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.

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64 thoughts on “How to talk to your doc about nutrition

  1. Oops – think my comment went into the ether….
    This is brilliant! I hope you submit it to KevinMD – that blog gets LOTS of eyes on it.

    Thanks again for your support over the summer – I’m still benefiting from your coaching and reinforcement.

  2. Brings to mind a scripture…” A soft word turns away wrath”. Thank you for your well thought out encouragement to work with our physicians respectfully to change personal care to fit. – justme Anita

  3. Yep, already left an endocrinologist who thinks I’m insane, in spite of lower weight, lower blood sugar, lower blood pressure, no acid reflux, no depression, etc.

    Granted he is pretty old and set in his ways, but he wasn’t interested in studies. He said he got all the information he needed “from trusted sources.” He kept insisting I needed to have gastric bypass surgery to fix my diabetes. Upon finding that I am “fixing” my diabetes myself, primarily with diet, he told me I was playing dangerous games with my life and if I couldn’t follow HIS advice (read that as Authority Figure), I should find another endocrinologist because he couldn’t, IN GOOD FAITH, continue to treat me. Insert my jaw-dropping reaction here…

    Oh well, on to the next doctor, to see what can be done with them! : )

    You are very right, we might want to avoid the older docs who (apparently) have such a stake in conventional treatment (or stock in the companies) that they cannot accept results that happen in front of their eyes. But then, he might have felt threatened at the idea that I didn’t really need him much anymore.

    He was my first disillusionment with the medical field, but I’ve had a couple since then. In a smallish town, even in America, it’s hard to find different doctors. My best result has been a general practitioner who agreed to write the diabetic prescriptions I needed as long as my weight kept dropping and my labs came back acceptable. So we do what we can!

    Thank you for being out there, in the vanguard of the new practitioners.

    • Gastric bypass to treat diabetes? That’s truly scary. I’ve seen many an older doc who considers themselves an Authority on Everything. I know it’s not easy to find someone who would listen, let alone be “Paleo-friendly”. Like you said, we do what we can. Internet can be a great resource too, so you are doing the right thing.

      • Gastric bypass is a ‘treatment’ for diabetes. It’s called surgically imposed lifestyle intervention and should (primarily) be used for individuals who wont/cant/don’t want to change their lifestyle without it.

        And, regarding energy balance. I still state that carbon balance is fact. We don’t have calculators, and real foods ARE (likely) a self sustaining solution (if people would eat them and adopt lifestyle changes).

        I think ‘your’ movement (not meaning just yours) would be better received if instead of saying that energy balance is false, stating that energy balance in ‘real life’ is not applicable. That I (mostly) agree with.
        But carbon bonds are still the trump card. Those bonds, once in the body, must be metabolized producing CO2 and H2o and producing to ATP and heat. We can discuss the minutia of metabolic advantage, etc (metabolic efficiency, uncoupling proteins, hormone interactions and substrate use) where the data is mixed…..But carbon in – carbon out still determines weight gain or loss acutely.
        I know you have connections with others who blog about this topic. I am really open minded about the correct course of action to help individuals with better health. I would enjoy a critique of why energy balance is not true from a carbon balance standpoint (if that is where ‘you’ stand)
        I do like reading your blog! Keep at it.

        • Hi Brian. I appreciate your willingness to look outside the paradigm.  I have already mentioned to you that the main problem of the calorie theory is its total lack of applicability. And I’m not arguing against the laws of thermodynamics on a cellular level. But i believe people are too trusting when it comes to numbers.

          Here is an example. Let’s say you want to test the a kilogram is a kilogram no matter where it is. (apologies if anybody reading is stuck in the imperial system). You decide that you will eat one kg worth of rice (pick whatever, I just find rice easier to eat in large quantities) and then weigh yourself immediately after. You expect that your weight will go up by 1 kg.
          Here are the confounders I can see offhand (from minuscule to RIDICULOUS)

          1. You leave several grains of rice on the plate

          2. Your grocer is a sneaky piece of goods and cheated you out of some rice when weighing it so you don’t really have 1 kg to start with.

          3. Your baseline weight measurement was taken last week at your doctor’s office and post-experiment weigh-in is at home

          4. You are weighing yourself at a different time of the day.

          5. You are a woman and premenstrual and have been retaining water for the last 3 days

          6. Your home scale is wrong

          7. Your doctor’s scale is wrong

          8. Your grocer’s scale is wrong

          Here is the best one:

          9. How do you know that a kg is a kg? What if the kilogram safely stowed away in Paris has oxidized, melted, been substituted by terrorists and now weighs 1.1 kg?

          And that is a kilogram, one of the safest and most reliable units of measurements on the planet. Can you measure a calorie at home? Can you measure the amount of calories that you “burn” while at rest? Can you measure the calories you burn when you go for a jog? Can you measure the amount of calories in your breakfast? Can you estimate the mass of your breakfast in grams? Do you routinely measure the mass of your faeces? You don’t think you are losing some carbons through stool? 
          This is just one of the issues I have with calories. To me they are just numbers, maybe correct in the pure scientific sense, but arbitrary nonetheless. 

          Steven and Chip Morris make good points in their comments as well. 

          To say that I consider calories useless is an understatement. 

          • Oh my goodness, best rant about calories that I’ve read so far (here or anywhere). I must share it with others (don’t worry, I’ll include a link back to this page).

  4. OK, I admit it. I’m a freak 😉 I have had mixed experiences with GP’s. These days I am much more confident in communicating my views and I require explanations for everything. My current Dr seems open to different ideas. Since I almost never get sick I rarely have the need to see her though. I wonder what she would think about my lifestyle?

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  6. I appreciate the advice on how best to confront doctors but you write this:

    Let’s say you have finally turned your back on the “calories in = calories out” drivel

    How is calories in = calories out drivel? Are you saying that the energy balance equation is wrong? Are you arguing for some type of “metabolic advantage” for eating lower carbs? If you are, I strongly suggest you read Anthony Colpo’s demolition of what he calls “MAD” or Metabolic Advantage Dogma.

    Calories are KING when it comes to weight loss. This doesn’t mean that eating 2000 calories of donuts is the same as eating 2000 calories of healthy foods. But suggesting that calories don’t matter for weight loss is inexcusable. The Carbohydrate-Insulin hypothesis of obesity is in the process of being DESTROYED. Read CarbSane’s blog for an excellent scientific smackdown of the nonsense that calories in does not equal calories out.

    • Well of course calories in, calories out matters, but that is merely the end point, the result of many factors influencing influencing it. People are finding holes with the CIH, but that doesn’t mean that focussing on calories in, calories out as the starting point – the message broadcasted to the public – is right.

      Calories in, calories out has to get around the negative feedback hormone for weight gain – leptin, and the role of leptin resistance in obesity. It has to explain how malnutrition/famine coincides with obesity (such as the case of the Pima). As well as other factors such as mitochondrial function and gut flora, which have an effect on metabolism.

    • As far as I know, the success rate of calorie-in-calorie-out (well, starvation) diets is below 5%. How it could be the KING strategy for a weight loss? How could you count what your body is doing with all that calories? Besides that, most people can’t reliably account even how much they are eating. Micromanagement can’t regulate a complex system. Former Soviet Union tried it with the economy. It just doesn’t work, especially on a long run.

    • What? You mean you don’t have one??? It’s like not having YOUR hairdresser :)). Lucky for most us, our lifestyle does a great job of protecting us from the medical profession. Some folks aren’t so fortunate though. I wish you many many years of not encountering anyone with a stethoscope :).

  7. Great advice for all of the consumers of healthcare out there 😉
    There are good and bad MD’s in practice, just like any other profession. I keep an attitude toward life like I’m at a buffet table….yes, I’ll take some of that, oh, look, STEAK and BACON, yum, oh no thanks, don’t care for bread….I just pick the info/MD’s/etc that I jive with and walk away from the rest without getting angry. Makes life easier and more enjoyable that way. And, also to mention that Robb Wolf runs a Paleo Physicians Network which lists healthcare practitioners by state for those that are looking – it’s a start.

    • Good point, Ann. It seems a recurrent theme nowadays: unless they agree with me a 100% I will not give them a second go. I wouldn’t stop going to an awesome restaurant just because they serve pasta because I don’t have to get pasta. Thanks for the reminder about the Paleo Physicians Network: here is a link if anybody is interested.

    • Once again, thank you for your kind words and that glowing reference on the MDA forum. I was wondering how the primal/paleo docs out there are going to feel about my post. Glad it resonated with you too. And like you, I find doctor-bashing a fruitless (albeit frequently enjoyable) exercise. I get frustrated with both sides.

  8. Just last week I made an appointment with my doctor so this is very timely. I’m curious to hear what my doctor thinks.

    My husband has his yearly physical a few weeks ago and he was very freaked out by his newly high total cholesterol (218 total). I reassured him with very mainstream links regarding studies showing that high HDL and low triglycerides were more important markers of cardiovascular health than the total or LDL.

    I suspect my numbers will have changed similarly. My HDL at my last visit was, i now realize, scarily low. (will my doc freak out at a high total? will she care what I’ve been eating? I’m going to go in without any expectations.

    I’d love to find a doc that’s paleo-friendly, but all the one ones listed in my area aren’t MDs.

    • The “dangers of high cholesterol” get drummed into us on an almost daily basis. So I wouldn’t be surprised if your doctor is concerned. Sometimes it’s good to remind them that even in the mainstream it is still a risk factor, not a cause of heart disease. Stand your ground, show that you are informed. I love the post by Paul Jaminet about the high blood cholesterol level of breastfed babies. (don’t have a direct reference but check out his site)

  9. Thanks Anastasia – I was looking forward to this blog post, and it’s excellent. I’ll be passing this along.

    My father, uncle, and brother are all medical specialists, and
    each one has been astounded at their own results as they have changed their diet. My father and uncle were in their 60’s when my experience with diet triggered them to change. My father’s cholesterol fell to normal after a lifetime of high cholesterol and a bypass. My uncle’s blood pressure fell to normal and he lost that ruddy look in his face. My brother came through a bone marrow transplant with very little GVHD due to taking high dose omega 3.

    What convinced my family was my N=1 experience – which they could not help but see. And I followed this up with the clinical studies. Without these studies, or reading books I gave them, I don’t think they would have seen the relevance for themselves.

    • Hi Julianne, as you remember from our talk, these thoughts have been brewing for a while. I know first hand how difficult it is to influence own parents and family. You are very lucky (and obviously very convincing). Great way to start with n=1, follow up with studies, then they experience it for themselves, then maybe pass some of it on to their patients.

      • Needless to say – It was a year after I changed my diet that my father decided to give it a go. My uncle followed because of my dad’s results. My father’s (excellent) doctor is yet to be convinced, thinks my parents are slightly nutty I think. Too skinny (they aren’t, they only look it in comparison to the average) and my Dad’s LDL too high. His fasting insulin is so low, she can’t quite figure it out. He scoffs at statins, fortunately, and tells people to go off them. Not your everyday 80 year old (still working) psychiatrist!

  10. Excellent! I suspect my youngish doctor is open minded–or at least not authoritative as she accepted my disinclination to get a blood work up (on the grounds that I would not be willing to take meds or make conventional changes to my diet no matter what it showed) with aplomb. One can only hope! But your ideas are excellent and I will definitely use them if/when I have to.

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  12. Good stuff.
    I’ve been putting off a followup with my cardiologist for these reasons. The last time we spoke he waxed lyrical that the stent they put in me last Christmas was the result of too much meat (himself, he’s a vegetarian).
    Since then starting with Gary Taubes’ book “Why we get fat”, I feel I’ve been on something of a journey reviewing some very compelling science with regard nutrition. The result is saturated fat is definitely back on the menu, I never left a table hungry, I am 20 kilos lighter, and I have never, ever had a physique like this (6 pack is coming along nicely :-)).
    Anyway the appointment is booked for the start of next month, and hopefully my blood work should speak for itself. Great post, a confidence booster.

    • Nice story, Simon. Wonder if your doc will attribute your success to the stent as well :). Cardiologists i know are pretty set in their ways, good luck!

  13. I’m wondering if I should just move on with my doctor. She is very clear she wants me on statins and even after reading an article from Yahoo about particle size, she said her advice was still the same. Four months later my LDL is up 100+ points after eating paleo/leptin reset protocol. The LDL was 170 to begin with after two months of Atkins. My trig/HDL ratio is .6. I’m wondering if I’m wasting my time going back to her.

    • There is absolutely no benefit to taking statins for women. I’ve read repeatedly that the studies all show NO advantage for women of any age or health status and no advantage for men over 65 or men without heart disease under 65. My dad is 66 and on a statin, I keep insisting he shouldn’t be on it and it’s doing more harm than good (possible side effects and increased chance of cancer and diabetes). This is something Tom Naughton hits repeated on his Fat Head blog (www.fathead-movie.com).

  14. My big fear is I’ll be in a hospital some day and have a dietician insist that I must be on a low calorie, low fat, low salt diet (high carb of course) while there. How does one heal from a surgical wound, for example, full of carbs and ringers lactate, a calorie deficit, hyponatremia, and hyperinsulemia??? Scary!

    So how do you tell the professional “expert” nutritionist that you believe everything she has learned, practiced and preached is wrong and you need protein, fat, calories and some salt to heal and regain strength. hospitals seem suddenly more sinister.

    • I would claim myself as a person who is on a ketogenic diet due to migraines (which is true in my case). I would worn doctors of very possible abnormal blood sugar measurements in response to normal high-carb food. May be they would declare me a diabetic for life as a result. Who knows?

      • As a diabetic in the hospital you would be getting toast with margarine, skim milk and cardboard wheat cereal with juice for breakfast. I KID YOU NOT.

    • I just had surgery in July and told my doctor I’m allergic to wheat she put me on a gluten free diet… my first meal was a wonderful grilled salmon salad.

    • Hospital meals are truly scary. I see the half-finished trays at patients bed daily and shudder. Little nutrient value, little taste and in my opinion little aid to recovery, if not worse, a hindrance. I’m dying to write a post on this, I wonder if I’ll be allowed. My advice if you are ever unfortunate enough to end up in a hospital: get someone to bring you food from home. It’s always good to have some bone broth or casseroles in the freezer for emergencies. Hospital food is that kind of emergency!

      • “As a diabetic in the hospital you would be getting toast with margarine, skim milk and cardboard wheat cereal with juice for breakfast”

        Exactly! Terrifying!

      • I spent weeks in rehab after a car accident in 2006. I was eating “healthywholegrains” back then, but one look at some of the stuff the facility sent me from that kitchen — wriggling neon Jello, anyone? — and I organized a team of friends to bring me real food from outside :}

  15. In America, we ‘solve’ this problem by requiring every productive member of society to pay out-of-pocket to participate in a broken system, under which no one can afford anything but high-deductible catastrophic care…

    …thus avoiding the problem of seeing doctors in any situation but immediate, life-threatening emergency.

    JS

  16. Slightly off topic I’m sorry, but I was wondering whether anyone knows of a primal/ancestral friendly doctor in Melbourne, close to CBD preferred. I would like a GP who similar ideas on health to me!

    • Hey Lee, have you had any luck with finding the Doc in Melbourne? I’m in the same position.

      Anastasia – any suggestions or can we do the phone consult with you??

      Also, I’m looking forward to your interview on LLVLC 🙂

  17. Good start. Diet is secondary, perhaps slightly so, to fitness inducing activity which is the signal to DNA for sequencing healthy protein and skeletal muscle hormone production, transition of IL-6 to synergistic anti-inflammatory along with HGH and testosterone. Sedentary conditions signal sequencing of unhealthy proteins. Those writing in the Paleo movement are largely negligent of the work of Frank Booth and others.

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