Tuesday, December 18, 2007

The Perils of Crossing the Establishment Boundaries on Dietary Advice

Two opinion pieces in USA Today bring forth the very problematic issue of dietary advice when dispensed by a practicing physician and that advice happens to be contrary to the conventional wisdom.

In the first, Doctor's dietary advice for diabetics not enough, Connie B. Diekman, president of the American Dietetic Association - Chicago, goes to great lengths to reinforce the notion that doctor's are the wrong source of dietary advice and that Registered Dietians are "are more educated about the science of food and nutrition than any other health care professional, but they also know how to translate that science into useful, practical advice that anyone can understand and follow."

She also says that "Dietitians do not simply hand a person a menu. A registered dietitian takes into account a person's age, weight, blood cholesterol levels and other medical needs to develop a plan that is right for that person.

There is no "one-size-fits-all" eating plan for managing diabetes. Patients need to pay attention to portion sizes, timing of meals and specific food choices. They need to eat smart, avoid weight gain and balance the day's food choices with regular physical activity.

A registered dietitian is the best source of advice in all these areas."

In the second, Eat in moderation, the CEO for the American Association of Diabetes Educators - Chicago, Lana Vukovljak, weighs in with - "By touting his "five-fingered diabetic diet" as the key to weight loss and controlled blood glucose, he is perpetuating misinformation and doing his patients a disservice. Eichenbaum advises patients to avoid "bread and baked goods, potatoes and root vegetables, rice, pasta and fruit except for berries." But that diet severely restricts meal plan options, ignores cultural preferences and lifestyle needs, and often results in increased non-compliance. Dietitians and diabetes educators stress the necessity of dietary changes and physical activity. Instead of making broad dietary directives that eliminate entire food groups, however, they encourage moderation and reduced portion sizes. They also make dietary recommendations that factor in an individual's cultural tastes and lifestyle requirements.

Diabetes education helps people incorporate behavior change into their lives by personalizing recommendations and simplifying nutritional messages."

It appears whatever was written by Eichenbaum caused a big stir - two major organizations responded with very clear implications that the author was unqualified and potentially dangerous to patients well-being, thus readers need to ignore whatever it was that appeared in the paper.

What exactly caused the hub-ub?

Well, it was another opinion piece in USA Today, Simple diets work best with diabetes, written by a Dr. Dan Eichenbaum, MD who is an opthamologist in North Carolina.

In that he had the audacity to write, "In numerous studies, elevated blood sugars have been linked to diabetic vision loss despite potentially successful medical and surgical treatments. Medication should be used to control blood sugar only after an optimum diet and exercise regimen has been established.

Most patients, however, expect medication to control blood sugars no matter what they eat. They adjust insulin or pill dosages to cover their dietary indiscretions. Unfortunately, dieticians routinely give patients complex diets that require a ruler, a scale and a calculator. It is no wonder that few diabetics can adhere to these elaborate eating regimens.

I explain to my patients that eating carbohydrates is like putting diesel fuel in a vehicle that can only run on gasoline.

Just as a gas engine won't burn diesel, a diabetic's "engine" cannot burn carbohydrates."

But, he didn't stop there, he also included foods he specifically tells his patients to avoid - bread, pasta, potatoes, baked goods, root vegetables, rice and even fruits except berries. He keeps it simple and says "Patients who eliminate these items lose weight and can easily control their sugar levels. Expecting patients to abide by a diet that is difficult to follow causes non-compliance and increases their risk of blindness."

I point to these today because they highlight the position many clinicians are in when it comes to offering patients dietary advice - they're squarely between a rock and a hard place.

If Dr. Eichenbaum had instead penned something that simply regurgitated the current party-line dietary guidelines, do you think there would have been a similar response questioning his qualifications or patient care?

Hey, have you ever seen Dr. Mehmet Oz slammed in the mainstream media or have his qualifications questioned when he appears on Oprah or Larry King Live espousing the consensus opinion for dietary recommendations?

Of course not - he's preaching the consensus opinion and therefore what he says is okay, his apperances are even highly promoted with viewers encouraged to watch and listen to him. This despite the fact he is not a registered dietitian!

See, as long as your advice is aligned with the consensus, you'll be fine; step outside the boundaries publicly and you'll quickly find your advice ridiculed by the establishment, along with having your qualifications challenged and the clear implication that your patients should wonder if you're harming them!

It does not matter if you've based your advice on hard data from peer-reviewed studies; it certainly doesn't matter that your training as a physician included statistics, biochemistry, biology and other pertinent subjects; and it doesn't matter diddly that your patients see improvements when they follow your advice - what matters is you've crossed the line and made it public that you're dispensing nutrition advice contrary to the current dietary recommendations published by the leading health organizations and you're not a "registered dietitian" to boot.

The above responses to this doctor's words drive home one of our biggest challenges in public healthcare today - the consensus-driven-model that explictly endorses dogma trumping the evidence-based model.

All one needs to do to begin to truly understand how deep this consensus-based-model runs, is to take some time to read through various position statements published by the leading health and medical organizations about what they recommend for diet to clinicians in practice and the public.

Take the American Heart Association position paper on diet, you'll find it's almost identical to that issued by the American Diabetes Association, which is itslef almost identical to that issued by the American Dietetics Association, which is basically the same as the American Cancer Society - the list goes on and on as to this universal message contained within each position statement published by these organizations.

These documents are often held up as the "standards of care" for use in medical practice, informing the clinican that they're written from and based upon the best available evidence, brought together by committee and agreed upon through consensus of those bringing the document together for publication.

These position papers also routinely include references to the alternative approaches that have support in the data, but these are routinely dismissed as inconclusive, deemed controversial, inappropriate or potentially harmful, with the explicit message that no one should advise such an approach to any patient because the evidence is not strong enough. Noticably absent are those studies with the strongest data, while those studies with findings considered minor enough to dismiss are included and highlighted to make the position against their efficacy appear strong.

The interesting thing is, in various position statements, there is a very clear consensus between the organizations when it comes to dietary recommendations - they're all making the same basic recommendations, they all claim to be based on the best available evidence, and they all affirm similar beliefs about macronutrient ratios in a "healthful diet," which leads anyone reading them to believe they're supported by research and evidence from high-quality data. Surely they must be right if all agree on the simple basics!

Wait...wait...wait.....no one seems to ask - are they all so similar because the evidence is so strong and supportive of the dietary recommendations contained within, or are they simply the result of long-held beliefs and dogma driving consensus across organizations?

You can actually begin answer that question yourself.

Simply get your hands on at least three to five position statements from different medical organizations about their dietary recommendations. Then, if you want, you can read them all, but you don't really have to since they're all likely the same bottomline message anyway.

No matter what, your real investigation about the underlying forces driving how the statements are prepared starts in the references.

Look at and compare them in each and between each paper and you'll start to see how they point to each other as basis for supporting evidence and consensus.

It really doesn't matter what organizations you choose - you'll find this "circular reference tactic" within them all, with NONE actually providing conclusive hard data to support their position. They don't need to actually provide mountains of supporting data because with the circular reference tactic, they have each other, and by pointing to the other as supportive and evidence-based they imply the data is "over there" without really doing anything more than taking anyone following the references on a wild goose chase while maintaining the status quo for the the party-line dogma about diet and health.

Then foot soldiers within these organizations will criticize and challenge anyone who dares to not only look beyond these circular reference tactics to find solid evidence that points to an alternative approach, but then actually recommends the alternative to patients and says they do in a public forum, like the media. Such challenges to the status quo simply cannot and will not be tolerated as we can see from the responses above to one doctor who did just that.

Given the strong and dire warnings about the "obesity epidemic" in our country, isn't it time we actually look at the literature and see what the data contains and really hammer out a true evidence-based model of dietary recommendations for the public?

Isn't it time for us to move past this idea "we know" what works, to actually go find out what works based on data and hard evidence?

14 comments:

  1. Anonymous2:24 PM

    Rather than hire a dietician, why not just hire a parrot?

    ReplyDelete
  2. Anonymous4:04 PM

    Fantastic Post Regina. This is exactly what one finds if you are in the least bit curious about dietry matters. It would seem that there are no free independent thinkers left in these institutions who actually con the public into thinking they are working day & night to save their lives. When in reality these associations are just in it for the money they make & the power of being able to make everyone dance to their tune. Thank God there are people like you willing to highlight this absurd nonsense for what it really is.

    ReplyDelete
  3. It's also curious how they select an appropriate diet based on expected compliance. Shouldn't the core recommendation be based on best practices with variations for people who can't adopt the recommendation?

    ReplyDelete
  4. Nicky3:43 AM

    Dr Eichenbaum's patients are lucky people, I hope they appreciate him - I'd LOVE to have a physician who was supportive of the kind of diet that keeps my diabetes under control!

    The other fun game allied to circular references is to take a big organisation and see how many different kinds of dietary advice you can discover on their web site. The American Diabetes Association is a classic - there's every spectrum of opinion on there, from low carb upwards, once you get past the dumbed-down uselessness on their front pages. Shame their left hand doesn't talk to the right more often...

    ReplyDelete
  5. Folks,

    Money talks. The only way you will ever get the establishment to change their horrible policies is to let the organizations who profit when you patronize them know that you will take your business elsewhere if they continue adhering to discredited policies.

    I recently wrote a long letter to my local hospital detailing why the high carb diet they fed me there made me tell my friends with diabetes "good control ends at the hospital door."

    The hospital took it seriously. I got a long phone call from a doctor there with substantial political power. If twenty five more people would write to that hospital, explaining why they will go elsewhere unless they change their dietary ways, they'd pay attention to it. They spend a fortune advertising, trying to get patients.

    We moms of the 1970s and 80s completely changed the way the medical establishment approached childbirth and nursing by making it clear we wouldn't go to hospitals that didn't change their ways.

    Now we have to do the same thing with doctors, hospitals and nursing homes.

    Don't wait until you are in the hospital or putting mom in the nursing home. Contact your local hospitals and nursing homes now and ask if their nutritionists are still using discredited research to provide dangerous high carb meals to the patients most at risk from those high carbohydrate loads. Cite Taubes. Cite the A1c heart attack studies.

    Get your friends to do it too. If only 1000 of us would write these letters, I bet we could change the culture.

    ReplyDelete
  6. hi there-- new to your blog... some very interesting stuff. only recently have i uncovered that everything i knew about fats and carbs has been wrong (thank you sally fallon and gary taubes). so, now i find myself on a quest to find the real story... one of my favourite sayings is, "in god we trust, all others bring data." this site is good source of real data... thank you!

    ReplyDelete
  7. Well said, Regina!

    ReplyDelete
  8. I consulted a registered dietitian once and was given a standard low-fat diet sheet. There was no questions asked of me as to food preferences. Eating low carb has so many more food choices than the recommended low fat. Nature just doesn't make many low fat foods. Trying to eat low fat was hell. Eating low carb is heaven.

    ReplyDelete
  9. Thanks, Regina. It can get so discouraging. Is it better to come up with a diet people can comply with, even though it will generate exactly the opposite health impact needed? How’s that working out?

    Jenny, good comment.

    ReplyDelete
  10. Thanks Regina....it seems from time to time that we're making progress, then you see this kind of response. You'd think the doc was promoting bulimia!

    Good comment Jenny!

    ReplyDelete
  11. Dr. Eichenbaum's advice is fantastic. That's what I do and it works great. The notion of not ignoring cultural preferences and lifestyle needs is a cop out. It is all about choice. I used to love bread, pasta, & potatoes and thought I could never live without them. Now I do without and don't even miss them. This "often results in increased non-compliance"??? Nope, I find compliance with low carb easier than compliance with low fat. I find low carb to be much less restrictive. "Cutting out food groups???" If a food group, such as grains, jacks up your blood sugar, how can it be healthy? These diabetes experts speak with forked tongue. They say to see how food affects blood sugar, but still insist on eating 6 - 11 servings of grains a day per the food pyramid.

    These kind of tactics we used to force feed the low fat dogma, despite shaky scientific backing and are still being used to maintain it. I wish I could find a doctor like Eichenbaum.

    ReplyDelete
  12. I'm lucky now to have an endo whose thinking parallels that of Eichenbaum. It pains me that others are not so fortunate.

    Several years ago, though, before my IR diagnosis (back when it was just "hypoglycemic") the RD I consulted put me on Ensure supplements (hello, corn syrup!) and recommended that I eat at Taco Bell because of their "healthy" fast food.

    ReplyDelete
  13. Why is it that apparently potatoes and bread are such a cultural mainstay one cannot possibly ask people to do without them, yet we ask people to do without red meat and butter and eggs all the time? Since when are those NOT cultural mainstays?

    ReplyDelete
  14. itsme7:47 AM

    This is what one should expect from registered dietitians and diabetes educators. They are technicians. They don't get paid to think!!!

    In reality, they don't have a choice. They have to follow the party line. Because they are technicians, they will always be behind the research curve. And we all know that because of the systemic anti-low-carb biases that it will be a long time before "mainstream" science accepts low-carb as the best alternative for many or even most people. Until that time, technicians of any stripe can only be against low carb.

    ReplyDelete