Just Read: Diets for Health, Goals and Guidelines (Except what if the guidelines aren’t working?) – American Family Physician

I had high(er) hopes for this article, published in the journal of my medical specialty, American Family Physician (@AFPJournal), especially after other medical journals such as JAMA have begun to take a more expansive view of nutrition.

However, I am disappointed.

This quote for example.

Diets for the treatment of specific medical conditions are beyond the scope of this article.American Academy of Family Physicians. A, Schneiderhan J, Zick SM. American family physician. Am Fam Physician [Internet]. American Academy of Family Physicians; 2018 Jun 1 [cited 2018 Jun 4];97(11):721–8. Available from: https://www.aafp.org/afp/2018/0601/p721.html

The majority of Americans now have specific medical conditions

Here’s what’s happening in California

Here’s what’s been happening to Americans over the last 25 years

Here’s what’s happening to our livers

The review completely missed a large body of literature covering all of the things this piece purports to cover:

• preventing type 2 diabetes mellitus
• decreasing cancer incidence and mortality
• preventing age-related cognitive decline
• preventing cardiovascular disease (CVD) incidence and mortality
• decreasing overall mortality,
• and treating obesity

Patients can understand more than we think they can

Patients are more likely to understand information about foods rather than nutrients, so focusing on food categories may be useful.American Academy of Family Physicians. A, Schneiderhan J, Zick SM. American family physician. Am Fam Physician [Internet]. American Academy of Family Physicians; 2018 Jun 1 [cited 2018 Jun 4];97(11):721–8. Available from: https://www.aafp.org/afp/2018/0601/p721.html

As I wrote in this post (Why Doctors should meet patients (and each other) where they are: My intersection of LGBTQ , LCHF, and LetPatientsHelp), I’m interested in this area because it seems to be another one where the profession tends to tell people what to do instead of encouraging/promoting their own curiosity and ability to learn for themselves.

I have been in rooms with patients who understand nutrients quite well, well enough to reverse their metabolic syndrome and educate each other.

In these rooms I have not heard patients telling each other what foods to eat, because I can tell that’s not what they need/want to be told.

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When was the last time you concluded a CME in a room of humans taking control of their health destiny – health professionals, scientists, citizens, together. This was my first. I think this #diabetesreversal is actually a thing ✌️#LCHF #LCB18 #LowCarbBreck #ketogenic #FutureStartsHere #CitizensIncluded #FoodIsBetterMedicine 🥓🍖🥩🥦🌷📸

A post shared by Ted Eytan, MD, MS, MPH (@tedeytan) on Mar 5, 2018 at 5:30am PST

Remember What Happened

The image at the top shows what’s been happening since the first dietary guidelines came out in 1977. Here it is again:

The authors acknowledge what happened after these guidelines were produced:

Efforts to reduce fat consumption over the past 40 years led to increased intake of refined carbohydrates in place of fat and overall increased caloric intake, which increased triglyceride levels and the risk of type 2 diabetes and contributed to weight gain, increased LDL cholesterol levels, and decreased high-density lipoprotein cholesterol levels, but did not affect rates of CAD.American Academy of Family Physicians. A, Schneiderhan J, Zick SM. American family physician. Am Fam Physician [Internet]. American Academy of Family Physicians; 2018 Jun 1 [cited 2018 Jun 4];97(11):721–8. Available from: https://www.aafp.org/afp/2018/0601/p721.html

…and then they continue with the same advice in those guidelines, which created these artifacts from today:

Here’s how the advice is implemented in practice at professional meetings:

Grains and Glycemic Index

While I understand that glycemic index and even glycemic load are only a small part of healthy nutrition, I was curious about this statement:

Grains are available as highly refined food products that contribute to poor health (e.g., white bread) or as minimally processed whole grains that contribute to a healthy diet (e.g., brown rice). Patients may have difficulty understanding which grains and grain products are healthy. The glycemic index and glycemic load, which take into account the amount of carbohydrate in a food, can help with this understanding.American Academy of Family Physicians. A, Schneiderhan J, Zick SM. American family physician. Am Fam Physician [Internet]. American Academy of Family Physicians; 2018 Jun 1 [cited 2018 Jun 4];97(11):721–8. Available from: https://www.aafp.org/afp/2018/0601/p721.html

I haven’t taken the time to look at glycemic index values carefully, so I decided to take that time, and here’s what I found. Note the difference in glycemic index/load for white vs whole wheat bread, and white and brown rice.

Product	Glycemic Index – Glucose = 100	Glycemic Index – Bread = 100	Available Carbohydrate	Glycemic Load	Serving Size
Coca Cola	53	76	26	14	250 ml
Orange Juice	50	72	24	12	250 ml
Rice White	72	103	40	29	150 g
Rice White (Insulin Resistant Subjects)	59	85	36	21	150 g
Rice Brown (USA)	50	72	33	16	150 g
Rice Brown (Canada)	66	94	33	21	150 g
Rice Brown (boiled)	72	103	40	29	150 g
Rice Brown (Insulin Resistant Subjects)	50	72	33	17	150 g
White Bread (Pepperidge Farm USA)	71	102	16	11	30 g
White Bread (Insulin Resistant Subjects)	70	100	14	10	30 g
Healthy Choice 100% Whole Grain	62	89	14	9	30 g
Whole Wheat Bread (USA)	73	104	14	10	30 g
Snickers Bar	43	61	35	15	60 g

Here’s a chart version:

Creating a better FMRevolution

Remembering/reminding that the specialty of family medicine was created in the 1960’s as

1. A rejection of medical knowledge as a “lump” to be subdivided infinitely, reducing people to parts
2. Understanding of the depth of a person and the things that work to keep them healthy
3. Support for an emerging consumerism in medicine, built on trust and transparency

(more in this blog post I wrote: I am a Family Physician. Where did we come from (and why should you care)? – Part 2 of 3)

I am hoping further explorations like this could encompass these values and go beyond what we’re told and what we want to tell people. We tried that in the 20th Century and it didn’t work.

This Century is much better that way 🙂 .