First, Do No Harm

01 Aug
Enormous ripe figs. Yea or nay?

Enormous ripe figs. Yea or nay?

A couple of days ago I was reading Dr. Andreas Eenfeldt’s blog The Diet Doctor and in a thread’s comments a physician named François wrote the following:

Thirty years ago, when I went through medical school, we covered nutrition in one single afternoon: “get rid of the darn thing and move on to more important stuff”. I would have hoped things would have gotten better with passing years. They have not. Nutrition (even “useless” main stream nutrition) is paid lip service in medical school. And it is not only medical education: there is a strong feeling among my colleagues that nutrition is a waste of time. I am just finishing a course in tropical medicine and the grain-based diet of many third world countries affects very negatively many diseases because of the massive lack of nutrients of these diets. We were given an excellent lecture about that very subject. It was very badly received and most of the 110 people in the class (I was, as far as I can see, the only exception) bitterly complained about this “useless” course.

This crystallized for me some of the issues that lie behind our current miasmatic state of health. It also made me wonder, first, why should this be the case and second, does it even matter since there is no agreement on what “good nutrition” is? And finally, a third question came to mind: how does this affect the patient who needs help?

The first thing I did was search online and lo and behold a simple query produced a lot of viable hits immediately. It seems that a lot of people are asking my first question.

Right away I found considerable copy which seems to indicate that yes, in fact there is very little time spent on nutrition in medical school. This story says:

Only a quarter of schools have a course dedicated to the subject, and more than half of graduates rate their nutrition knowledge as inadequate.

Nutrition education in U.S. medical schools is lacking, leaving new physicians unprepared to counsel patients about obesity and related health issues, according to a study in the September issue of Academic Medicine.

A steady decline in nutrition instruction is alarming, given rising obesity rates and proven links between dietary habits and chronic disease risk, said Kelly Adams, MPH, one of the study’s authors and an assistant project director of the University of North Carolina at Chapel Hill’s Nutrition in Medicine program.

The Chicago Tribune ran an article which makes a similar point:

On average, doctors receive 19 hours of total nutrition education in medical school; in 2004 the average was 22.3 hours

One survey published in 2003, for example, found that 96 percent of internists and 84 percent of the cardiologists who responded did not know that a low-fat diet, in general, would increase triglycerides in the blood.

“But that’s just a newspaper story,” I thought. What do the people in the profession think? Here is a lengthy thread (15 pages or so) on the subject by educated people in the health care business. What leaps out at me is that there is no consensus at all. There is one person who thinks the subject is woefully lacking in med school, but there is another doctor who feels that doctors’ education is not the issue – obese people are that way because “they just eat too much food that makes them fat”, even going on to say that over-eaters should be taxed because he is having to pay for their healthcare; this is classic blame-the-patient philosophy that certainly doesn’t help and we know now that it doesn’t work at all. A doctor should know better, surely.

I have also read that the American Medical Association has opposed efforts to get more nutrition education into med school, but I cannot find corroboration of that while searching now, and unfortunately, I didn’t bookmark the source at the time; it may have been in print media, anyway. However, I did find evidence of the California Medical Association doing something similar, although it was continuing education, not med school. “Last year, a bill was introduced in California to mandate that physicians get continuing medical education in nutrition (see Nutrition Education Mandate Introduced for Doctors). Unbelievably, physician trade groups such as the California Medical Association came out in opposition to the bill, which would only require doctors to get a measly 7 hours of nutrition training anytime before 2017”

But wait – what if all of this isn’t true? What if doctors are actually taught about nutrition in med school and the rest of us are just behaving like uninformed conspiracy theorists? I found one physician who says that the idea that med students are not given sufficient nutritional education is a myth, that doctors do in fact study a lot of nutrition and are much better informed about it than the rest of us want to believe. (So much for Dr. François in the earlier paragraph!) Of course this doctor is also making a living (probably a rather well paid living at that) doing lap band surgery on obese people, so he may have a somewhat…differently motivated perspective on things. In that article he comes right out and says “Food can kill you, but it can’t cure you,” and he goes on to say “you cannot cure heart disease with diet, nor can you cure cancer with diet, nor can you cure appendicitis with diet, nor can you cleanse the liver, or cleanse the colon.” He cites Steve Jobs as an example of someone who tried to cure cancer via diet and failed, without mentioning that the Ornish diet Jobs went on is probably the worst possible thing someone with pancreatic cancer could try – in other words, there is more than one diet-based approach available for this problem, just as there is to allopaths who try to treat a condition. I don’t think this doctor would be very good at skinning cats, which can be famously skinned in many different ways. I can think of another doctor who tells a very different story; Dr. Terry Wahls seems to have overcome (not “cured”, necessarily) her MS by changing her diet and her now-famous YouTube videos are must-see material if you haven’t already seen them. So here we have two doctors with opposing viewpoints. I know that from my own experience with metabolic syndrome it IS possible to directly affect your medical condition just by changing your diet, but Dr. Wahls has gone way beyond just lowering your blood sugar and triglyceride levels – it’s pretty clear which dog I think is the winner in this fight.

For another opinion I asked a naturopath I know what she thought the reason for the apparent lack of nutritional education in med school was and her response was direct: Simple. Most medical doctors don’t appear to think that food and nutrition have much to do with health. There are some notable exceptions to be sure.

And what about those notable exceptions; if you do find a physician who thinks this is an important subject, how do you evaluate their approach? They are the professional people – we are the autodidacts without formal training; we get things wrong and we don’t agree. But the same thing seems to be true for the professionals. You can find doctors who will tell you to eat vegetarian diets (no thanks, but that’s me – I don’t want to be Steve Jobs), Mediterranean diets, even paleo diets, or (worst of all, but so far the most typical approach) low-fat diets with lots of “healthy whole grains” and lean meat. I say “worst of all” because it seems to me that the ones that espouse this particular dogma are simply reciting rote memorized information and at best they simply have not looked outside of their own spheres of interest for far too long. And because my own particular bias leads me to think that this approach doesn’t work; well, it certainly didn’t work for me.

Thus I discover that my second and third questions are really the same thing. In order to help yourself you have to have some control over the process and you have to try to find a physician you can trust. What a long-winded way to get around to saying what’s obvious to everybody but me, LOL.

There is also the issue of paying for these services. Most of us are not wealthy enough to just go to a doctor and pay her, so we rely on insurance (if we are fortunate enough to have it in America) or we do without. But if you have insurance, unless it is a pretty top-line policy you may not be able to see anyone who is not going to offer up the standard line, which is “Take this medication, don’t eat too many fats, and get some exercise. Next patient!”. So the list of problems continues for a lot of us.

I didn’t expect to truly answer the questions I posed in the beginning of this thing, but I also thought things might be less complicated than they seem to have turned out. I am left with these queries, which are quite different from each other:

1. If med school students receive too little nutritional education, why is that? If it is deemed not important enough to have a place in the curriculum, why is that (and who influences the deeming)?

2. If you have to find a doctor you can work with, how can you best do this? Obviously, a large and separate topic.

3. How in the world can many people in this country hope to do that and pay for it too?

The first two can be approached on an individual level – they are opinions or decisions for you and me to make on our own. The third is a societal question that is beyond the scope of individual action, unfortunately.

And note that I didn’t even bring up the question of hospital food…until now.

Stay young and monstrous.


Posted by on August 1, 2014 in *Top Posts*, Health


Tags: , , ,

9 responses to “First, Do No Harm

  1. Francois

    August 1, 2014 at 6:15 am

    Interesting analysis. I agree with you that the lap band surgeon is on a crusade to get more patients. And a number of his statements (all?) are pretty dumb. In the end, it’s only his opinion and, as you know, just like assholes, everyone has one. Wish you the best and wish you a diet-interested physician. try googling “paleo-friendly physician”… You may find some help there.

  2. tyrannocaster

    August 1, 2014 at 6:44 am

    Hi, François, and thanks for taking the time to comment. (And also for letting me use your quote). I actually have a great doctor I can see…if I’m willing to pay for the visits and lab fees myself. But my insurance won’t cover her. 😦 I was thinking of the people even less fortunate than myself when I wrote the section that deals with finding a doctor, because I know that there are so many of them. Our healthcare is via my wife’s job and all it offers is an enormous HMO; this is, of course, better than nothing and in the event of a traumatic accident I have no problem with going to them. (In fact, that happened last summer when Mrs. Tyrannocaster managed to get a concussion and had to go to the emergency room – good service there, which you would both hope for and expect from western medicine.) But otherwise, their approach to non-trauma or non-infectious issues is guidelines oriented and typically results in approaches that I have little faith in, given the “successes” I have had in the past with them, ie, none.

  3. Gwen

    August 1, 2014 at 9:15 am

    Hi! new to your blog! Me? I’m leaving my GP behind this fall, and going to start seeing a Functional Medicine MD that my insurance covers. I’m done with faulty, outdated medical advice, pushing of statins, and fighting in general. (with a female doctor!) I’m going to start trusting a like-minded professional.

    I totally believe that the FDA pushes this agenda (pro grains/wheat) to support the MILLIONS of acres of wheat and soy farms that are the bulk of middle America. A drive from Chicago to TN will confirm how much of our land (USA) is corn fields.

    Great post!

  4. tyrannocaster

    August 1, 2014 at 11:18 am

    Gwen, with soy, wheat and corn those three are the holy trinity of the agribusiness health model. While I’m not a big fan of the FDA in general, I really blame the USDA more; however, if you stop and remember that the USDA is an organization which was specifically formed to advance the interests of the American agricultural business community (as opposed to, oh , let’s say – “the public”, which I think is what a lot of us believe even if only subconsciously) then things are a little easier to grasp. But “they’re on my side” or “they’re here for me” could not, I think, be further from the truth. And I offer that famously unhealthy food pyramid as Exhibit Number One. While it’s true that the stupid “my plate” has replaced it, that replacement isn’t much better while having none of the easy-to-grasp visual sense of the old pyramid. Heck, why not a cube…why not a four dimensional cube or a Klein bottle, LOL. At the very least they could use a Möbius loop; that would allow you to have a couple of different philosophies which conflict with each other at the same time! 🙂

    Personally, I’d like to see some of that acreage turned over to hemp if they are going to farm monocrops. But better yet would be a return of at least some of it to prairie.

    In any case, both organizations (FDA and USDA) are complicit in the monstrous health debacle we are experiencing now; they may not be doing it explicitly (although I like the X-Files as much as the next guy) but it’s happening on their watch. They too, should have to swear to First, Do No Harm.

    • Kay

      August 2, 2014 at 1:04 pm

      “Hear, hear” to your write-ups on the non existant disease/nutrition dialogue between patients and medical professionals. It’s a crime really, and so sad. Luckily I started Googling right away when presenting with ankylosing spondylitis symptoms, and now, 3.5 years of the paleo zip + no starch has me active and well functioning again. Thanks to the ever increasing anecdotal documentation people are sharing on the web, surely the point will be pushed to the forefront… some day…
      Remarkably healthy looking pictures of yourself, post retirement. Chapeau!

  5. Tyrannocaster

    August 2, 2014 at 2:07 pm

    Thanks for the hat tip, Kay. I had to look up ankylosing spondylitis as it’s a term I have seen but never known anything about; it sounds nasty, but I can see how dropping the carbs (and certainly the wheat) could really have a major beneficial effect; wheat is responsible for so much system-wide inflammation that causes all sorts of problems down the line, and a lot of doctors – no, make that most doctors – don’t think to ask about diet as a possible cause. It sounds like you have been wheat free a few months longer than I have, which means we both have been able to do this thing and stay at it; in my case, it really has not been hard at all, as the alternative is what? Go back? (Big game show buzzer sounds and a voice intones “THANK YOU FOR PLAYING; NEXT CONTESTANT!)

    Thanks for taking the time to comment – it’s what makes these posts worthwhile.

  6. Andie Butler

    August 5, 2014 at 5:03 pm

    Great post, Tyrannocaster; I thank you! I am an equine veterinarian turned holistic health coach for people. I found this post from your comment on Marksdailyapple. I decided to get into this field when I came to understand how entreprenurial bias tainted the practice of veterinary medicine, and I had figured out that things were as bad, if not worse, in the practice of human medicine. I think that the problem with nutrition and human docs is three-fold: First, nobody makes any money if the patient just needs to change his/her lifestyle. Second, nobody’s ego gets stroked if the patient just needs to change his/her lifestyle. Third, the doc him/herself may need to change his/her own lifestyle. That means taking responsibility for ones own health, and giving up whatever foods one may be medicating oneself with, and is probably addicted to. In other words, denial. And of course there is the whole component of the power of the agribusiness industrial complex manipulating regulations, research, and academics. It is a simple problem, but the solution is complex, if there is one!!!

  7. Tyrannocaster

    August 5, 2014 at 5:54 pm

    Andie, thanks for the thoughtful response; so far it has been quite difficult to get anybody to actually suggest reasons for this funky situation. I take your points, all of which make perfect sense, but I admit I hadn’t really thought about the third one much, even though I have read that many doctors feel uncomfortable giving people advice on nutrition when a pretty high percentage of physicians themselves are overweight. My wife works in healthcare and she used to work at a local hospital with a specialty focus on cardiology (cardiology, is of course, one of the more “glamorous” specialties and it often raises more money than other departments) and she was always astonished by how many of the surgeons smoke and weigh too much.

    Anyway, I wish more of us understood the ramifications of your first point, which from a patient’s perspective include this one: if you can improve your situation by eating differently (and/or other lifestyle changes, as opposed to pharmaceutical interventions) it won’t cost you as much. You’d think insurance companies would like this but they don’t seem to, beyond emphasizing things like regular exams that look at guideline-mandated specs, which is the thing that my HMO (Kaiser) is crazy about.

    You are also dead on to bring up the question of veterinary medicine, because most vets are lacking a decent knowledge of how nutrition works in the animals they treat; I have a special interest in this because of all the dogs I work with as a trainer and some of the experiences we have had. In one case, one of our Belgian Tervurens was diagnosed with kidney disease at the age of ten and the vet’s recommendation was to put her on a special version of Science Diet kibble made for kidney problems. This was a low-protein food, which I didn’t know anything about at the time, but because it’s Science Diet (and I have never trusted them) we did some research on the subject. Eventually we found a site called whose owner claimed to have helped her Shar Pei in a similar situation just by giving the dog a diet of raw meat, cooked vegetables, fish oil, and a bit of eggshell. (Not low protein at all.) Now, this vet didn’t think much of this idea but he had enough savvy to run it by one of his vet techs, who was a lot younger and was “more into that sort of thing” and she thought it sounded okay so with her blessing we tried it. Within two days the dog acted years younger. Most importantly, her urinary problems decreased and so did her water consumption. And within 30 days, since she was doing so much better, we had the bloodwork done again and it verified the improvement. The dog lived for three more years and when she finally did die it wasn’t from kidney problems.

    But this was a few years before I found out about my own problems caused by poor diet and it never occurred to me to apply this experience to my own situation. We just get used to the way things are and tunnel vision is hard to break out of.

    Inertia is incredibly powerful.

    Thanks so much for stopping by.

  8. Andie Butler

    August 6, 2014 at 10:16 am

    Vets do get more nutrition than human docs, I believe, though I did not take the nutrition course at my vet school, because I had taken animal nutrition in undergrad. The course that I took focused on food animal nutrition, as their diets are highly manipulated to maximize their value as production animals, whether for their meat, dairy, offspring, etc., pretty much at the expense of their health. I learned then how SICK an unnatural diet can render its eater!!!! Humans tend to be so loath to perceive of themselves as animals, which we ARE!!! We need to eat and live as nature intended in order to thrive, or at least not to be sick, as much as possible, in this unnatural world. And for sure docs are just as unhealthy as the general population, for the most part. High sugar/carb foods are incredibly addictive, as are gluten-containing foods. I marvel when I talk to people about giving up high starch, sweets, baked goods, etc., as the look of anxiety,fear, and dread take over their faces. Sometimes it makes me chuckle, other times it makes me sad…


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