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

2018.05.30 Washington, DC Low Carbohydrate Meetup, Washington, DC USA 01-458
View on Flickr.com)

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

2018.05 Low Carb and Low Carbon Presentation Slides 417
2018.05 Low Carb and Low Carbon Presentation Slides 417 (View on Flickr.com)

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

2018.05.29 Low Carbohydrate Meetup, Washington, DC USA 452
2018.05.29 Low Carbohydrate Meetup, Washington, DC USA 452 (View on Flickr.com)

Here’s what’s happening to our livers

2018.05.29 Low Carbohydrate Meetup, Washington, DC USA 438
2018.05.29 Low Carbohydrate Meetup, Washington, DC USA 438 (View on Flickr.com)

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.

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:

2018.05.30 Washington, DC Low Carbohydrate Meetup, Washington, DC USA 01-458
What Happened?

“Most people became heavier at about the same time. …We believe it is implausible that each age, sex and ethnic group, with massive differences in life experience and attitudes, had a simultaneous decline in willpower related to healthy nutrition or exercise.”

Source: Rodgers A, Woodward A, Swinburn B, Dietz WH. Prevalence trends tell us what did not precipitate the US obesity epidemic. Lancet Public Heal [Internet]. 2018 Mar; Available from: http://linkinghub.elsevier.com/retrieve/pii/S2468266718300215 2018.05.30 Washington, DC Low Carbohydrate Meetup, Washington, DC USA 01-458 2018.05.30 Washington, DC Low Carbohydrate Meetup, Washington, DC USA 01-458 (View on Flickr.com)

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:

2018.05.29 Low Carbohydrate Meetup, Washington, DC USA 441
2018.05.29 Low Carbohydrate Meetup, Washington, DC USA 441 (View on Flickr.com)
2018.05.30 Low Carbohydrate Meetup, Washington, DC USA 457
2018.05.30 Low Carbohydrate Meetup, Washington, DC USA 457 (View on Flickr.com)

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

2018.05 Low Carb and Low Carbon Presentation Slides 412
2018.05 Low Carb and Low Carbon Presentation Slides 412 (View on Flickr.com)

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:

Glycemic Index and Glycemic Load of Selected Foods 459
Glycemic Index and Glycemic Load of Selected Foods 459 (View on Flickr.com)

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 🙂 .

2018.01.14 Pharmaceutical Ads from the 20th Century 238
One size does not fit all. 2018.01.14 Pharmaceutical Ads from the 20th Century 238 (View on Flickr.com)

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