where do you recommend they go? Should they call you?
Dr. D'Adamo: I think that's a tough one to address. For example, I had people call me about fish oil and atrial fibrillation. I think reading the actual study and not just the media report is incredibly important—not just reading the interpretation, but reading the actual study all the way down to the funding sources. Many times there are also rebuttals that are put forth, or commentaries that are subsequent to the publication that present an alternative view. This is the process of science unfolding the way it should, in which findings and hypotheses are challenged. As for public-facing resources, I like Examine.com, the Natural Medicines database (https://naturalmedicines.therapeuticresearch.com), and webinars and workshops that address these kinds of topics from organizations like the Institute for Functional Medicine. Ultimately, I think reading the actual study, reading what the authors put forth, not just in the abstract, but looking at their methods, the results, the discussion, is important. I know that's a tall order for some people who aren't research methodologists. But I think just not taking it at face value, at least getting the full text, giving it a thorough read, searching for commentaries on a particular publication is important. I'm always happy to answer questions, so anyone can contact me if there's a study of interest to them, and I really enjoy that analysis of methods and application and strengths and limitations and so on, and what does it mean, clinically. I'm curious to see what you think. Where do you point people?
Dr. Rountree: Well, if there is a controversy about a botanical medicine, sometimes I refer people to the American Botanical Council (ABC), or HerbalGram.com to try to find out what Mark Blumenthal's team has to say about it. The ABC has a team of medicinal plant experts that will be able to offer an informed perspective. For example, years ago a preliminary study suggested that black cohosh promotes breast cancer. Ever since then all the oncologists are afraid to give it to their breast cancer patients. But what if I have a patient with a history of breast cancer that wants to take it for hot flashes? How do I provide her with the latest research on safety and efficacy? That's the type of issue for which I would typically consult the ABC's publications. So I do have a handful of go-to sites, places that I can look. I mentioned the vitamin D Council is a pretty good resource. There's a website or two that focuses on omega-3 fatty acids. What I'm thinking is at some point, we need to be able to offer a collection of these websites to people as a networked reference. Because I do think a lot of docs out there feel really overwhelmed by the negativity that they encounter in the press.
Dr. D'Adamo: Yes, I know. Sometimes the Council on Responsible Nutrition has had good rebuttals. That at least gives another viewpoint for issues like this, and then I think maybe the clinician finds that the truth might be somewhere in the middle of opposing views.
Dr. Rountree: I do want to second your recommendation for the Council for Responsible Nutrition as a great resource for docs. I'm wondering what suggestions you have for practitioners that want to get more involved in this research. I'm especially thinking about someone who doesn't have an academic affiliation. How can they become involved in contributing clinical data or moving the needle in some related way?
Dr. D'Adamo: I think they can become involved, first, by becoming as informed as their schedule allows, following some of the publicly-available resources that we've talked about. They can search and follow clinical studies that are registered on ClinicalTrials.gov. I read many of these registrations as a principal investigator to stay abreast of what is coming down the read. If someone reaches out to me and says, “Hey, I've got a clinical practice, I'm seeing patients with metabolic syndrome, I'd be curious to see if berberine, for example, can help them.” I will always entertain these types of conversations. So I think you can reach out to clinical trial investigators like myself and others to see: are they doing anything of interest? Would I be willing to potentially become a clinical site in such a study? You can search ClinicalTrials.gov to see what types of studies are open or ongoing or may be completed. Published studies that you have read, you could contact the investigator, because a lot of the time we're looking for clinical partners who have patients that can help enroll patients in our studies. One of the things that we're doing—one of my hats, too, is I'm a research advisor for the Institute for Functional Medicine—is we're looking to catalyze more research in the field. We've developed Functional Medicine Research and Publication Standards that we're going to be putting out in the near future, so that would be another way that we can engage those clinicians that are in our field already.
Dr. Rountree: Is this an invitation?
Dr. D'Adamo: Yes. It's an invitation.
Dr. Rountree: So this invitation is to a clinician who is thinking, “I'd love to study the impact of a specific diet, or botanical medicine, or a dietary supplement on a particular health condition.” Are you up for having them contact you?
Dr. D'Adamo: They can certainly contact me. I may not always have a grant to do it, but I may know someone who does, or can help guide them in the right direction, or know someone who's doing a study in that area that they may want to have a clinical co-investigator who can help them recruit patients in a protocol. So yes, they can contact me. It's a relatively small world in this field, so I'm probably going to know somebody. Or again, let's take the berberine example that they can look up and see what research teams have done a recent berberine clinical trial. If you contact investigators—it could be me or people like me—much of the time they would be interested in hearing from you and they may need good clinical partners for it, so that's one of the best ways to get involved. Sometimes you can reach out to the supplement companies, as well. The best companies are often interested in clinical research of their products.
Dr. Rountree: Great. And if somebody wants to follow your work or contact you, what's the best way for them to do that, to find out about your latest research, etc.?
Dr. D'Adamo: Well, I'm not a big social media person, so the best way probably to contact me is via email, and take a look at our University of Maryland Center for Integrative Medicine page. I've also got a profile page at the Nova Institute for Health in Baltimore. So they can contact me through either one of those routes, and I'd be happy to chat about anything we talked about today, whether it's nutrition studies or integrative health interventions in underserved communities, dietary supplements, the Functional Medicine Research and Publication Standards, etc. I love connecting and love helping people in research and would welcome the conversation.
Dr. Rountree: Great. Well, I can't say enough about how appreciative I am of the work that you're doing, especially for underserved communities. Having spent time in the Baltimore area, which is actually a great place in many ways, I have an idea of the situations you're dealing with. And so I want to thank you for your contributions, and I'm excited to see more of the same.
Dr. D'Adamo: Well, thanks, Bob. I appreciate what you do, too, and look forward to seeing you hopefully soon.▪
To Contact Dr. Christopher D'Adamo
Christopher D'Adamo, PhD
Director, Center for Integrative Medicine (CIM), University of Maryland School of Medicine
Baltimore, Maryland, USA
Fellow, Nova Institute for Health
Website:
https://novainstituteforhealth.org/chris-dadamo-ph-d/
E-mail: cdadamo@som.umaryland.edu
