Shonky pseudoscience by NZ Herald

bang_headOccasionally I read stuff that makes me angry. Really angry. Moronic popular media pseudoscientific articles “debunking”, “educating” and “linking nutrient x with disease z” normally fall into this category. The award for the popular media article with the dumbest headline and the most questionable content of the month goes to NZ Herald article “Researchers write off benefits of vitamin D“.

Researchers who have debunked one of the claimed benefits of vitamin D capsules are sceptical of the links that have been made to a much wider range of medical conditions.

Auckland University physician Professor Ian Reid and colleagues concluded after studying 23 trials that most healthy adults need not take vitamin D supplements for the prevention of the bone-weakening condition osteoporosis.

Let’s start with the headline. The researchers DID NOT “write off the benefits of vitamin D”! The article relates to vitamin D SUPPLEMENTATION. Unfortunately we use the term “vitamin D” interchangeably with the pro-hormone 25(OH)D that we synthesise in our own bodies and with the white pill that you can take orally to supplement your serum levels of this. Still, shouting out “there are no benefits to vitamin D” is extremely stupid and deceptive. All vertebrates have to synthesise vitamin D to survive, and have been doing so for over 350 million years.

I have not got access to the actual study (only the abstract) so I will reserve the judgement on the paper. Let’s have a deeper look into this NZ article instead (it may very well be that it doesn’t fully reflect the authors’ conclusions).

Love this sentence:

Use is said to be very high among patients of GPs in wealthier areas.

That, I assume, either implies that GP are trying to scam their more affluent patients into buying a totally unnecessary supplement, or that health-conscious and gullible wealthy worried-well are using vitamin D in addition to their chiropractic appointments, yoga retreats, and other voodoo. Both are pretty insulting implications.

They have become something of a cure-all – or prevent-all – with low blood levels having been linked to multiple sclerosis, winter colds, heart disease, cancer, mental illness and numerous other medical conditions. Professor Reid has found reports of links to 53 conditions.

‘When you get 53 different diseases associated with low vitamin D levels and when those diseases are incredibly disparate … it’s pretty hard to see a common biological explanation for those associations except the fact that people don’t go outside and lie around in the sun [when they are sick].’

Hmmm. 53 “incredibly disparate” conditions linked to low vitamin D levels. That does sound rather suss. That’s, like, this is miracle vitamin, or something. What could possibly all these conditions have in common???

Erm. I assume Professor Reid has heard of inflammation. And I hope that Professor Reid is familiar with the extensive body of research looking at vitamin D as much more than just a “bone-building vitamin” but a powerful immunomodulator. Its method of action is so broad that vitamin D receptor (VDR) is expressed by the cells in most organs of the body: intestines, bone, kidney, skin, brain, heart, breast, parathyroid glands and gonads.

This from the Scandinavian Journal of Clinical and Laboratory Investigation (Reichrath et al, Hope and challenge: The importance of ultraviolet (UV) radiation for cutaneous Vitamin D synthesis and skin cancer, 2012)

Of high importance was the discovery that in contrast to earlier assumptions, skin, prostate, colon, breast, and many other human tissues not only express the vitamin D receptor (VDR) but also express the key enzyme (vitamin D-1 α OHase, CYP27B1) to convert 25(OH)D to its biologically active form, 1,25(OH) 2 D [1,2,6]. This active vitamin D metabolite is considered as an not exclusively calciotropic hormone, but additionally as a locally produced potent secosteroid hormone regulating various cellular functions including cell growth and differentiation.

Cell growth and differentiation: that may have something to do with all those cancers, huh?

 

No, there is no plausible biological explanation at all.

 

Not sure why Professor Reid mentions any of these conditions at all since his paper actually only looked at the effect of vitamin D supplementation and the risk of osteoporosis. I am going to take a stab in the dark and say that osteoporosis is a multifactorial disease. From the abstract it transpires that 10 of the studies analysed use such piddly doses of vitamin D as 800IU. I wonder why they even bothered. For the populations in question the typical doses of 600IU to 1000IU of cholecalciferol barely going to maintain their levels, let alone increase them significantly. Compare this to 10,000IU your body can potentially synthesise from 30 minutes of direct sunlight.

Most healthy adults in New Zealand got enough vitamin D from the sun, said Professor Reid.

Riiiight. This may indeed be the case in sunny tropical New Zealand but here in Australia we have a few issues with vitamin D deficiency.

Research by Deakin University found that one third of Australians is now vitamin D deficient. The authors of this 2009 paper were quite alarmed by this fact, seeing it as a “major health problem worldwide”:

Low levels of vitamin D can contribute to a number of serious, potentially life-threatening, conditions such as softened bones; diseases that cause progressive muscle weakness leading to an increased risk of falls, osteoporosis, cardiovascular disease, certain types of cancer and type 2 diabetes.

One thing on which I will agree with Professor Reid. Popping vitamin D pills is not the answer. Some the links between vitamin D deficiency and various conditions are undoubtedly related to changes in our lifestyle. Going out for a walk in nature will not only top up your vitamin D levels but will boost your cardiovascular fitness, strength, circulation, and promote overall mental health and wellbeing. The whole is always more the sum of its parts. And this is supported in the literature. This systematic review, for example, concludes that cancer prevention related to sunlight, cannot be fully explained by the vitamin D effects alone. Just like with our diet, we should aim to receive all the necessary nutrients naturally. Ideally we will get most of our vitamin D through sunlight exposure and, to a much smaller extent, diet. However many of us work indoors from 9am to 5pm without ever seeing sunlight. Supplementation is sometimes necessary.

Irresponsible reporting such as this can cost somebody their health.

 

A case for simplicity

Case 1. Bev

Bev is a jolly 63yo farmer who came in to the hospital after suffering a minor stroke. One quiet afternoon when I spot our medical student looking a bit out of place (well, even more so than usually) I take him to see Bev for a neurological exam practice. Bev looks flattered and obediently sits back in her bed, being the perfect patient. I remind the student that we start with a general observation of the patient,the side of bed assessment. He dutifully recites “alert, comfortable and in no respiratory distress”. I gently nudge him to describe the patient’s body habitus, the student gets instantly embarrassed and looks lost. How do you tell a patient she is fat? I explain while looking at Bev that her central obesity is an important risk factor which may be pertinent to diagnosis at hand. Bev chuckles good-naturedly: “I love me food, I’ve always been a good baker!”.

Most medical students hate the neuro exam: it’s tedious, long, complicated and seemingly impossible to make smooth. I don’t rush him and Bev seems happy with the attention. The student correctly identifies the weakness on the left side of Bev’s face. He asks Bev to blow up her cheeks, Bev makes a valiant attempt but ends up making a noise like letting out air of a balloon and promptly laughs. I hear laughs from the other side of the curtain: evidently this has been a source of amusement to other patients as well. Bev’s limb weakness is improving and we take her for a gait assessment. With her tiny feet, narrow shoulders, perfectly rotund middle and a wide crooked smile, she looks almost comically cute. The student summarises the findings of his examination and correctly identifies that Bev has likely suffered an ischaemic stroke in the area of a middle cerebral artery in the right brain hemisphere. I thank Bev for being the perfect model for us, she wisely nods:
- They all gotta learn somehow, don’t they? So you think it’s gonna get better for me, doc?
I point out that she already has made marked progress and then ask her how she feels about the future.
- Oh I know. I gotta watch that cholesterol, don’t I? No more fish’n’chips for this chickie! (laughs)
I tell her I’ll come back to chat to her about diet before her discharge, thinking I’ll get to her before she gets fed some pseudo-nutritional rubbish.

Two days later, on my day off, Bev suffered a major stroke. The nurse found her in the morning, stiff in her bed, unable to move, call out or ring the bell. The stroke affected the other side of her brain and left her completely paralysed on what just 2 days ago was her “good side”. I never got to see her again because she was transferred to another hospital to a dedicated stroke unit.

Case 2. John

I only find out about John at morning rounds as he was admitted last night. I barely have enough time to register “64yo male transferred post BKA” on my handover sheet as we enter his room. BKA stands for Below Knee Amputation. John has just had his second one. As I stand in the room while the consultant chats to John about his surgery my eyes keep drifting to an empty space below John’s knees. No matter how many times I have seen it, this sight still unnerves me.

I distinctly recollect one of my most distressing experiences in operating theatres when I was assisting in a BKA. My job was to stand at the bottom of the table and stabilise (a.k.a hold tightly) the foot and calf of the leg being amputated. I still remember own visceral startle when the toes suddenly started to move, as if in a mute protest, when the surgeon was severing the tendons at the knee. At some point through the cut the lower leg stopped being a part of the human being and became an object. As the last thread connecting it to the breathing body was dissected I was left holding that object in my hands, temporarily stunned, until the nurse offered a big bucket to deposit it in.

John is looking defiant. The consultant has just finished drawing a pretty bleak picture and suggesting a nursing home placement. I feel the hot wave of indignation at this seemingly cruel crushing of a patient’s determination to maintain independence and mobility. John repeats mulishly that he wants to have double prosthesis, he wants to walk again. Later that day I find out that my anger was misplaced. While his raging diabetes destroyed the small vessels in his feet and opened him up to ugly ulcers and gangrenous infections, John’s dementia caused him irretrievable short term memory loss and, consequently, an inability to learn new skills required for amputation rehab. He has been on insulin for years but has been steadily forgetting to inject himself in the evenings when he gets most confused.

Case 3. Pat

Pat is a 47 year old Indigenous woman who presented to our Emergency Department with chest pain. The ECG and cardiac markers do not show any signs of heart muscle damage but she is at high risk for coronary artery disease as she is a former heavy smoker and a diabetic. Routine nursing observations show that her average blood sugar has been between 25-30 mmol/L (450-540 mg/dL) over the last day. She normally takes metformin but it’s clearly not doing very much. Like many Indigenous patients she doesn’t look grossly overweight, with her skinny arms and legs sticking out of her hospital gown. The gown cannot fully hide her round belly though, and I have to double check the notes that she is not pregnant. No, she is not. I try to be gentle when I tell Pat that she is likely going to need “the needles”. Sometimes the mere mention of injecting insulin serves as a good wake up call and a good opener to the lifestyle modification conversation. Pat doesn’t seem phased: “Ok doc”. I feel a hint of frustration: the conversation is not going the way I planned. I try to bring it back to the diet, saying that stopping junk food may be an easier solution than injecting yourself every day. “I don’t eat junk food, doc! I didn’t have Maccas for yonks!” – she protests. I note a half empty 2 L apple juice bottle on her bedside table: “And what’s this? You can’t have that with your sugars!” She looks confused. I take a breath and start to rant about soft drinks and sugar but she has already turned off and when her mobile phone rings she picks it up leaving me with my mouth open mid-sentence. As she starts to chat, I walk away taking the juice bottle off her table and pouring it out into the nearest sink.

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My other life, on this blog, as a part of Whole9, on social media, is like another world. Highly motivated people sharing their success stories, intelligent eyes watching our Whole9 South Pacific presentation, challenging questions being asked – I find my enthusiasm recharged and renewed. Although recently I see more and more splinters appear in the community.

Recently a video made rounds in “Paleosphere”. Some bloggers that I respect and follow found it offensive in its simplicity. I won’t comment on the video itself, I have a few minor quibbles with it myself, although I wouldn’t hesitate for a moment to show it to my average patient. I want to comment on the “It’s not that simple” critique. Maybe it’s not that the message is too simple, maybe we are trying to make it too complicated. We dissect this diet thing to its smallest constituents, calories vs grams vs ratios vs micronutrients vs cytokines vs endocannabinoids. Critical scientific discussion is enormously valuable and discourse should only be viewed as the way forward. But somehow discourse all too quickly  turns into a personal attack, a spiteful tweet or a post from the safety of a computer screen. And, sadly, some who used to offer valuable contribution to the body of knowledge now seem to offer nothing but negativity. Are we turning into the equivalent of elderly cranky academics arguing about the best fire-fighting methods while the room is engulfed in flames?

What about your average reader who has just googled Paleo or primal or ancestral health? Are we causing “paralysis by analysis” by not making it crystal clear what we actually all agree on? Even those firmly indoctrinated in beef broth/bacon/kale seem occasionally lost. Sometimes getting lost is easy if you are given a way out – maybe Lustig is wrong and sugar is ok? Maybe Taubes is delusional and it’s time to count calories again? Oh no, this thing is not simple at all! Let’s browse through some blogs, maybe we can catch the author out, find an error in the archives and pronounce the final judgment. It’s not exactly helpful for own health problems but sure is satisfying.

I did not choose the three cases for their dramatic value, I chose them because they are average. I see between 20 and 30 Bevs, Johns and Pats daily. Sure, I love reading the latest research papers in a search for truth but for these guys I want SIMPLE. I need a heuristic. If your goals are getting to a single percentage body fat, running a marathon or continue setting PBs by doing smashfit 5 days a week (hopefully not all at the same time!) you may need more tweaking but you are not exactly your Average Joe, are you? My favourite Internet testimonial this year is a 71 yo lady on a social security budget who reduced her HbA1C, came off insulin and halved her blood pressure medications, probably without giving a second thought to the latest blogosphere drama.

We are onto something good here. It’s real and, let me tell you, it may better than any expensive medication I can offer my patients. SIMPLE will get most people most of the way there. Here is my heuristic:

- eat meat/fish/eggs + vegetables (tubers, greens) three times a day to satiety and activity levels

- prioritise your sleep

- move in a way you enjoy

Do this every day for 3 months. Without dissecting, or philosophising, or looking for a loophole. This may just be enough to see change.

 

 

 

 

 

 

Saturation be damned

Night time reading

I love interacting with this informed and educated community of ours who take responsibility for own health, read and interpret scientific articles, ask intelligent and incredibly tricky questions and look at the world through a prism of human evolution. It’s really really cool. I also don’t own a television or read newspapers. I know, I am missing out on the vital information on the recent exciting advances in the field of laundry detergents, easily foldable exercise equipment and female hygiene products. But I’ll take my chances.

So when I was approached recently by an Australian reporter to comment on why saturated fat might not be as bad as everyone thinks, I was temporarily stunned. Everyone still thinks that? An hour-long lunch outside in the company of co-workers brought me back to reality. Listening to the less-than-lithe lady lecturing a younger employee that “pasta is perfectly healthy as long as you avoid creamy sauces and stick with tomato-based ones and add psyllium husks to increase fibre” plunged me back to earth from the AHS12-induced heights.

Oh boy. On this planet, margarine is still a health food.

So I thought I’d write down some thoughts on fats, why we still need to talk about them, the strength of evidence and where we go from here. The article ended up being published at The Age and I was amused to see our hour-long phone conversation and the exchange of several emails with attached studies reduced to one sentence quoted from me, but I am not complaining since I think the article was quite well-balanced and hopefully gives people some food for thought. Here is the link.

If you are totally new to all this, I recommend that you read my post on fat basics and the slightly more complicated polyunsaturated fat primer.

Don’t all scientists and doctors agree that saturated fat is bad?

My main gripe with conventional advice to reduce saturated fat in the diet is that it makes it sound that everyone in science and medicine agrees that it is the right thing to do. They say “scientists” and you imagine a group of nerdy-looking men and women in lab coats and glasses with clipboards, all nodding in unison: “Saturated fat will kill you”.

Bad cow, bad!

Sorry, no. Far from it. In the year 2012 we still run trials on dietary fat and its effect on mortality, cardiovascular disease and weight. In fact, a Pubmed search on “dietary fat” yields close to 700 article from 2010 to present date.

If “saturated fat will kill you” is a done deal why do all these folks get research grants and waste years of their life on the pointless pursuit of the truth that has long been discovered and incorporated into every government-led nutrition advice?

And yet, the consensus is farther away than ever. Nutrition and Metabolism Society publishes critiques of the American Dietary Guidelines, as well as scores of papers on the subject. Then there is THINCS, The International Network of Cholesterol Skeptics, which really sounds like an evil mad scientist organisation from a Bond movie, but in fact has respected members like a biochemist Dr Mary Enig and a scientific researcher Dr Uffe Ravnskov.

Not to mention a fine gathering of clinicians, scientists, nutritionists, researchers, physiotherapists, bloggers at Harvard Law School this year for 2012 Ancestral Health Symposium, most of whom seemed to think that bacon is rad and margarine is bad.

Can you refute XYZ study and the rest of the body of evidence on saturated fat?

Yawn. I have no intention on memorising every study conducted in the last 50 years, no matter how bad or good they are. We have been eating fat, lard, meat, eggs, butter, ghee, coconut oil for thousands of years. I think the burden of proof lies on those who say that these traditional foods have been our silent killer all along. All I can do is to politely present the vast body of scientific evidence that does not support the lipid hypothesis (YES! IT IS STILL A HYPOTHESIS!)

Sarcasm alert. Lipid Hypothesis 2.0 = we have come to realise that total fat intake has no bearing on heart disease or weight (sorry! Our bad!) But it’s all about the type of fat. There are only 2 types of fat: saturated (=evil, comes from animals, eating animals is bad, you immoral cruel self-serving glutton) and unsaturated (=pure good, comes from vegetables, like cottonseed, soybean, canola and sunflower, botany be damned). Substituting unsaturated for saturated fat is the real reason why we are healthier, thinner and fitter than thousands of generations of traditional cultures because they couldn’t work out how to get 10% of their daily calories from PUFA, suckers.

 

He needs to be told how unhealthy he is from his 40% SAFA intake. Those coconuts will kill you, buddy! (Source: http://www.thatpaleoguy.com)

Several studies have shown improvement in CV markers and mortality when saturated fats were replaced with PUFA. Regardless of how good/bad sat fats are, shouldn’t we make the substitution just in case anyway?

This is a very common reasoning from many educated doctors and academics. They are now aware that sat fats are not much of a problem. Great. But what’s the harm in tinkering our diets if all we have is improvement, right?

Wrong.

I have a real problem with a blanket advice to increase PUFA in general as if they are all the same. PUFA are not all created equal, they have different physiological functions and effects on the body! (go back to basics). At the very least they should be differentiated into omega-3 and omega-6. However, even that’s too simplistic.

If you are planning on dividing fats on the basis of the biochemical structure and biological function, you have just only scratched the surface. Behold! All saturated fats are actually not the same either. Lauric fatty acid is metabolised differently and has different effects on serum lipid profiles than stearic. Even omega-3 are not a homogenous group (gasp!). The intake of the shorter-chained ALA (alpha-linolenic acid) does not come close to providing the same benefit as the long-chained DHA due to inefficient conversion.

Jacobsen’s analysis of 11 cohort studies, quoted in the article as the final proof of the miracle qualities of PUFA,  showed that substituting PUFA for SAFA seemed to reduce CV events and mortality. However, simplification, as usual, can only take you this far. The analysis lumped omega-3 and omega-6 PUFA together and did not take into account the deleterious effect of trans fatty acids separately from SAFA.

“Linoleic acid selective PUFA interventions produced no indication of benefit but rather a fairly consistent, but non-significant, signal toward increased risk of coronary heart disease and death. ” (Kuipers ER al, 2011, hyperlinked above)

That’s what happens when you simplify a complex concept. Why? Because the public are so dumb they won’t get it? Because 2 types of fat is quite enough to remember? And to make things even more visually and conceptually appealing let’s represent them as ying and yang, bad and good, dark and light?

So you have some studies, “they” have some studies. How do lay people know who to trust?

As much as I respect Evidence Based Medicine, I am well aware of its limitations. You can pull apart every study, point out the confounders, small sample size, confirmation bias, lack of double-blinding, the grant approved by a completely impartial third party with key investments in related area. Let’s not reduce the process to “Mine is bigger than yours.”

Nothing in biology makes sense except in the light of evolution“. Repeat this 5 times before going to bed every night.

How much omega-6 was available in our diet as Homo sapiens for 2 million years up to the advent of industrial processing? How much oil can you get out of a soybean without the benefit of extraction chemicals?

Aaaaaaah! Would you just tell me how much PUFA/SAFA/Carbs I should be eating?

Talking about macronutrients (fatty acids, carbs, etc) is useless unless it applies to food. If the advice to increase PUFA translates into “eat more fish” I will be the first one to shout it from the rooftops! But what if it translates into “eat more peanut butter”? Still PUFA! But are you going to get the same benefits? You don’t need to read an insightful review by Christopher Ramsden on omega-3 vs omega-6 to know that peanut butter ain’t gonna make you healthier than salmon. But sometimes we really really want to believe it. And deluding ourselves is oh so easy when somebody in a position of authority gives you the green light.

Yum

Focusing too much on macronutrients is what allowed abominations like “low fat banana bread” to become a healthy morning tea snack. The “reductionism” approach has successfully indicted natural foods such as eggs, coconut, avocado, butter. At the same time we have low fat sausage rolls, sugary cereal, margarine and other foods devoid of any nutrition, riding on the coat tails of the lipid hypothesis 2.0.

One of the benefits of using the evolutionary approach is that it allows you to make rational decisions about your life choices without having to double-check them with Pubmed. And it doesn’t involve re-enactment of Paleolithic times, although heaven knows, I find some modern social conventions really tedious (like people requesting to know how I am going on a Monday morning prior to my first cup of coffee). As the opponents of the Paleo approach correctly point out, we don’t really know what our ancestors ate. But I sure as hell know what they DIDN’T eat: excessive amounts of sugar, grains, seed oils and other industrially produced food-like substances. Not even almond flour cupcakes. Sorry.

Regulating your fat intake is easy: eat fish, seafood, meat (preferably grass-fed), eggs, some nuts, seasonal fruit and veggies.

Go back to eating food, not labels.

First week of being a doctor

I hate you. I hate you. I hate you.

Nurses

- Are you Jasmine? No, Tenelle? No, Daniel? Ahhh, Anastasia.

- Here, have a cookie, dear, you look pekish.

- You can’t talk to me, I’m not even here! I’m on morning tea!

- Poor new doctors. They look like little lost puppies.

- You are so pretty and stylish. You must be from Melbourne.

- Can you re-chart Mr Smith’s meds ASAP? No, the next dose is not due for another 3 hrs. Yes, it’s still urgent.

- Yes, I can fax this for you. Yes, I will do the ECG. Yes, I will pass it on to the nurse who is looking after your patient. Yes, I will find the chart that you were carrying around and lost somewhere in the ward. No, I don’t do bloods.

Patients:

- Hello, Mr Wendell. I’m one of the doctors who will be looking after you. Yes, all  female doctors in this hospital are attractive. It’s one of the application criteria.

- Mrs Smith, I’m going to put you on high flow oxygen to help with your breathing. Yes, I know you are feeling just fine but I just saw your blood gas. Your blood oxygen level is incompatible with life.

- Now let’s not be naughty, Mr Brown. You cannot put your hand on my knee while I’m flushing your drip.

- (inserting a cannula) Mr Randall, look out the window. Blue sky and sunshine are so invigorating, arent they?

- (inserting a cannula) Mrs Clayton, look out the window. The torrential rain is so soothing, isn’t it?

- (inserting a cannula) I’m sorry, Mr Randall, your veins are being a little tricky today. Not to worry, we will have another go. I think I saw a vein on your foot that looked promising. No, I’m not turning you into my pin-cushion, you naughty man.

- Do you know where you are, Mrs Forrester? The bowling club? Not quite. Do you know what year it is? 1986? No, we are a bit past that. May? You are way ahead of us, it’s still January.  I think you should just go back to your bed and have a nice little nap. Now if I can only remember what ward you are in…

The most time wasted:

- Um, how come this discharge summary doesn’t print? I’m hitting the print button. The other print button? Ok, what does this mean? Click draft? Not draft? Oh draft here, but not there? I think it’s coming out. Oh no, that’s the wrong one. How did that happen? Um, thanks you’ve been great help.

- What’s the name of this printer? Pin-jko-fjr9? Cool, thanks

- What’s the code for the doctors’ room? 02938#? Cool, thanks.

- What’s the code for this drug room? 94847#? Cool, thanks

- Does anybody know the code for this coffee machine?

- Excuse me, where can I find blood tubes? Tongue depressors? A flashlight?   Blood culture bottles? Imaging request form? The OTHER imaging request form?

- I can’t log onto to my computer.  I can’t log onto the patient system. I can’t log on to the radiology system. I can’t log onto the pathology system.  What do you mean, I can log on to check my emails?

Pathology/Radiology

- Hi, I need an add-on to the morning blood test. Sure, I can drop everything and run the request up to the second floor.

- Hi, I need to order a blood test. So I order online but you don’t get it online? You need a hard copy which you will personally enter into your separate data system? And there is no human error involved? Awesome.

- Hi, I have ordered a blood test. Will it be collected? The collectors are gone? Sure, I would love to stick this old lady with the needle, this paperwork is driving me mental.

- Hi, I’m sorry I know I asked you this before but I’m chasing a result for Mrs Smith. I’m sorry, my boss is hassling me. When will it be ready? Is it ok if I call in 30 mins? I’m sorry, I don’t mean to be annoying. It’s ready? Thank you. I’m sorry. Thank you.

- Hi, I need an ultrasound on Mr Smith. Is it possible to get it done this afternoon? Really? What about a CT on Mr Brown? Cool. How about an MRI on Mr Collins? Yeah ok, I know I am pushing it.

Getting paged:

- Can you chart something for Mr Brown’s pain?

- Mr Smith is short of breath, can you come and see him?

- Mrs Lee has a temperature of 40, can you come and see her?

- Mr Clark is having chest pain, can you come and see him?

- Mrs Lang has a potassium of 2, can you come and see her?

- Mr Williams’s stool is really black, can you come and see him?

- Mrs Drake has passed away, can you come and see her?

- Mrs Wood is going home now. Is her discharge ready? What about Mr Williams? Mrs Nguyen? Mrs Tang? Is ANYBODY’s discharge ready?

- Can you talk to the patient’s family? The patient’s priest? The patient’s lover wants to talk to you separately from the patient’s wife?

- Can you insert a cannula? Or ten?

- Mrs Carmody’s sugar is 33mmols. Of course she had toast and margarine, and marmalade, and cornflakes, and skim milk, and apple juice for breakfast. It’s a standard diabetic diet.

Room 7. Certifying the death of Mrs Drake. Sitting down next to her bed is a luxury I cannot miss. I listen for her breath and heart sounds for way longer than the necessary one minute. For the first time today it’s very quiet. I close my eyes and keep listening. The pager beeps and gives me a jolt. Goodbye Mrs Drake. I have to go and see a patient.

The definition of insanity…

It is now exactly 3 days until I start working. To say that I am nervous would be an understatement of the century. For now, I’ve been pushing any hospital-related thoughts to the deepest corner of my mind (from whence they tend to re-emerge just as I’m falling asleep causing me to break into cold sweat). My plans for my last few days of freedom and frivolity are to soak up as much sunshine as possible, ride my bike, watch really bad action movies from the last century (Lethal Weapon, yes, really) and overall do as little as possible.

In between all these exciting activities I also read the draft of the new Australian Dietary Guidelines, as a special type of punishment for my laziness. 288 pages of government-speak is no joke. I find myself re-reading the same paragraph 3-4 times and its meaning still devilishly eludes me. I don’t want my readers to suffer the same fate so I will be feeding you those pearls of wisdom one post at a time. Just a few statements and observations for you today.

“Diet is arguably the single most important behavioural risk factor that can be improved to have a significant impact of health”

I was very impressed with this profound statement in the Introduction. I am sure many of you feel like doing a little fist pump in the air: finally, the role of diet is getting recognised and appreciated not just as something that might make one fat and obese. But also as an important health determinant. Good stuff.

However, seeing diet as a “behavioural” problem has never sat well with me. We fall into that thinking all too easily. Ever glanced over an obese woman eating an ice-cream and did a little “tsk, tsk, tsk” to yourself? But overweight has not always been seen as primarily a  character flaw. One of Leo Tolstoy’s best characters, Pierre Bezukhov, (for those of you who braved “War and Peace”) is described as a big stout man. And no, it is not a reflection of his lack of willpower. And yes, he gets the girl in the end.

Venus and the Lute Player, Titian c.1560. Source Wikimedia Commons

Interestingly, because the media and government health agencies are so preoccupied with being PC, they use different tactics to accuse overweight and unhealthy people of being disgusting slobs without actually calling them “disgusting slobs”.

Here is one used in the Introduction to the Guidelines in the chapter dedicated to adherence.

“Adherence to dietary guidelines in Australia is poor”.

=disgusting slobs continue ignoring our well-meaning advice and insist on becoming a chronic disease burden while laughing into their French fries.

It is such a sad sentence I think they need an emoticon :(

A couple of paragraphs later:

“There have been changes in the intakes of macro-nutrients over the past 3 decades, generally in the direction encouraged by previous dietary guidelines” (my bold italics)

Say what? The compliance is SO POOR that people change their intakes in accordance with your guidelines? (I wrote a post about one of the multi-million dollar lifestyle modification campaigns in Oz and the subsequent “non-adherence”.)

It all becomes clear when we see this statement in a table form.

Call me an optimist but looks like both men and women REDUCED their fat intake, INCREASED their fibre intake and INCREASED their carbohydrate intake.

Kiddies INCREASED their dietary fibre (somebody is actually eating their bran muffins!), INCREASED protein and INCREASED carbohydrate.

It also looks like reduction in fat didn’t result in reduction in total calories consumed. Bugger me! I thought fat being more calorie dense and all…

Does anybody need a reminder on how the obesity and overweight rates in Australia went while we were busy modifying our intakes “in the direction encouraged by previous dietary guidelines”?

“I don’t know why the sacrifice didn’t work.

The science was so solid.”

King Julien XIII, Madagascar 2

Down the rabbit hole

Many assume that because I critisise the conventional approach to nutrition that I am a rebel. An alternative, slightly nutty medical practitioner in flip flops, long tribal skirt and myriads of beads hanging from her neck: “So, you have a neck of femur fracture? I recommend this delicious broth from organic frog livers followed by cupping of your right buttock and acupuncture to your left testicle”. To add insult to injury, I also teach yoga. Victoria has kindly forwarded to me this entertaining representation of a yoga teacher. Thank you, Victoria, I suddenly feel the urge to buy more Lululemon.

I’m not a rebel at all. In fact, I like rules and do not reject them out of some vestigial teenage rebellious principles. My “problem” is that I like to know the reasoning behind the rules. So when the Australian National Health and Medical Research Council, a.k.a the NHMRC, comes out with a Draft of The Australian Dietary Guidelines I do not snigger resentfully. Sure, I find it hilarious that of all the species on the planet humans are the ones who need the leaders of their pack to tell them what to consume to survive. Can you imagine “Dietary Guidelines for Lemurs: reduce incidental consumption of red beetles and increase the portion of green crunchy leaves daily”?

That way! I think...

Tell me what to do and if I agree with it, I’ll follow like a lamb.

So what’s the story?

The last revision of the Australian Dietary Guidelines (ADG from here) and the accompanying Australian Guide to Healthy Eating (AGHE) occurred in 2003. Things clearly haven’t been going that well since we need a multi-million dollar revision 9 years later. But of course, we all know that.

The fact that caught my attention is that the Drafts to ADG and AGHE are available for public comment. That means that you and I can make an individual online submission to the NHMRC until February 29, 2012 (here is the submission page link).

The development of new guidelines is a serious business. The official website, eatforhealth.gov.au, states that more than 55,000 scientific journal articles were researched. In addition, various experts in food, nutrition and health, food industry representatives and the public (not me?) were already consulted. The information on the evidence which formed the scientific basis of the guidelines is outlined in the Evidence Report, formally known as a Review of the Evidence to Address Targeted Questions to Inform the Revision of the Australian Dietary Guidelines (you gotta give it to the government, they are always thorough). Interestingly, the literature review was limited to 2002-2008.  If you think that’s a little Gen Y (nobody before us had any idea about anything) don’t worry. They also used the previous 2003 guidelines as a blueprint. So if somebody stuffed up writing those it’s really nobody’s fault.

One of the major differences in this revision is the emphasis on foods and food groups recommendation rather than nutrients. I am an optimist and I see it as a major step forward. The recent trend towards “nutritionism“, as Michael Pollan called it, resulted in the overhaul of the way we traditionally view food. Food used to unite us, connect families and countries, make us happy and healthy. Food circa 2012 is a combination of “only a 100 calories”, fat free, no-sugar, high fibre, healthy wholegrains, high in antioxidants, reduces cholesterol, calcium fortified, plus vitamin D, low GI…

Any recommendation to step away from nutrients gets thumbs up in my books. A further look into the guidelines however seems to contradict that fine premise, more on that later.

I’m sure that now you are all dying to hear what we should and should not eat. Please be aware that if you are in the US, Canada, Europe or anywhere else in the world where people do not routinely say “you little rippa” and “she’ll be right mate”, none of this applies to you. Please refer to your own government’s advice. Because everybody knows that human metabolism is government-dependent.

Guideline 1:

Eat a wide variety of nutritious foods from these five groups every day:

 plenty of vegetables, including different types and colours, and legumes/beans

 fruit

 grain (cereal) foods, mostly wholegrain, such as breads, cereals, rice, pasta, noodles, polenta, couscous, oats, quinoa and barley

 lean meat and poultry, fish, eggs, nuts and seeds, and legumes/beans

 milk, yoghurt, cheese and/or their alternatives, mostly reduced fat (reduced fat milks are not suitable for children under the age of 2 years).

And drink water.

Guideline 2:

a. Limit intake of foods and drinks containing saturated and trans fats

 Include small amounts of foods that contain unsaturated fats

 Low-fat diets are not suitable for infants.

b. Limit intake of foods and drinks containing added salt

 Read labels to choose lower sodium options among similar foods.

 Do not add salt to foods.

c. Limit intake of foods and drinks containing added sugars. In particular, limit sugar-sweetened drinks.

d. If you choose to drink alcohol, limit intake

Guideline 3:

To achieve and maintain a healthy weight you should be physically active and choose amounts of nutritious food and drinks to meet your energy needs.

 Children and adolescents should eat sufficient nutritious foods to grow and develop normally. They should be physically active every day and their growth should be checked regularly.

 Older people should eat nutritious foods and keep physically active to help maintain muscle strength and a healthy weight.

Guideline 4

Encourage and support breastfeeding.

Guideline 5 

Care for your food; prepare and store it safely.

If you have read my blog before (or even had a look at my Start Here page) you might know that I have a slight problem with the Guidelines 1,2 and 3. Over the next few weeks I will be looking in finer detail into each of those guidelines and the evidence behind them with the aim to make an online submission. Feel free to join in the fun. Better still, send in your own thoughts on the Draft to the folks in NHMRC.

How (Not) to Put On Weight During Thanksgiving

We don’t celebrate Thanksgiving in Australia. We have managed to appropriate most other North American holidays without actually knowing their true meaning (Halloween, anyone?) mainly because we just need another excuse to take a day off and stand around the barbeque with a few drinks discussing world affairs, our bosses and why Demi and Ashton have unfollowed each other on Twitter. For now Thanksgiving is all American. The media and the Internet kindly provide us with a small glimpse into what actually goes on during this festive occasion and a lot of talk happens to be about food. I saw this gem of an article today from Medical News Today, a very respected establishment, offering a few helpful tips on how to avoid being a gluttonous slob over Thanksgiving. I decided to improve on some of their suggestions and now I offer you a guide on

How (Not) to Put On Weight During Thanksgiving.

1. Start stressing out about the celebratory occasion a few days in advance. Try to guess what kind of food will be on the table and estimate the total amount of calories, fat and carbs. Don’t sleep the night before tossing and turning while calculating your calorie budget for the next day.

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2. Start denying yourself food a week prior to the occasion. Every calorie that does not go into your mouth will accumulate in a magical space that you can call on at Thanksgiving dinner.

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3. Alternatively,  make a day before your carb loading day. Surely if you overfill your glycogen stores and calm your nervous system with extra sugar you will have more willpower to walk past the crusty bread platter without collapsing into a heap.

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4. Do go out and exercise in the morning. Preferably do something mind-numbingly repetitive for a couple of hours like a Stairmaster in the gym. Face the wall so that you are forced to watch the screen counting the calories spent. Realising how bloody long it takes to burn each  calorie will make you think twice about shoving more food down your gob.

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4a Such exercise will have an additional benefit of assisting with your hunger control. Everyone knows that doing long bouts of cardio is a marvelous way to stay sated.

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5.  Have a breakfast of champions: a bowl of wholegrain cereal full of fibre to make you fill so bloated that you can’t even look at the turkey without letting out a sneaky one. Don’t have a single ounce of fat with your breakfast: your arteries will be swimming with saturated fat in a few hours time. Let’s try to avoid a heart attack at a family party.

Don’t forget your orange juice: freshly squeezed, of course. Do you see those orange bits floating in your glass? That’s more fibre, it will lower the GI of your juice from 250 to a respectable 79 and help you maintain even blood sugar levels for the rest of the day.

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6. Talking about blood sugar. You will quickly realise after your breakfast that you are ravenously hungry. That’s good. Keep topping up your blood sugar level  every 2-3 hours with such wholesome snacks as bagels with low fat cream cheese, tiny tubs of no fat soy yoghurt with fake chocolate flavour and a few multi-grain cereal bars.

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7. If you have time just before dinner go for a quick run around the block. Last chance workout!

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8. If you are a guy wear a pair of pants size smaller. Ladies, pull that ridiculously tight, preferably pastel-toned dress out of the back of your wardrobe. Your clothing will serve two purposes: first, being so tight it will make it impossible for you to sit down comfortably at the table without looking like you are about to be cut in half. You will be relegated to standing in the kitchen and eating low calorie finger food. Nothing like spending your Thanksgiving dinner munching on carrot sticks and low-fat low-salt low-calorie cardboard crackers.

Secondly, you will be so mortified about every lump and bump spilling out of your neckline, your sleeves and between the buttons it will be shameful to eat at all. Now is the time to punish yourself severely for all the indiscretions since the last Thanksgiving.

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9. If you do decide to partake of the gluttonous orgy that is the Thanksgiving dinner eat only the bland and unappetising dishes. Ask the hostess to provide a glass of water, a 100g of steamed unsalted piece of salmon and some salad with low fat dressing on the side. If the hostess is your mother, do not forget to remind her that you have to eat this way because of all the dietary mistakes she made when you were a child.

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10. Finally, if you find yourself ravenous, cranky and slightly dizzy by the time dessert comes around, don’t worry and give yourself permission to have a piece of each dessert (in moderation, of course. Don’t be stupid and go back for third helpings!).  You only live once. This is a once-a-year family occasion. After all, you can always repair the damage by running a half marathon tomorrow.

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Good luck! You are going to need it!

How to talk to your doc about nutrition

Iatros (a patient) 480-470 BC. Good thing medicine has evolved since then.

Let’s say you have finally turned your back on the “calories in = calories out” drivel, donated the hearthealthywholegrains to the neighbourhood birds where they rightly belong and swapped your industrial seed oils, masquerading as vegetable derivatives, for good old-fashioned butter. You feel great, you are losing extra weight, you have reduced your medications and enjoying a healthy relationship with food for the first time in your life. Proud, you announce to your family doctor that you now eat like a caveman and in return you get a blank look with a hint of concern for your mental and physical wellbeing.

What do you do?

Disclaimer: I’m not a general practitioner, PCP or a specialist (yet!). I’ve spoken to many and been taught by a few. As a pre-intern and before, a medical student, I have been a part of the treating team in general practice, outpatients clinics and in the hospital setting. On that basis, I will take the liberty to draw some tentative observations and give some generic advice on this subject. Health professionals reading this, please feel free to chime in.

If you just want to rub it in to your doctor’s face because you have had a tough relationship with the medical profession in general, I get it. You can stop reading now ….

However, if you are intending to maintain a mutually respectful and useful relationship with your GP and even educate them about a couple of things, you might need a few hints.

1. Don’t make assumptions

This might sound obvious but you shouldn’t assume that all docs are stuck in the dark ages and will be naturally resistant to anything out of mainstream. If you are working yourself up for a confrontation you are going to get it. If you expect an open mind from your doc, you need to approach that conversation with an open mind yourself.

2. Don’t accuse the doctor of ignorance or incompetence

It mightn’t be a good idea to start the talk with: “You know nothing about nutrition, I read this blog from a medical student that says so”. May I also refer you to my other post where I point out how many years medical training actually takes.  It’s deplorable that nutrition is not part of the curriculum but it is hardly the fault of a person in front of you, who has studied 12+ years and might have x years of experience. Tread with caution.

3. Be careful with conspiracy theories

We all know about pharmaceutical, agricultural and political interests involved in the business of food supply. But as a conversation opener it really sucks.

“Doctor, I have stopped eating wheat because Monsanto’s unethical practices compromise the health of the planet”
“Riiiight… Erm, have you been under a lot of stress recently?”

4. Bring science to the table

Whether you are a science guru or a curious web wanderer you can use Evidence-Based Medicine to your advantage. If you have access to studies and a deep desire to educate your doctor in the error of his/her ways there are a couple of things you can do.

~ pick your battles: choose one area at a time, eg. Saturated fat is a necessary part of human diet, not a killer substance designed to punish us for our gluttony
~ find the evidence: doctors prefer randomised controlled trials and meta-analyses, like this one:
~ bring a hard copy to the consultation. Emails are less likely to be read as most GPs are very busy. Even better, highlight the abstract of the article and leave the paper for your doc to read. They might or they might not. A simple overview will go a long way to spike their interest:

“Hi, doc, I’ve come across a recent study you might be interested in. Looks like they analysed 21 prospective cohort studies with a total of almost 350 thousand people with a follow up between 5 and 23 years. They found that there was no link between saturated fat intake and risk of coronary heart disease, stroke and cardiovascular disease in general. Seems to be one of several studies in the last 10 years that exonerates saturated fat. Me, I’ve never liked that low fat yoghurt, they just replace fat with sugar. Here is copy if you want to check it out”

~It’s ok if you are not well-versed in the intricacies of Evidence-Based Medicine. Many bloggers out there pull out the latest studies and break them down for those less time/inclination/patience (PubMed…yawn) making a job easier for you.

5. N=1 is a great start

Your results are the best proof that your Paleo/primal/traditional/low carb lifestyle works. You will see the new respect in your doctor’s eyes when they see a drop in your blood sugar numbers if you are a diabetic. They will join you in rejoicing when your long-standing eczema, for which they have written countless steroid cream prescriptions, goes away. “MY irritable bowel syndrome is better now that I don’t eat bread or pasta” might even get your doc interested enough to read that study on gluten that you have printed out for them. Don’t underestimate the deep (sometimes very deep) desire of most doctors to help people and see them get better. They might even suggest a similar strategy to another patient of theirs with the same problem.

6. Admit it: you are a freak

If you think that it is normal to read 5 blog posts a day on nutrition, follow 200 health professionals on Twitter or know the difference between fructose and sucrose, I hate to break it to you. It isn’t. You are officially a part of 0.01% *of the population who a) care about their health b) seek out information c) use their brain d) dare to question the conventional advice. You are a rare breed.

*no actual statistics was used to determine this number. Please do not send emails requesting scientific references

The majority of patients are not like you. They want an instant result with little effort on their part. I do not blame them: they have been conditioned to believe that everything can be solved with a pill, a surgical procedure, a new face cream and an AbCirclePro.

Do you know what most doctors think about lifestyle change recommendations? It’s not that they don’t work. It’s that people don’t follow them.  The frustration leads to indifference. Like many patients, I have issues with the advice to “just eat less and move more”. But sometimes doctors have to deal with people unwilling to stop injecting IV drugs, smoking cigarettes, drinking a bottle of scotch before lunchtime and feeding KFC to their one-year olds. You might just rekindle a jaded doc’s belief in the power of good.

7. Go for the young’uns

Medical students and junior doctors get picked on. A lot. If you survived medical school with your ego intact, congratulations, you must have started at a higher baseline than me. Maybe this is why, in my experience, young doctors are much more likely to admit that they know nothing about nutrition. And why they tend to defer to government guidelines, dietitians and nutritionists. Another reason why the young docs are “an easy target” is because they are still relatively uninfluenced by the pharmaceutical propaganda. They are still naively excited by free Viagra pens. So don’t be afraid to share your experiences and ideas with medical students and hospital residents. Sure, you might get a funny look and a sneaky PRN order for haloperidol (sorry!). But one comment may be all it takes to plant a seed in someone who can look at the system with fresh eyes.

Adult circumcision. Wall painting from Ankhmahor, Sakkara. 2350-2000 BC The oldest known illustration of circumcision.

Doctor-bashing is practically a national sport nowadays. You can always count on an after-dinner horror story about corrupt GPs handing out antibiotics like candy, inept hospital interns missing blood vessels and arrogant surgeons leaving objects in body cavities. If you have decided to turn your back on the Western medicine you might have a good reason for doing so. But if it’s just a knee-jerk reaction born out of frustration with the system and a couple of bad apples, I might be able to convince you to reconsider. And at the end of the day, even if you cannot find the doctor who is willing to let go of the fat phobia or recommend kimchi for healthy gut, the next best thing is a doctor who treats you with respect, empathy and is prepared to listen.