Has Evidence Based Medicine lost its mind?

Have I lost my Mind? Or has Evidence based medicine failed itself?

Last night was a pretty ordinary night at the accident and urgent medical centre where I was doing an evening rostered shift. There was nothing extraordinary about Ted* (not his real name). In fact there was nothing extraordinary about his presentation either. Just another octogenarian. He could have been your dad or grandad, your brother or uncle. A person, an individual. Someone who is dear to you. Evidence based medicine has turned him into ‘just another octogenarian’. But he is Ted. He is a person, not a number. He is not actually quite the same as any other octogenarian even if they have the same clinical diagnoses. But evidence based medicine has turned everyone like Ted into generic Ted.

Let me tell you more. You can decide what to make of the story. You can decide what you would do.

Ted arrived at the after hours medical centre with his daughter. That’s what they had been told to do. “Arrive after 5 and someone will see you”. He was from out of town and staying with his daughter to recuperate from his foot infection. He had been staying with another daughter who lived a 45 minute drive from his usual place of residence. You see, Ted at the age of 81 was till living independently at his own house, near to his own GP. But he had an infected foot and was staying with his daughter. He then travelled here to stay with another daughter. She wasn’t sure how long it would be for. But he was going to run out of his medication. But the locum GP at his regular practice would not do a repeat prescription for him as he/she hadn’t seen him before. So now he was in my waiting room. He needed more pills and his foot was still painful. Oh, and he was constipated and just wanted a ‘good shit’. He didn’t need to be in an urgent care facility where there are 2 doctors and a full waiting room. He did need care. But this story is not about that kind of care (important nonetheless).

He had the requisite medipac of drugs. I right cocktail. At least he brought them along because he didn’t have a clue what the pills were or what they were for other than he’d had a ‘heart attack’ in January. Prior to this he had been on no medication at all. Nada. Nothing. And he had got to 81. Pretty good in my eyes.

The medicine list:

Aspirin 100mg daily

Metoprolol 23.5 mg daily

Enalipril 2.5 mg bd

Atorvastain 80mg daily (I kid you not!)

Ticagrelor

That’s exactly what happens when Evidence Based Guidelines are used for generic Teds. Except that Ted is Ted, not generic Ted.

But Ted came in also for review and dressings on his sore foot. It looked rather like a diabetic foot to me. He had a lovely macerated digital space between is 4th and 5th toes. But he is not diabetic. His finger prick glucose was 11. Pretty high considering he ate last at lunchtime.

The elephant in the room: are these drugs of any benefit at all for Ted? He has no idea of any benefits. He takes them because the doctor at the hospital discharged him on these because he ‘had a heart attack’. Because that’s everyone who has a heart attack gets. Ted is not everyone. Ted is Ted. What actual benefits will Ted get from this cornucopia of drugs.In all likelihood none at all. And about the side effects and drug interactions?

We know that there is a correlation between statin use and diabetes. And 80mg? Better than poison. We know that beta blockers aren’t that good if you have diabetes. And aspirin in the elderly – quite a high risk of bleeding. And ticagralor? Is there any safety data for use in the elderly? So here is Ted with his muscles very likely affected by his high dose statin, and a sore foot. That increases his risk of falling. So does blood pressure medication. Falls in the elderly have a high morbidity and mortality – broken hips, brain bleeds – and he is on two drugs that can make bleeding worse.

So is it possible then that drug side effects have contributed to his sore foot and increased his morbidity (and mortality) risk? If so, it means that the medicines he has been prescribed ‘because he had a heart attack’ may not be doing anything useful for Ted at all, but may indeed reduce his quality of life. Did anybody bother to ask Ted what he might want for himself. It’s called informed consent.

Ah, well at least Ted might not die from a heart attack. But will he live longer or better?

Is Paleo a threat to your health?

“Nothing in Biology Makes Sense Except in the Light of Evolution”

Theodosius Dobzhansky, Evolutionary Biologist

Quite  a profound quote.

For the better part of the last year I have been drawn more and more to the Paleo lifestyle. Let’s be clear I am not a cavewoman and have no aspiration to be one. I live in the 21st century and what is past is past. That doesn’t mean I cant use the past to learn from and take action to do the very best I can for my future health. I only wish that I had found my way to this approach years ago. Instead I blindly assumed that  the ‘authorities’ (aka Dietary guidelines) were well researched, valid and up to date with current science. Epic fail ,Dr Olver. But the future is what matters now. I have to thank Prof Noakes for being the spark that lit the fire.

The thing is, so many people out there in our easily accessed cyberworld are putting their own spin on what Paleo is that the true core message is being both lost and misinterpreted. This is not a good. It is in fact is a very destructive process as many people who could benefit from this approach are being dissuaded by the very people who have themselves benefited from such an approach. And don’t the media just love to stir up ‘debate’ without the full story! You bet it makes me cranky. It does seem to me that the driving forces creating  this dissent are our old friends Money and Ego. Put your spin on a fundamentally great framework, tweek it and make your own rules, tell everyone why yours is the best one, make the pages look pretty and Voila! you have a book. What a shame you have to contribute to destroying the hand that feeds you.

Fortunately not everyone out there is intent on making mega-money from informing us of  the really positive benefits of the Paleo approach. I apologise in advance if I quote their words. They are just so good at what they do I can”t help repeating what they say! (that’s you Thatpaleoguy  Jamie Scott and Primalmeded Anastasia Boulais). There are others too whom I greatly respect: Robb Woolf; Mark Sissons and the Hartwigs to name just a few. Just why do I value what they say?

They have a great depth of knowledge

They look critically at research before passing on their knowledge

They do not criticise others for their choices, but they do call out when those choices are being made due to misinformation

They value autonomy : everyone is free to choose what they wish to shove in the ‘piehole’. Just do it with knowledge and for the right reasons for you.

And they look at Paleo as a framework/template/ approach not as a ‘diet’ with a rulebook.

For me a Paleo approach is quite straightforward. Its not complicated either. And somehow my health really seems to have gotten a whole lot better despite almost every dietician, magazine and guideline telling me my health will suffer if I cut out a food group. How could my health not suffer if I cut out all those essential wholegrains? (Yes, all 8-10 servings a day recommended by our friendly heart foundation and our Healthy Food Guide Magazine).  And of course I must surely be clogging my arteries with all that delicious clarified butter and red meat, not to mention all those eggs I’m enjoying. I couldn’t possibly get anough calcium with no/low dairy intake could I? And while we’re at it: Paleo is so boring, it’s lowcarb; it’s high protein and on it goes.

In truth I bet I eat way more vegetables than most vegetarians. I do not live on meat alone. I just eat real, proper food that tastes delicious. I do not count calories. I do not work out macronutrient ratios and nit pick over the fine nuances of what I eat.  High protein – not so.  We all should be eating around 30g at each of our 3 meals.  So I guess compared to most average conventional diets mine may appear to be high protein. Low carb? If  I want it to be  it can be very low but  I probably  hit around 100g a day – sometimes more sometimes less. Compared to the average of 300g +and above from all those ‘healthy wholegrains, pasta and ‘essential energy snacks ‘ my daily intake is low. It probably needs explaining that carbohydrates are not an essential nutrient group. Our bodies can make glucose but they cannot make essential amino acids and essential fatty acids.  (Go and Google some biochemistry if you don’t believe me). And guess what? Despite my risky, unhealthy and dangerously boring Paleo based diet I’m still alive (and thriving, no less). I’m not malnourished nor vitamin deficient. On all the basic parameters by which we assess ‘health’  I have seen improvement. And the naysayers still want to tell me what I’m doing, is dangerous/ risky/ unhealthy/unproven?

Ha ! They can carry on eating cereal and toast for breakfast (with their ‘healthy’ low fat sweetened fruit yoghurt and trim milk), sandwiches and wraps for lunch (with margarine, token slice of ham a lettuce leaf and a shaving of carrot) and the ‘no sugar added’ fruit juice to go with it and dinner with a bowl full of pasta and a bit of that store bought pasta source (you know, the low fat, heart tick healthy one). And don’t forget the office morning teas that you cant resist because you are a bit peckish despite your healthy breakfast, with lunch  still a few hours away.

It always amazes me when I read the anti- Paleo rhetoric and the Paleo-vs Paleo stand offs.. Those who criticise so loudly seem to really miss the point. They miss the very essence of what a Paleo approach really is. How can eating fresh, real unprocessed food, getting enough sleep and being active ever cause your health to get worse?? I don’t think anyone would say any of those factors are detrimental to health. So why all this “Paleo is a fad”, “Paleo is bad”,” Paleo rules can’t be broken”?

I wonder whether this anti-paleo phenomenon ( and  paradoxically – paleo perfection )is more deeply seated in the human subconscious. Anything that challenges the status quo of an individual, a community , a country is perceived as a threat. Human beings hate change and they like to be in control (even at a cellular level  our  biochemistry  is tightly controlled to  keep us alive). Suggesting to people that they honestly evaluate how they eat and live is challenging to say the least. Deferring to ones comfort zone is the easiest default option.  Challenging the ingrained dietary ‘laws’ which have pervaded our lives is a really difficult process. We have to think, ask questions and be prepared to find answers that don’t fit with our current deeply set belief systems. It also takes effort .

And guess what: Just like in a well known advert: Good things take time. There is no such thing as Paleo perfect. There is no rulebook. The Paleo approach provides a framework for everyday use. You can tweek it anyway you like. The more closely you stick to the framework, the more likely you are to see benefits. It doesn’t mean that if you use the framework only half the time that you have ‘failed the diet’. But by the same token it doesn’t give you licence to say Paleo doesn’t work either! Just be really honest with yourself.  It’s your life and your health. Being healthy doesn’t just happen in our 21st century world and it is not always easy. We are constantly and chronically exposed to a world encouraging us to eat all the time. (It is useful to bear in mind that the food industry is not tasked to look after our health. Their brief is to sell their products so that their shareholders remain happy). Looking after your health is your own task and your own responsibility. If you think it’s hard to do – ask someone with poor health just how hard it is to be unhealthy.

If you are perfectly happy with your health then you are quite free to carry on with whatever approach you are taking as it is the approach you have found that works for you. All good. I’m not   persuade happy, healthy people to change.However my experience tells me that most people are worrying about the state of their health all the time.  They want their ‘cholestrol’ checked all the time, (that’s another whole story), they want to lose weight, they are worried about getting cancer, they are tired and they are constantly analysing everything they eat. (Ever heard ” I really shouldn’t have that ..” as the  the office morning tea morsel heads to the mouth?) People are clearly unhappy with their health and are in a perpetual state of ‘trying to get healthy’. The sad thing is that they never get to ‘being healthy’ because they keep following the same old advice. If that advice was in fact working for them then they would be feeling healthy!

Go try the Paleo approach and you be the judge.

A Blind Leap of faith….

There comes a time when one needs to put up or shut up ( so the saying goes). I have made a challenging decision to blog more publically  – To have faith in what I am doing. To not hide behind a cyberwall in case I say something someone doesn’t like or agree with. When I first decided to write this blog my motivation was to keep a record for myself and intermittently jot down some of  my thoughts so that I could reflect on them down the track. All these  months later my little world view has expanded beyond anything I could have thought. I’m not talking about a narrowmindedness or lack of being world aware. I have discovered a whole fountain of new and exciting knowledge that has rocked my previous belief system to its very core. I am ‘fessing up’ right now, in public : “I believed that the nutritional guidelines were the “Holy Grail” of nutrition advice for healthy living”. How wrong I was. And how stupid. The truth is right there in front of me. I just needed to see it.

“Without inspiration the best powers of the mind remain dormant. There is a fuel in us which needs to be ignited with sparks.”

Johann Gottfried Von Herder

I first called the blog “Everyday Low Carb – A doctors personal experiment”. That was how it all started. Just my own n=1 experiment with a low carb diet. I have changed it now to what you see. It reflects who I am and where I might travel. I can go nowhere on my own. Traveling  never ends. We just go different places and by different roads. We meet different people on the way.  The “You TwitFace” spaces have inspired, taught and introduced me to concepts and people  I couldn’t have imagined to exist. I feel privileged to be able to connect and learn.

Sometimes I talk too much, sometimes a good rant feels like therapy. Sometimes I have something useful to say and sometimes I am just talking to myself. Listen in if you like. Your company is welcome……I know I am not jumping in blind -just leaping with faith. Believe in yourself.

PS: the blog title is quite ironic really. When I thought of it. it was really just my own motivational phrase. Now I have to believe that I can help in some way to get people eating Real Food and to embrace life and enjoy it. Eat,Sleep,Love and Play. This mission is possible. I cant change the whole world but I might just be able to change one person.

Low Carb, Paleo, Primal, Whole Foods, Organic, Confused?

It’s been a while since I last jotted down my thoughts and progress. I have thought a lot about what I could or should say. I am still holding steadfastly to my n=1 personal experiment and I am still committed to follow it for a year before a can truthfully answer the question for myself. Well, what is the question then? Maybe I’m not so sure. Just perhaps there is more than one question.

To be honest, though, the biggest driver for me is to lose weight, no matter how I try to colour it any other way. But then getting to a healthy weight which I can sustain is healthy too. I am a little disheartened by the slow weight loss despite being really diligent at managing what passes between my lips. Some people report such rapid and impressive weightloss and I am certainly not seeing that happen for me. Perhaps, though they are not really the average or common patterns. Perhaps the people with spectacular weight loss are just happier to shout out about their success (and they should indeed be happy and proud). Maybe those of us who have a very slow loss are less inclined to shout out about it. But maybe many become disheartened and give up believing it doesnt work. That’s why I have to commit to this for a whole year because I really do believe that eating this new way is healthier and makes a lot of sense too.

I’m sure I’m not the only one who feels a bit confused. There are so many blogs and websites analyzing, commenting, evaluating and giving their own personal spin on the ‘new healthy eating style’. How can an ordinary person find their way through the maze? I think it would be fair to say that everyone has his or her own philosphy and opinions. That’s what makes it so complex and so interesting. (and who doesnt like a good drama every now and again).

This is my overview of the complexity of my new look at healthy eating:

  •  lots of carbohydrates, especially those from grains are not good for a large number of us
  • we dont need to eat increased amounts of protein ( ie it is not a high protein eating lifestyle)
  • we should be eating more healthy fats than we do ( in place of carbohydrate calories)
  • healthy fats are not the ones we have been told are healthy! bring on butter, coconut oil, etc and out goes canola and sunflower.
  • Eat when you are hungry and it till not hungry rather than until full

Gotta read this! Some more low carb science

I saw Mark Sissons comments on this paper earlier in the week and it certainly made me smile and think that there absolutely truth in the alternative hypothesis of Low carb eating being good for you. Then I read Peter Attia’s blog: he is just so good at explaining the science and seeing the need to use good science honestly. I imagine I will re-read this article many times.

The Eating Academy | Peter Attia, M.D..

How to deal with that ‘E’ word

On my last wave of ‘dieting'( following WW points) a few years ago in 2008 that ‘exercise’ word featured obsessively in my day to day pursuit of losing weight. I cycled, did spin classes and even did some running. And so I did lose weight and I managed to keep it off mostly till around 2010 when the wheels fell off an slowly I crawled back to my fat state. Thankfully I got a grip on the situation at a weight about 10kg below my previous start point. The ‘E’ word is not helpful: for me i just see a gym, sweat and lycra and that endless pursuit of hard cardio. Does it have to be this hard to be good for me? I don’t think so. I hate riding my bike alone and my old mates just want to ride as fast as they can and race each other round the bays. It doesn’t push my button any more. Running is hard. It’s hard on the breathing and it’t hard on my knee ( old damage from ski-ing). And now I also have a delightful little Jack russell terrier who just loves to get out.

So a mindset change has been evolving for me. I have to get rid of the notion that in order to be doing good I have to sweat like a  pig. Exercise per se is not effective in any big way for weight loss. It has lots of other benefits, though and so it is important. I used to drive 20 minutes to do an hour spin class and then drive the same home: I could go for a fabulous hilly bush walk straight from my front door for the same amount of time and do just as much good for myself and the dog can come too. Yesterday we walked for 10km. I worked up a sweat but never felt like it was too hard. And I hadn’t eaten but felt absolutely fine – maybe some real good fat burning adaptation happening!

So the ‘E’ word is getting a new name: the ‘A’ word: activity. That’s right. I am going to focus on incorporating activity as many days as I can – working around family and the weather. I am not going to beat myself up about how many minutes it takes or how fast I go. I will smell the fresh air all the way.

What to do with a bad day

Although my motivation to go LCHF is for long term health benefits their is no denying that I really really want to see those scales move downwards. I had such feelings of disappointment weighing in today with a meer 200g weight loss for the week. My in between weigh ins looked so much more promising. I can’t throw in the towel now, can I? If I do I can only do harm. I just have to accept that good things take time. At least my waistline has shrunk 3 cm over the last month or so. So I’ll take that as a big tick.

It is a beautiful but chilly winter day here in Wellington. So instead of writing a long note I am going to take the dog for a walk up in the hills behind where I live. How lucky I feel to live 10 minutes from the city center and still I can head for the hills from my back door. I’m off to charge those insulin receptors……