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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. 2019;179(8):1021-1022. 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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    7 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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    It's just that easy.
    Joe Weatherly, DO | FP
    Research in nutrition is lacking. There are few high quality trials that help eliminate contamination and meet clinical relevance to help direct "nutrition". In my opinion, when we emphasize what we "know" to each other by mandating it be part of an unproven system like CME/board recertification, it just exaggerates the fact that we use our power in medicine because we can. Not because we should.

    Efforts to improve awareness using poor quality information is what prime time television and social media outlets are often accused of.

    While I appreciate your desire to have patient's become
    interested in their recovery and do their part, I'm not sure "we" aren't already also doing our part.
    If your patient in the story chooses to participate in regular healthcare visits, their provider relationship is likely centered around long term goals and interventions that have "known" risk/benefit associated with them. These discussions allowed for education, maybe about soy, caffeine, eggs, vitamin D and calcium, primary prevention of asvcd with low/high dose aspirin and all the other things we "know". Some providers believe research is clear in benefit and some don't. These lead to a variety of care styles and outcomes for a variety of people. Then your patient choses what they want to do.

    Thinking that standardizing CME on nutrition and supplements and further adding to the education we will all have to unlearn someday when we actually know benefits and harms is unhelpful.

    Observation of very ill patients in the hospital setting may lead one to think I about more education on nutrition and that  passing another 5 question quiz will give every patient more resolve to be more compliant with the long term plan. I doubt it. I think we for sure don't have evidence of that.

    Physicians never smoke, eat poorly or too much, have great work/life balance and consistently make efforts to changes their lives to improve their own outcomes, I think this might lend credence to the idea that education breeds health, or it might be evidence that choice is frustrating and health is complex.

    We play an important role and our education meets a very high standard. Adding to the out of clinic requirements when there isn't great science to support much of nutrition in prevention isn't the answer.

    Improve research, communicate and allow patient's the right to make choices you don't agree with once they are aware at the level their provider is able to provide.
    CONFLICT OF INTEREST: None Reported
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    Be clear on evidence limitations
    Justin Tondt, MD | Eastern Virginia Medical School
    I wholeheartedly agree with the premise of improving the medical community's nutrition knowledge.

    However, I would disagree with the statement “the evidence would argue for a low-fat, plant-based diet for both doctor and patient”. Dr. Barnard is certainly correct in that a large amount of observation evidence shows benefit for this dietary pattern, for example https://www.ncbi.nlm.nih.gov/pubmed/26143683. Dr. Barnard himself has also shown benefit of this dietary pattern in randomized control studies, such as https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2677007/. Unfortunately, compared to other dietary interventions, a low-fat, plant-based diet has not been shown to be more effective (https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4667723/ + https://academic.oup.com/ajcn/article/105/1/57/4633933).

    I acknowledge
    that Dr. Barnard did preface the statement with “to different authorities that may mean different things”, but if we, as a community, are going to advance our knowledge, then we should be clear on what the current limits of the knowledge are. In this case, if an effect is shown in observational studies but not randomized control trials, then there is likely a confounding factor as many health behaviors are associated with meat vs plant intake (https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5574618/). Additionally, since hunger is arguably the strongest predictor of weight loss (https://www.ncbi.nlm.nih.gov/pubmed/23512619), we may benefit from shifting focus to a diet’s satiety rather than its macronutrient composition.
    CONFLICT OF INTEREST: None Reported
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