Doctors: Please Stop Telling Your Patients to Eat “A Diet of Moderation”
 
We all know it usually means low-fat

Caveman Doctor would like you all to note that the following article does not refer to all doctors, nutritionists, dieticians, or healthcare experts.  There are many amazing caregivers out there, both well-versed in the literature and amazing at providing superior care.  However, when it comes to nutrition, this doesn’t always seem to be the case.  Caveman Doctor was recently watching a video (whatever a video is) on YouTube (whatever YouTube is).  He became very angry when a doctor said she eats a diet of moderation when it clearly wasn’t the case. 

Moses parted the sea, just in time to eat a diet of moderation and present the Ten Commandments.

We have all heard it before a million times: “Eat a diet of moderation.”  This diet advice flies around the medical field as though it were the Biblical equivalent of the first of the Ten Commandments.  Eat a diet of moderation.  However, what does eat a moderate diet even mean, and what constitutes a moderate diet?  That really is in the eye of the beholder.  The “diet in moderation” advice leaves doctors, patients, nutritionists, and everyone else to interpret the meaning in their own way.  Is this moderation a micronutrient, vitamin, or food-type moderation?  What is in moderation: foods, nutrients, fats, proteins, or carbs?  Amazingly, one usually hears in the same breath, “eat a low fat diet.”  So make sure to eat a moderate diet.  But also make sure to eat a low-fat, but moderate diet.  So what are we really supposed to eat?

Take for example the following video.  It is from an episode on the Dr. Oz Show, where he is interviewing the journalist Gary Taubes, Dr. Dean Ornish, and Dr. Barbara Howard, who was the current head of the American Heart Association (AHA) at the time of filming.  The AHA is considered by many the ultimate authority on diet and nutrition as they have a strong connection to heart health in the eye of the medical world.  This video actually has several parts, where all three fight about their opinions on the best diet.  It is rather amusing, interesting, and informative if you have the time to watch all of it.  However, let’s focus on minute 7:22, after Dr. Oz asks them what they ate for breakfast:

No surprise, but it appears the head of the AHA promotes the good old “diet of moderation.”  Yet, here was her response when Dr. Oz asked her what she ate for breakfast:

“Whole grain cereal with blueberries and orange juice, and then they gave me a snack here which was a bowl of oatmeal and my message is moderation.”

Call me crazy, but that doesn’t sound a whole lot like moderation.  I know I am biased as I refer to the literature and data when I make my dietary suggestions, but I don’t recall hearing any protein or fat content in her breakfast of “moderation”.

In fact, I did a quick calculation in my head, and my math showed that her breakfast was around 90% carbs.  I don’t trust my math, so I plugged it into Fitday:

Purple represents carbohydrates.  Call me colorblind or crazy, but I see a pie chart with a whole lot of purple in there – actually almost all purple.  Yet, her message is moderation!  Is it any wonder why patients are often clueless when it comes to dieting?  I am a physician and I don’t understand her recommendations.  She preaches a diet of moderation, yet she ate a bolus of nearly all carbohydrates for breakfast.  This video was made to give viewers a perspective on nutrition and clear the air, but it definitely left me more confused.  How often does this happen to you?

This is the disconnect between the message of the establishment and its practicality.  Her message is clearly not moderation.  Her message is low-fat.  Actually, her message is low-fat, low-protein, and high-carbohydrate.  She just doesn’t come right out in say it.  Given the fact that trials on dieting demonstrate that low-carbohydrate (not low fat!) diets cause weight loss^1-10, this is the same message that is likely responsible for a large portion of the obesity epidemic. Not only does the nutrition establishment give you the wrong advice, you are often blamed for your failure to lose weight.  Yet, in the words of Gary Taubes, many in healthcare point to “laziness and sloth” as the omnipotent cause of the obesity crises.  Yet, I have seen in myself, my family members, and my patients, what happens when one consumes a diet similar to the carb-bomb described by Dr. Howard – lots of weight gain accompanied by lots of frustration.

I understand that we don’t want to give patients an overly complicated message or one that is difficult to follow.  The whole point of this website is to make the literature on health and nutrition more manageable, and hopefully, easy to follow.  However, sometimes we dumb it down too much.  Sometimes, we dumb it down on purpose.

Why do we dumb it down?

First off, it is very hard to practice medicine correctly in a society where our governing body provides its people with health recommendations that are not based on the available data.  For instance, Michelle Obama, the nation’s First Lady, recently unveiled her new food plate in an effort to end obesity in our country.

Unfortunately, the science tells us that this suggested meal is the problem itself. We run studies that show one thing, and then we have high profile people telling our citizens something totally different.  These recommendations may be well-intentioned, but are based on no solid evidence, and this is very concerning.

Also, looking at this picture, the amount of fat makeup in the diet looks sneakily similar to Dr. Howard’s diet from the video.  Only less than ¼ of the plate is protein, and depending on your interpretation, this scheme could be telling you to eat no fat whatsoever.  Basically, it’s the same old, no-fat, little protein, nearly all carbohydrate diet.  They cut the plate into fourths to make it appear like a diet of moderation, but looking past the different colors, it’s clearly the same old wrong message.  Follow this pie chart and don’t be surprised when you can’t lose weight.  Don’t be surprised as well when you are told it’s your fault for being lazy and eating too much.

This is all coming from the same organization that gave us the infamous food pyramid:

I wouldn’t wish this diet on my worst enemy.  Seeing that the pyramid is based on a majority of bread and pasta (6-11 servings!!!!), it is no surprise that obesity rates have climbed sky high.  However, this is nothing new, as we have known for centuries that these foods caused obesity.  As Tolstoy stated in Anna Karenina over a hundred years prior to the food pyramid:

“He had very quickly been brought down to the required weight of one hundred and sixty pounds, but he still had to avoid gaining weight, and he avoided starchy foods and desserts.¹¹”     Leo Tolstoy, 1870

The fact that starches led to obesity was common knowledge for quite some time, yet the basis of our diet, pushed by our governing body, was starches.  These have somewhat shifted to grains lately, though this change makes little difference.  As rational people who are searching for factual information, how are we supposed to follow recommendations that fly in the face of scientific fact?

This leaves us with a big problem: What is a good physician to tell his or her patients?  Do we ignore the recommendations of the government?  That’s an easy yes for me, but understandably, may not be for others.  Do we give our patients data from the clinical trials?  Once again, I think yes, but this might start to get a little in depth and would definitely take a load of time.  Finally, do we ignore the data and assume that Michelle Obama and the higher-ups know better than us and the literature, and that their recommendations are better than scientific studies?  Few physicians are courageous enough to do this publicly.  One that has been preaching the good message for decades is Dr. Michael Eades.

Regardless, we as physicians are put in a nearly impossible situation.

As a result, physicians often answer with: “Eat a diet as low as possible in fat because I’m scared you’ll have a heart attack because all the anti-fat scare tactics I have heard in the past 30 years.  But, in case this makes you obese, because I also have seen that low-carbohydrate diets actually do work for weight loss, not to mention we have been pushing low-fat for 30 years and people have only gotten fatter, I did tell you to eat a diet of moderation”. This way, no matter how you look at it, the blame falls on the patient.  For some strange and unfortunate reason, the ones who made and make the wrong recommendations never get blamed (sarcastic tone included).  Instead, it’s you, the patient that is supposedly undisciplined and slothful.  And when all else fails, the medical world loves to fall back on the “you just eat too much and are not active enough.”  Regardless, the onus is usually going to fall on you.

I once gave a talk to nurses, dieticians, and physicians.  I had a slide with the 3 most common, but incorrect, responses to dietary questions from patients that make my hair stand on end.

One was “eat a diet of moderation”.

I offended nearly everyone in the room when I said this was wrong advice.  Why was everyone so offended?  Well, it was because many healthcare practitioners, including some in that room, use this as their primary answer when asked by patients what constitutes a healthy diet.  This response if the equivalent of saying:

1. I don’t really know about nutrition
2. I don’t really care about nutrition
3. Nutrition is a complex subject and I don’t have time to talk about it
4. The worst: nutrition isn’t important in medicine.

Unfortunately, even in my field of cancer care, some people actually believe number 4.

We all know people that follow this advice of a low-fat, or moderate, or whatever you want to call it diet.  How many people do you work with that eat a little muffin (all wheat, therefore grains) for breakfast, a sandwich (grains and protein) for lunch, yet are very overweight.  Are these people undisciplined and slothful or just following bad advice?

I understand the logic of avoiding extremes; however, when dietary recommendations by health professionals suggest moderation, more often than not, they are hedging their bets and pushing a low-fat diet or one that leaves patients more clueless and confused.
 
 

Back to Dr. Howard:

The breakfast mentioned above by Dr. Howard, a “moderate” 125g of carbs, is more than the average amount of carbohydrates I often eat in a day.  Actually, it’s around the total amount of carbs a ton of people who share my diet eat.  Also, many of them eat close to 3,000 calories a day, some even more.  The vast majority of the people who follow my diet are not only not obese, but rather lean.  Many were overweight prior to changing their diet.  Most have increased their caloric intake, some by 500-1,000 calories per day.  Why isn’t the “calorie is a calorie” theory applying to them?  Why aren’t these slothful, undisciplined people overweight?
 
Interestingly, the caveman diet that I preach is the epitome of a balanced diet.  Most days I eat around 100-125 grams carbohydrates, 100-150 grams of fat, and 150-175 grams of protein.  That’s nearly a third of each.  That sounds to me like moderation, not the nearly 100% carbohydrate recommendations by others.

I’ll leave you all with a final story:

A few years ago, I was taking care of a patient who had to have her foot amputated due to a gangrenous infection.  She was an obese diabetic whose blood sugar ran 3-4x the normal value on a regular basis.  Her blood was so full of sugar, she could no longer fight the bacteria that were eating away at her toes, and thus we had to amputate her foot.  As my friend, who performs these surgeries regularly, clearly put it: “the blood in these patients is a candy shop for bacteria to feast on.”

In preparation for her surgery, I ordered her a diabetic, weight-loss diet.  The next morning when I saw her during rounds, her diet tray was sitting there: orange juice, apple juice, a blueberry muffin, and toast – a carbon copy of Dr. Howard’s breakfast from above, the same diet that Tolstoy’s character avoided to lose weight.  That night, I received a call from the nurse at around 3 am.  The patient, on close insulin control, eating the food that we prescribed for her, had a blood sugar well over 500 – 5 times the normal value and dangerously high.
 
Who’s to blame, her or us?
 

 
 

References:

1. Brehm BJ, Seeley RJ, Daniels SR, D’Alessio DA. A randomized trial comparing a very low carbohydrate diet and a calorie-restricted low fat diet on body weight and cardiovascular risk factors in healthy women. The Journal of clinical endocrinology and metabolism 2003;88(4): 1617-23.

2. Dansinger ML, Gleason JA, Griffith JL, Selker HP, Schaefer EJ. Comparison of the Atkins, Ornish, Weight Watchers, and Zone diets for weight loss and heart disease risk reduction: a randomized trial. JAMA : the journal of the American Medical Association 2005;293(1): 43-53.

3. Foster GD, Wyatt HR, Hill JO, et al. A randomized trial of a low-carbohydrate diet for obesity. The New England journal of medicine 2003;348(21): 2082-90.

4. Gardner CD, Kiazand A, Alhassan S, et al. Comparison of the Atkins, Zone, Ornish, and LEARN diets for change in weight and related risk factors among overweight premenopausal women: the A TO Z Weight Loss Study: a randomized trial. JAMA : the journal of the American Medical Association 2007;297(9): 969-77.

5. Hite AH, Berkowitz VG, Berkowitz K. Low-carbohydrate diet review: shifting the paradigm. Nutrition in clinical practice : official publication of the American Society for Parenteral and Enteral Nutrition 2011;26(3): 300-8.

6. Samaha FF, Iqbal N, Seshadri P, et al. A low-carbohydrate as compared with a low-fat diet in severe obesity. The New England journal of medicine 2003;348(21): 2074-81.

7. Seshadri P, Iqbal N, Stern L, et al. A randomized study comparing the effects of a low-carbohydrate diet and a conventional diet on lipoprotein subfractions and C-reactive protein levels in patients with severe obesity. The American journal of medicine 2004;117(6): 398-405.

8. Shai I, Schwarzfuchs D, Henkin Y, et al. Weight loss with a low-carbohydrate, Mediterranean, or low-fat diet. The New England journal of medicine 2008;359(3): 229-41.

9. Stern L, Iqbal N, Seshadri P, et al. The effects of low-carbohydrate versus conventional weight loss diets in severely obese adults: one-year follow-up of a randomized trial. Annals of internal medicine 2004;140(10): 778-85.

10. Yancy WS, Jr., Olsen MK, Guyton JR, Bakst RP, Westman EC. A low-carbohydrate, ketogenic diet versus a low-fat diet to treat obesity and hyperlipidemia: a randomized, controlled trial. Annals of internal medicine 2004;140(10): 769-77.

11. Tolstoy L, FitzLyon K. Anna Karenina. Oxford: Oneworld Classics, 2008.
 
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