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Less Is More
July 1, 2019

Ignorance of Nutrition Is No Longer Defensible

Author Affiliations
  • 1Adjunct Faculty, George Washington University School of Medicine and Health Sciences, Washington, DC
  • 2Physicians Committee for Responsible Medicine, Washington, DC
  • 3Barnard Medical Center, Washington, DC
JAMA Intern Med. Published online July 1, 2019. doi:10.1001/jamainternmed.2019.2273

It was the middle of the night, and the patient’s intravenous (IV) line was clogged. Having refused the recommended foot amputation, the patient was receiving IV antibiotics to fight a festering infection, a complication of longstanding diabetes.

During the few minutes it took to replace the IV catheter, the patient let me know that whatever pride I held in my phlebotomy skills was unjustified and that my needle sticks only added to the misery of hospital life. Each time I was called to replace the IV during the patient’s hospital stay, I found myself thinking, “Why not just get the amputation over with?” It seemed that the patient was only delaying the inevitable. But I was wrong. The patient eventually left the hospital, foot still attached.

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    5 Comments for this article
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    I wish my late dad could have known better
    Nir Tsabar, MD/DSc | Clalit Health Services, Israel
    Just say it please:

    Choose low carbohydrate diets,
    without sweeteners or processed food.

    Animal fat was duly exonerated. https://www.ncbi.nlm.nih.gov/pubmed/28864332
    It helps achieving satiety and prevents over-eating.

    The 70 years old Procter & Gamble - American-Heart-Association legacy should be abandoned.

    Spreading this knowledge and limiting misleading advertisement is crucial.
    CONFLICT OF INTEREST: None Reported
    Advice to "improve/change your diet" is not helpful
    Richard Schmidt, BPharm PhD | Semi-retired pharmacist
    Patients need to be advised simply to "eat a lot less", "avoid all sugary / artificially sweetened carbonated drinks" and "move about more". And they should be advised that the hunger they will inevitably feel should be recognised as a good thing and that it is not dangerous.
    CONFLICT OF INTEREST: None Reported
    What we can do to reduce overweight in patients with type II diabetes?
    Giuliano Ramadori, Professor of Medicine | University of Göttingen
    people unfortunately do not want to hear that they can do something to normalize glucose serum level if the suggestion is reduction of daily calorie intake. It is in most of the cases very difficult to get the patient to admit that the daily calorie uptake may be twice that which would be necessary.
    The patient just want to have a "good" new drug. This also fits with the interests of the industry.
    It is not a question of the componenets of the food but of the total amount of calories/day.
    CONFLICT OF INTEREST: None Reported
    two other useful facts
    Earl Killian |
    Although Americans generally get excess nutrition in many categories, 90% aged 19+ get less than the adequate Intake of fiber[1] and the median is less than 65% of the adequate intake. Physicians could usefully educate patients about the need for more fiber.

    With regards to carbohydrate, the ARIC study found that 50-55% of energy from carbohydrates minimized mortality. it is worth quoting from the summary findings of one research publication[2]:
    "During a median follow-up of 25 years there were 6283 deaths in the ARIC cohort, and there were 40181 deaths across all cohort studies. In the ARIC cohort, after
    multivariable adjustment, there was a U-shaped association between the percentage of energy consumed from carbohydrate (mean 48·9%, SD 9·4) and mortality: a percentage of 50–55% energy from carbohydrate was associated with the lowest risk of mortality. In the meta-analysis of all cohorts (432 179 participants), both low carbohydrate consumption (<40%) and high carbohydrate consumption (>70%) conferred greater mortality risk than did moderate intake, which was consistent with a U-shaped association (pooled hazard ratio 1·20, 95% CI 1·09–1·32 for low carbohydrate consumption; 1·23, 1·11–1·36 for high carbohydrate consumption). However, results varied by the source of macronutrients: mortality increased when carbohydrates were exchanged for animal-derived fat or protein (1·18, 1·08–1·29) and mortality decreased when the substitutions were plant-based (0·82, 0·78–0·87)."

    1. http://nap.edu/10490 Appendix Table E-4 (pages 1036-1037)
    2. https://www.thelancet.com/journals/lanpub/article/PIIS2468-2667(18)30135-X/fulltext
    CONFLICT OF INTEREST: None Reported
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    During the patient’s entire stay, no one on the medical staff had talked with the patient about the fundamental cause of the problem.
    Charlie Schmidt, BSBA | Consumer, recent former patient
    This happened to me during a 4 week in-hospitalization for a diabetic emergency. I had 5 physicians taking care of me and countless RNs and MAs, and not one, not even one ever discussed the T2 Diabetes talk, or Nutrition 101 talk. Thank goodness the hospital did have an internal Video Library system and I had my smartphone with internet access so I self-educated, managed my T2 Dx and education. Also, no one on the hospital staff even explained to me that T2 can be possibly controlled and even cured just with diet and exercise options, but no they sure wanted me on insulin and expensive new oral meds first. Thank goodness I had family, friends, and even strangers testify to me that they had relatives with T2 who had cured themselves through diet and exercise only. I guess I suffered from a crisis in care coordination and lack of care and aptitude that the conservative approach with diet and exercise should be mentioned on every new Dx of T2. Within 4 months, post-discharge of my hospital stay, I was successful at the diet and exercise approach and even surprised my PCP and cardiologist. Intermittent fasting 5.2, 10-15K Steps minimum per day, and/or HIT exercises (high intensity exercises 3X for 20 minutes per day everyday, especially after meals), Reduce avoid sugar, carbs, processed foods, adjust control portion sizes, give up soda. Lost over 50 lbs. Without insulin and oral meds. I believe only in the last year did the ADA/AHA Treatment Guidelines for T2 finally inserted written instructions and mention of the same recommendation, that T2 can be controlled and even cured with strict adherence to only diet and exercise. Finally, now if we humans can learn from our experiences, and reading history and treatment guidelines. Only my PCP apologized for her reluctance to be more proactive on this matter.
    CONFLICT OF INTEREST: None Reported
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