Monday, February 24, 2020

Retrospective #373: The “blame the patient” game

When your doctor writes in your file, “patient non-compliant,” let me be clear: I don’t really think that he or she, who is perhaps an internist/cardiologist (like mine) or maybe a family care doctor, is being disingenuous They almost certainly, or for the most part, believe in the advice they have given you. They advised you how to lose weight (exercise more and eat less, of a calorie-restricted balanced diet), they believed you could lose weight.  And when you failed to get the results they expected, eating this a “healthy low-fat diet” (avoiding saturated fat), they concluded it was because you didn’t follow their counsel. So, they deduce, you must have cheated! You were “non-compliant!”
Why do your doctor expect this result? Because the Clinical Practice Guidelines for each of the practice specialties, and the governing medical associations (the AMA, AHA, ADA, etc.), all told them to. That is the result of virtually all of the patient cohorts who were given this advice before you received it. So, the explanation – the reason – must be that it was the patient who failed to follow it…the patient who was non-compliant. That, by the way, is also when the Clinical Practice guidelines tell them to start you on drugs to accomplish what YOU failed to do.
It never occurs to your doctor that it could be the advice they gave you that failed to produce the outcome they (and you) desired. The advice to eat a low saturated fat, low cholesterol diet has now been in place for over half a century – since the time any doctor in practice today went to medical school. The advice was first popularized by the publicity given to the treatment of former President Dwight D. Eisenhower after his first heart attack in 1955. Before he died 14 years later, he was to have 7 myocardial infarctions, 14 cardiac arrests, and at least 1 stroke, but never mind….
The advice to eat a low saturated fat, low cholesterol diet was also strongly espoused by a University of Wisconsin physiologist, Ancel Keys. The bad science, publicized in his “Six Country Analysis” (1955), and later compounded in his “Seven Countries Study” (1958), has since been widely discredited, but never mind….
By January 1961, Keys was on the cover of the then popular Time magazine and had joined the Board of The American Heart Association. And to this day the AHA and the AMA and the ADA still espouses a low saturated fat, low cholesterol diet. The evidence that this advice is faulty – in fact, that it is the virtual opposite of the heart-healthy diet that you should be eating – has existed from “the beginning,” according to a timeline from Diet Heart Publishing.
The evidence supporting a healthy diet has now been well documented in the last 20 years, starting with Gary Taubes’s, 2002 New York Times Sunday Magazine cover story, “What If It’s All Been a Big Fat Lie.” It was followed by three seminal books: 1) Gary Taubes’s “Good-Calories, Bad-Calories”; Nina Teicholz’s, “The Big Fat Surprise”; and Gary Taubes’s, “The Case Against Sugar.” There are many, many others, but these three are among the best.
What got me going on this minor rant was an article in Medscape Medical News in 2017 that described the efforts of scientists to “reprogram” alpha cells in the pancreas to regenerate new beta cells in mice. These are the cells that make insulin until, as in Type 1 diabetes, they are destroyed by an autoimmune disorder. Or they just wear out from overuse due to Insulin Resistance, as in Type 2 diabetes.
What set me off in this article was the suggestion that an artificial pancreas or similar advance “may enable tight glycemic control with minimal patient intervention” (my emphasis). That would be great news for Type 1s, but from my perspective (as a long-term Type 2) it just reinforces the notion that “minimal PATIENT intervention” was the only course of treatment available for Type 2s in the clinical setting, SINCE PATIENTS ARE “NON-COMPLIANT” AND FAIL TO ACHIEVE THE DESIRED OUTCOMES WHEN THEY FOLLOW DOCTOR’S ADVICE. THUS, THE PATIENT IS TO BLAME!
But what if you, the patient, took control of your diet and your metabolic health, and ate a healthy, very low carb, moderate protein, high fat diet, including heart healthy saturated fat, without concern for dietary cholesterol? What if you did this and the outcome was a big weight loss and a lab report with a greatly improved cholesterol panel?
 Or, you could just follow the dietary advice given to President Eisenhower in 1955. Remember that outcome?

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