Archive for 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?

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December 18, 2007 at 7:48 pm 14 comments


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