The pitiful state of medical ignorance
In 1976 the classic film Network starred Peter Finch as crazed anchorman Howard Beale who launched into his now-famous rant “I’m mad as hell…” on air and galvanized movie goers everywhere. Even though Howard Beale is fictional, I often share his sentiments.
I got a call yesterday from an acquaintance who wanted to get together and talk to me “face to face.” I’ve played golf and had a few drinks with this guy over the last couple of years, but that’s about it. I agreed to meet him at a local coffee shop.
When we had our coffees in front of us – I, a full-strength, scalding hot Americano; he, a non-fat, decaf, double shot latte, just in case you’re wondering – we made small talk for a few minutes then he cut to the chase. A look of despair came over him, and he confided to me that he was a type II diabetic and was in real trouble. His doctor had been monitoring his HgbA1c levels for a couple of years, and lately they had been inexorably on the rise to the point at which drastic action was required. What drastic action? His doctor told him he was going to have to start insulin injections.
The guy had begged his doctor for a reprieve, which he got until the end of the year, then called me in desperation.
I went through all the quotidian doctor questions and discovered that he was taking three different drugs for his blood sugar, a high-blood pressure pill, a medicine for his GERD and, it should go without saying, a statin. I asked him about his typical diet, but I already knew the answer. He ate pretty much what he wanted to eat, but he did try to avoid desserts because he knew sugar wasn’t good for him. I then inquired as to whether his doctor had discussed diet with him as a part of his treatment.
He said the doctor had advised him numerous times to cut the fat from his diet. His physician had told him that his diabetes put him at a greater risk for heart disease – which is indeed true – and that, consequently, he should cut the fat, especially the saturated fat, from his diet and live mostly on complex carbs. He said he had tried, but just couldn’t seem to stick with it for any length of time. With a What-can-I-do? kind of shrug, he divulged that he was a real meat-and-potatoes kind of guy who felt he would always be hungry if he couldn’t have a steak or a burger from time to time.
I asked if his doctor had perhaps suggested a low-carb diet when the low-fat diet hadn’t worked for him. No, not really. In fact, he, himself, had asked about the South Beach Diet since he had a friend who had done well on it.
“Absolutely not, replied his physician. Too much fat. Remember, you’re at increased risk for heart disease. Besides, you don’t want to go on a fad diet. You’ve got a serious health problem, so you need to go on a diet that might make you better.”
For the most part I face widespread medical/nutritional idiocy with a fair amount of equanimity, but every now and then, when I brood on the cost in human suffering this idiocy all too often causes, I want to do the Howard Beale and scream “I’m mad as hell.” Problem is the idiocy is so widespread that my pitiful efforts to counter it are on par with King Canute’s trying to hold back the tide. If I can make a little difference here and there, I suppose it’s worth the effort, so I keep trying. But I still want to scream.
I started ruminating about all the misery this seemingly universal lack of nutritional understanding engenders when I read on Fred Hahn’s blog an email he posted from one of his readers. In short order, I came across a brief anecdote in a book I was working through. If that weren’t enough, I got a copy of Robb Wolf’s new book and read about his medical experiences. Then, hard on the heels of that, the meeting with my friend almost put me over the edge. I was ready to lean out the window and start screaming, “I’m mad as hell…”
First the email, which I have excerpted. You can read it in its entirety here.
I also want to really thank you personally for being a part of a program that has saved my life. That may sound dramatic, but here is my story.
I am 42 years old and 6 foot tall. A little over ten years ago I was diagnosed with Type 2 diabetes and given medication to deal with it. I was also told to lose some weight. I weighed between 200 to 205 at the time. I was also told to lower my fat intake and I could eat as much fruits and vegetables as I wanted.
Over the years, the weight stayed relatively consistent. I am not athletic at all, but am fairly active. However, the quantity of food has consistently gone down in my efforts to lose weight. Additionally, my blood sugar has constantly gone up.
In these last two years, my weight started creeping up some. As a result, I stated running fairly regularly. It had no, or very little effect on my weight. I pretty much stopped eating a regular dinner at night after work. All I would eat is some yogurt or some fruit cups at night. Remember, I could eat all the fruit I wanted. I still kept gaining weight, but my fasting blood sugar that I measured in the morning did come down a little.
On March 14th of this year, I weighed 215. I was taking 4 different diabetes medications, one blood pressure drug, pretty much taking a Prilosec everyday for heartburn as well as Tums fairly regularly. My doctor did not seemed concerned with the heartburn. I assumed it was from stress at work. I would also vomit fairly regularly. I assumed from the various drugs, maybe stress. My cholesterol as indicated from my blood tests when I visited my doctor were higher than recommendations as well as my blood pressure. Neither super high, but higher than what is considered normal and healthy.
I visited all the normal diabetes type web sites and none of them said anything or recommended anything that seemed to offer anything of value. I was mostly doing what they said. Lots of fruits and vegetables, lots of whole grains, try to lower fats and some exercise. Yes to all of the above. Yet I continue to get worse. I was beginning to believe this was just a part of aging and having diabetes.
How long was it going to be until I started having real health issues? For the most part I very rarely get sick. When was I going to start going blind, lose a foot or leg, have a heart attack, kidney failure, stroke out??? I was getting to be resigned that it was just a matter of time. Inside my head I secretly hoped that I would have a fatal heart attack at a relatively young age so I would not have to deal with the real issues of diabetes.
On March 14th in a round about way, I found the Protein Power book. It was opposite everything I knew to be true, yet it seemed more true about nutrition than anything I read before. How could everybody else be so wrong? I instantly started following it, cutting my carb intake to next to nothing or at least less than 30 grams a day. Before stating this, knowing what I ate, I am fairly certain my carb intake was close to 60 to 70 percent of my total calorie intake. I bought your book a couple weeks later.
I am sure you will not be surprised at all by the results. As of this morning I now weigh a little over 190. It has been close to 20 years since I have weighed that little. I have stopped taking two of the diabetes drugs completely, one of the others I am taking 80% of what I was taking, the other I am down 30%. I have not taken a single Prilosec or a Tums since I have started this change and this is the most stressful part of the year for me as it relates to work. I have only vomited once and that was on March 16 or day 2. Six weeks in, I had a doctor visit and blood test. Blood sugar way lower, bad cholesterol way lower and in the normal range, good cholesterol way higher and also now in the normal range.
Five weeks after I changed my eating habits, I started my slow burn routines based on your book. With some of the exercises I really struggled at first, but now am fairly comfortable with most of them. I am still learning and refining a few things, but I can say my increases in strength are just as dramatic as my weight loss. In the case of the chest press, the very first time I did it following your slow burn book instructions I did 3 reps at 100 pounds and was wiped out. Yesterday, at 130 pounds I did 6 reps in a little over 2 minutes. Time to increase the weight again.
As I said before, I was running fairly regularly for a few years. Not that fast, and really, not that far, 3 to 4 miles in around 45 minutes. Generally 3 or 4 times a week to do “some exercise” as recommended by my doctor and everything I had read about diabetes. I have cut back on the running since I started your workouts, but when I do run, I run significantly farther and significantly faster than I have run in years. I hated, hated, hated the running, but did it to do my exercise. Now when I do run, it is almost fun. I am so amazed at the changes in me.
So that is how you have had a part in saving my life. I do not know how to say thank you any more than that.
Not long after coming across this email, I was reading a book on TRIZ, a methodological approach to engineering problem solving that can be applied to other realms, when I came across a report of a disturbing doctor-patient interaction. The author is using this story to illuminate a problem solving technique called peeling the onion, which means to continue to dig deeper and deeper in the quest for a solution. Instead of illuminating anything for me, it just made me mad as hell.
One day, I was sitting in my doctor’s office anxiously waiting to hear the results of my most recent cholesterol screening. The previous year my cholesterol had gone up just slightly, which was very depressing. I essentially had no exercise regiment prior to that, but afterward I went into fat-free mode and started walking 4 miles a day. In spite of my protests, a couple of years earlier my doctor had put me on a low dose of blood pressure medication. I don’t even like to take aspirin.
As a result of my hard work, I was certain my current cholesterol level would be outstanding. I couldn’t wait to hear the great results.
Unfortunately, the test results painted a different picture. My cholesterol level was 30 points higher.
“That’s impossible. I don’t eat beef brisket anymore… ever! I don’t eat any sausage, never go to McDonalds, buy fat-free everything, and walk 4 miles a day. It can’t be true.”
“Yeah, it sucks getting old doesn’t it? Aging is that one thing you can’t control. Even though you’re trying to eat better and exercising, which is a great thing, these efforts are obviously not enough.”
“What? Older? It has only been a year! Urrrrrrr…this doesn’t make any sense. It’s not fair.”
“I think we should put you on Lipitor.”
“No. I don’t want to take anymore meds. Let me think about it for a while. This makes no sense.”
When something makes no sense to you, your curiosity needs to kick into high gear. Well, this surely qualified as nuts to me. Yes, I was a year older, but… come on. The test results couldn’t be right. Most people would probably just do as the doctor ordered, but I almost never take anything at face value.
The author then goes on to describe how he “peeled back the onion” by doing internet searches for cholesterol and found that one of the supplements he had been taking for his joint pain – glucosamine – had been found in some cases to raise cholesterol levels. He went off of the glucosamine, and as he tells it:
Two months later, my cholesterol was 30 points lower and back under the limit.
If I did not have a curious nature about most everything I would have been on another needless medication. It pays to peel the onion back.
I don’t think his glucosamine had anything to do with his cholesterol – the 30 point drop in his cholesterol was probably just the normal roaming range of his cholesterol levels over time. The take home lesson of this story is that this guy’s doc was ready to put him on an expensive medication with a number of pretty severe side effects because of one cholesterol reading above a particular number. The doc wasn’t treating a patient, he was treating a lab value. In this case the patient is a young man (mid 40s) with no history of heart disease, the very kind of patient for whom no benefit has ever been found for statin therapy. Why, when this patient’s low-fat diet failed to lower his cholesterol, didn’t his doctor suggest a low-carb diet? Studies have shown the low-carb diet to be more effective in solving lipid problems than the low-fat diet. So why wasn’t it suggested. Had this patient gone on his doctor’s statin of choice and not had his cholesterol fall, his doctor would have tried another statin. Why not try another diet?
If you read the entire book, the author mentions throughout how his days of red-meat eating are over and makes numerous references to his much-despised (but in his mind, therapeutic) low-fat diet. It’s really sad that he’s such a victim of medical ignorance.
I got a copy of Robb Wolf’s new book The Paleo Solution and started reading the first chapter, which describes Robb’s own story. In short, he spent years as a vegetarian, getting sicker by the day. All his physician’s told him that he was lucky he was able to follow the diet he was following because he would have really been much worse had he been following a standard diet. Robb ultimately came around to the low-carb, high-meat Paleo way of eating and solved his own health problems. When he went back to his various physicians to get blood testing – all of which was perfect for the first time – he was ecstatic. He told his doctor he had completely changed his diet.
“Doc! Have you ever heard of the Paleo diet?” I asked. “How our ancestors ate for millennia?”
His answer was typical of what I would encounter in the years to follow. “That is pseudo science. There is no proof.”
When Robb describes the remarkable difference in his health to yet another doctor, he is told:
It must be something else.
Why do these stories make me mad as hell? Not just because the people involved suffered as a consequence of medical hubris, incompetence and intransigence, but because so many millions of others do suffer miserably and aren’t lucky enough to escape their fates as these few were.
It’s difficult to imagine the number of people who go into doctor’s offices every day with weight problems, elevated blood sugar, high blood pressure, and abnormal lipids and are told with great authority to eat less and exercise more. If the patient asks the doctor for a specific diet, the doc usually has the nurse give the patient the standard 1800 kcal low-fat diet sheet. Depending upon the motivation of the patient, this diet may or may not be followed. If the patient does suck up and follow the diet, many, of not most, will fail. When these poor folks come back for their recheck, their doctor then wants to put them on some sort of drug. Believe me, the stories above aren’t atypical. This is happening all across the country thousands of times every single day.
And I’m mad as hell because it doesn’t have to be this way.
There is another option. These poor people could be given a low-carbohydrate diet to try. Most of the doctors who prescribe the 1800 kcal diet (along with a recommendation to exercise more) could give people the choice. A low-carbohydrate diet or a low-calorie diet. But the vast majority of them don’t. They simply opt for the low-calorie diet, then resort to drugs when it doesn’t work.
There is plenty of good research available now showing the low-carb diet to be at least the equal of the low-fat diet in virtually every parameter with most of the studies showing the low-carb diet to be superior. With this research backing the efficacy of the low-carb diet, why don’t more doctors offer it as an option? Naiveté? Stupidity? Pigheadedness? Who knows? What I do know is that it’s a real problem.
Lately the web has been full of various health gurus (mainly those involved in weight training and/or bodybuilding) making the case that the only reason the low-carb diet works is that it is satiating and spontaneously causes its followers to restrict calories. It’s the calories, say they, not the carbohydrate restriction that does the job. I say, So what? Who cares as long as it works? And countless studies have shown the low-carb diet to be as efficacious (if not more so) as the low-fat diet, so why isn’t it offered as an option?
If a doctor treats a patient with a specific drug for high blood pressure, and the patient’s blood pressure doesn’t respond, the doctor switches medications. Most doctors will fiddle with the medicines to get the problem solved. Why not do that with diets? Why just go with the low-cal, then move immediately to drugs if that diet fails? Years ago, during the interim in which low-carb diets were out of favor and not much good data existed on their efficacy, I could understand it. But why now?
It seems that almost every week a new study is coming out showing the superiority of the low-carb diet. Over the past couple of years we’ve had a trifecta of well-done studies published in major scientific journals demonstrating the effectiveness of low-carb diets. There was even a meta-analysis published in Obesity Reviews, the most mainstream of mainstream academic journals** showing low-carb diets work better than low-fat diets. So why don’t more doctors recommend them?
I’ve been infused with a little hope by a recent totally unscientific poll published in the Annals of Internal Medicine. Readers (primarily physicians) were presented with the following poll.
Surprisingly, the majority answered that they would give a low-carb diet a try first.
The particular issue of the journal publishing this poll was the one containing one of the more recent papers on the benefits of low-carb dieting. (I’ll post later on this amazing study that was designed to fail.) As a consequence, I would bet docs taking this poll were skewed in the low-carb direction. But who knows? I can always hope it means there is a light at the end of the tunnel, and that physicians are beginning to discard their low-fat tunnel vision. The fact that this poll even exists in a major mainstream journal. We should all take heart.
But until docs start changing diets that don’t work at the same rate at which they change blood pressure medicines, many, many people will suffer. And I’ll continue to get mad as hell every time I hear about travesties such as the ones I wrote about above. Too bad there aren’t diet reps that go into all the doctor’s offices like the drug reps do. Maybe if there were, things would change a little faster.
Since most of you reading this blog visit your doctor from time to time, perhaps you can play the role of diet rep. You can do it by telling your doc how your low-carb diet is working for you. And you can provide literature just like the drug reps do to add substance to your report. Here is a pdf file of the Obesity Reviews meta-analysis showing low-carb superiority. Meta-analysis of low-carbohydrate diets
So, be ambassadors for the low-carb diet so that more physicians might give it a try. If enough of you do that, your actions will provide a gentle but steady invigilation that will ultimately bear fruit. When physicians do gingerly recommend low-carb diets a few times, they’ll see the same astonishing results you have. More and more will start recommending low-carb to their patients as a first line therapy, which will decrease the number of tales of woe I’ll have to sit through. I can then dodder off into my dotage in a much more sanguine frame of mind.
If you haven’t seen it, here is a clip of the famous I’m mad as hell speech from Network.