Marks Daily Apple
Serving up health and fitness insights (daily, of course) with a side of irreverence.
11 Jul

An Open Letter to Doctors

DoctorI realized recently I’ve never written this kind of open letter. I figure if kids and Taco Bell got the benefit, maybe primary care physicians could as well. Kidding aside, there’s a genuine mismatch these days between standard medical advice and effective lifestyle practices. I think we can all do better. I’m not letting patients off the hook here either. (Maybe that’s fodder for another letter.) However, we naturally look to our physicians as our healers, as the experts, as our guides. Unfortunately, we’re not always well served by that kind of faith. I’m of course not talking about any one doctor or set of doctors. I happen to know a great many primary care doctors and other medical practitioners who are incredibly forward and critical thinking professionals. They balance their perspectives with the likes of medical logic, broad based study of existing research and close attention to real life results. While I think I’m not the only one who would have much to say to many specialists out there as well, let me specifically address primary care physicians here. They’re on the front lines – for all the good and ugly that goes with it. More than any specialist, they have the whole picture of our health (and a fair amount of our life stories to boot). It’s more their job (and billing categorization) to provide general health and lifestyle counseling to their patients. It’s with great respect that I offer these thoughts. As my readers can guess, this could easily be a tale of ninety-nine theses, but let me focus on a few central points.

The State of Weight Counseling

Can we talk about this for just a moment? Statistics vary, but generous numbers suggest two-thirds of physicians don’t counsel their patients about their weight – this at a time when approximately two-thirds (yup) of the adult population in our country is overweight or obese. I’m not pointing fingers at any specific people here, but this is disconcerting. It seems to be a downward aiming trend to boot. One study of primary care appointments, for instance, found doctors offer weight related counseling less often than they did twelve years ago. In fact, of the appointments researchers analyzed, doctors only discussed weight in a mere 6.2% of visits! In the year these statistics were gathered, 63.3% of adults were overweight or obese. Does this even make any sense? But there’s more. The same research found those with high blood pressure and/or diabetes were also less likely to receive weight counseling than they were twelve years ago – 46% and 59% less likely respectively. Any jaws dropping yet? Pardon me, but does this jive with some version of the Hippocratic Oath I don’t know about?

This utterly confounds me. Sure, I get it on an emotional level. It’s awkward. You don’t want to make anyone feel bad. But it’s your job to tell the truth – whether it’s convenient or not. It’s your job to steer folks in the right direction health-wise, to educate them in making better choices for their health. No one’s suggesting you call them at home to wake them up in the morning to encourage them to go workout. No one thinks it’s your job to write a personalized menu plan.

Nor is anyone saying you have to be a jerk about it. (Please don’t.) You really can have a conversation with a patient about his/her weight without shaming or blaming. The thing is, I’ll bet the person already knows he or she is overweight (just a wild guess). Mentioning it won’t dismantle any delusions of god-like svelteness or superhero health. I’d even venture to say they’re waiting for you to talk about it – as in, their weight and assorted related concerns/questions are already on their minds. Just be honest – and professional – and compassionate (without patronizing). Be down to earth about the real risks they face and the concrete strategies they can use. Bond as you would with any other patient. I say this because – guess what – research also shows physicians tend to bond less with overweight patients than they do with normal weight folks. As the researchers note, less engagement likely means less adherence to whatever good advice you do offer, and you might be wholly missing the patients who need you (and the care you provide) the most.

The Questioning of Conventional Wisdom and the Myth of the Magic Pill

With all of the above in mind, can we talk about the information itself? This is kind of big. In fact, it could be a book in and of itself. (I do have a few recommendations on that front….) I realize I’m not the first one to observe we’re living in a health care system that favors intense intervention and fails too often at basic prevention.

One of the things that troubles me most is the all-too-frequent, razor-focused commitment to conventional medical wisdom. I’m talking particularly about the red herrings and ridiculous claims like saturated fat is the bane of human existence, that dietary cholesterol is the culprit behind unhealthy lipid profiles, that 350-450 grams of carbohydrates are reasonable if not desirable each day, that whole grains (including GMO corn and gluten giant – wheat) are an essential part of a healthy diet. The research doesn’t line up – and never really did line up – behind these assumptions. The more our population follows these recommendations – eschewing whole foods like eggs, pastured butter, coconut oil and organic meats for the likes of whole wheat snack products and carb heavy dishes at every meal, the more unhealthy we get. Diabetes isn’t an organism that mutated. We’ve just never worked so miserably against our own physiology before in human history/pre-history.

The fact is, even studies published in some of the bigger name journals are beginning to demonstrate these truths and dismantle decades of erroneous conventional assumptions. To an extent, it’s a matter of reviewing the research, keeping up on what’s being said and shown. I know, I know. It’s difficult to impossible to stay abreast of the latest research – especially when you expand the scope beyond the most conventional sources. It’s tough for physicians to stay current on ALL the new research. It’s often fuzzy or contradictory, and much of it is still poorly conducted or biased in its funding, so even reading research can be a frustrating time expenditure. Even physicians agree that physicians regularly fall behind for various reasons. Some among them suggest more than anything “Continuing Medical Education” at the point of patient care – reports and summaries at hand of the latest thinking and evidence based findings. That sounds great. I have a more modest proposal, however.

Outside of accidents and serious genetic defects, 80-90% of conditions doctors treat are either prevented and/or cured…or at least mitigated…by lifestyle adjustments. And much of that is diet (although exercisesleep, sun, stress control all play an added role). How about just investing in some nuts and bolts education on lifestyle interventions. Ideally, a physician would get 2-3 months of focused diet/exercise/lifestyle training in med school aimed at fixing various common health issues, rather than just relieving the symptoms.

Medicine in our country (as a culture), however, focuses on the symptoms more than the source. A stent, for example, offers relief of a symptom but doesn’t address the larger health issue or seek to remedy it. Gastric bypass isn’t a fix but a procedure that circumvents the bigger source of the problem. In some extreme cases, it might be an advisable course of action in the context of a bigger plan. Most of the time, however, psychological and lifestyle means are much safer and much more effective in the long run because they can address the root causes.

When it comes to the top selling pills, the same principle holds. Statins address the manufactured symptom of high cholesterol. When we put our faith in them, we lose sight of the real processes going on in the body – the processes we need to be addressing. The same goes for PPIs and SSRIs. Respectively speaking, heartburn is generally associated with too little acid rather than too much. Taking them might alleviate some short-term discomfort, but they’re contributing to long-term digestive issues and nutritional deficiencies. Likewise, SSRIs and other mental health meds often cover up underlying therapeutic needs for stress reduction and sleep improvement as well as physical conditions like dietary allergies/sensitivities, nutritional deficits, and drug interactions. Can we all back up for a minute and reconsider the conventional teachings and protocols?

Sure, you can’t redo your med school experience. Likewise, it’s probably not in the cards to take a leisurely sabbatical during which you get to delve into the sea of research that’s been published in the last year let alone decade. Still, you can forge your own commitment to the process of learning about lifestyle interventions, about recent findings and reviews. You can open your own mind to the less popularly cited studies, to the less front and center journal selections. Find a few that suit you, that you can believe in. Dabble for a while in the outer reaches of lifestyle research. Choose some publications that interest you. Commit to following them. Likewise, choose some less formal reading to fill in the gaps. Look for some books and blogs (I know of one.) you can feel comfortable with but that nonetheless challenge your way of thinking. Good Calories, Bad Calories or Why We Get Sick, for example, would be good places to start. They’re relatively easy and decent ways to digest a lot of info at once.

And while we’re on the subject of good resources, how about giving out the names of books and articles in lieu of many of these prescriptions? The fact is, we lean heavily on the latest pharmaceuticals rather than lifestyle measures. How often do we really exhaust the lifestyle intervention possibilities before handing out the magic pills? Can we give patients more credit? Can we challenge them more effectively to change their diets and daily regimens before getting out the prescription pad? Is it asking too much to go out on a limb and ask patients to educate themselves? Suggest accessible, engaging material on the blogs and books you see fit. Can I suggest The Primal Blueprint as one possibility? Many doctors already recommend it to their patients and – no surprise – their patients have seen the same kind of incredible results that we see here on Mark’s Daily Apple every week. If you’re an interested physician, contact me here and let’s see what we can do together.

Finally, can I just say a word about the later decades of life? You see, I have some expertise here. I’m turning sixty this week – yup, 6-0. The thing is, I don’t really fit the common image of a sixty-year-old that we’re given in our culture. Call me an outlier if you will, but the fact is I direct my lifestyle to live and feel the way I do. I don’t work as hard at it as you might imagine. I don’t train for hours a day. I eat amazing food. I play hard and sleep well. I live exactly the way I outline above. Nothing particularly special. Nonetheless, I think I demonstrate (along with some friends) that with a little effort and forethought, a modest portion of commitment and unconventionality, sixty doesn’t have to mean a life of aches, pains, prescriptions, and increasing impairment. Feel free to check out some photos of me to see what I mean.

Thank you, by the way, for reading. I appreciate your taking the time and thought to consider one humble guy’s opinion. If you’re ever up for some conversation, I’d love that. That’s where good things start. In fact, let’s make it lunch – Primal style of course.

Have a good end to the week, everybody, and share your “open letter” thoughts!

You want comments? We got comments:

Imagine you’re George Clooney. Take a moment to admire your grooming and wit. Okay, now imagine someone walks up to you and asks, “What’s your name?” You say, “I’m George Clooney.” Or maybe you say, “I’m the Clooninator!” You don’t say “I’m George of George Clooney Sells Movies Blog” and you certainly don’t say, “I’m Clooney Weight Loss Plan”. So while spam is technically meat, it ain’t anywhere near Primal. Please nickname yourself something your friends would call you.

  1. It has taken me 25 yrs of evolving toward Eastern practices to put all this together. Intensive practice of Qigong is what really slammed this home. It all became instinctive and intuitive after that and all of what you wrote above about doctors became glaringly, embarrassingly (for them) obvious. The sad fact is that the letter will fall on deaf ears (except to us) because it is the very system that churns them out (American Medical Assoc) that runs the show – and they have big pharma money behind them. So why on earth would they want to set a curriculum for doctors that included understanding that would lead them AWAY from prescribing a pill for the incredible growing number of symptoms? Maybe I’m too jaded, but it doesn’t seem to me like we will see this change in our lifetimes. I know, negative outlook…and I have a GOOD doctor, too!! (naturopath)

    Suzanne wrote on July 11th, 2013
  2. As a family physician who preaches the benefits of the low carb lifestyles I know most of my peers do not. Getting beyond that, most that I know preach lifestyle changes routinely to their patients with chronic conditions and in many cases it is as effective as banging your head against the wall. Someone mentioned the “eat less exercise more” advice. I frequently do start with that in patients because it is extremely easy for patients to wrap their heads around the concept. For most of my patients getting more exercise is equivalent to getting any exercise at all. If I can’t get them to eat less of the food they like they aren’t likely to stop it all together. I frequently hear complaints of doctors being pill pushers. AT some level there is truth to that and like any field there are crooked docs out there. Move beyond that. Why do I as a physician start a patient on blood pressure medicine or cholesterol medicine? I don’t get paid per pill prescribed. In all but extreme cases I encourage lifestyle changes first and 90% of the time the patient doesn’t make the changes necessary to improve on their problem. I have to at least offer a treatment that meets the local standard of medical care. The patient doesn’t have to take my advice of course and that’s fine. There are 2 forces acting on me beyond simply doing what I think is best for my patient. First, if I am not proactive in treating diabetes, hypertension, hyperlipidemia, etc. and a patient has a bad outcome I can be sued successfully. Second, prevention and outcomes are now a tremendous driving force with private insurers and if certain quality measures aren’t met it effects me and not in a greedy way, but in a “we will drop you from our provider list” way. WHat percentage of my diabetics have a hemoglobin a1c below 7? What percentage of my hypertensives have a blood pressure below 140/90? WHat percentage of diabetics are on a statin and an ACE inhibitor? Finally, I think its only fair that some of your displeasure is directed towards dieticians and nutritionists who frequently continue to preach the traditional food pyramid.

    Swacher wrote on July 11th, 2013
    • Thank you for at least doing what you can in an imperfect system. We appreciate doctors like you.

      2Rae wrote on July 11th, 2013
    • Great point about dieticians and nutritionists. I was referred to a diabetes education class after my T2 diabetes diagnosis, and was told that I should be getting about 45 grams of carbohydrate per meal, plus three snacks a day of 15-30 grams of carbs. I know from experience that my system can’t tolerate anywhere near that level of carbohydrates. I was really shocked at both the advice received and the very perturbed attitude of the dietician when I questioned it.

      Janey wrote on July 11th, 2013
      • same experience with me, except I am T1. I had no clue how to eat when first diagnosed, so I was excited to see the nutritionist to get an idea of what was ‘good’ for me. What a joke! They told me to eat 330 carbs/day, as I was surrounded by an office full of cereal boxes and whole grains(almost like a nightmare). I tried their recommendations, and failed miserably. I am lucky common sense prevailed and I was able to educate myself, or I would be 1/2 dead by now(2 yrs later). instead, im the healthiest ive ever been even with T1D

        Shawn wrote on July 11th, 2013
    • I definitely agree that RD’s have a greater influence on dietary changes than physicians do, especially when you are in the hospital. Just today I heard a RD say “no salt, eat lots of fiber, bread is good, beans are good, rice is good”… didn’t even mention vegetables. Although, it is a bit different for our diabetic patients. At least for their education, they hear the “eat less sugar and carbs overall.”

      Erin wrote on July 11th, 2013
    • THIS. My husband is chronically ill. One doctor out of ten will ask him any lifestyle questions. The others offer pills and move on. It drives me nuts.

      I know an endocrinologist that staunchly gives every diabetes patient the advice to change their lifestyle and has in-depth talks about diet. I wish every doctor were like him, but you know what? Staucher makes a great point about the patient problem. For every patient that takes my friend’s advice to heart, there are so many more that come back after a month having made no changes, and wind up on pills or injections. They may complain, they may fuss- but they’d rather do that than give up crappy food. If I was confronted with a career-worth of that kind of feedback loop, I might be skipping straight to the pills too (not that that makes it right).

      Cat wrote on July 11th, 2013
  3. In addition to doctors not offering weight management counseling, I think a great many Americans ignore it anyway. Recent example: a coworker of mine with a prolific gut regularly wore a knee brace and complained of chronic knee and low-back pain. I asked if he’d seen a doc about his pain and he said: “Yeah, but all he ever does is tell me to lose weight.” Well, bud, maybe he’s on to something…

    Kurt wrote on July 11th, 2013
  4. my boyfriend is really overweight and his doctors NEVER tell him anything. I don’t understand it at all!

    Melissa wrote on July 11th, 2013
    • Why should anyone tell him anything, isn’t he responsible for his own health?

      Gil wrote on July 11th, 2013
  5. While I don’t disagree with most of what you have said you do realize that you are preaching to the choir, right? The people who need this information are not reading this letter. Furthermore, a large majority of pts look to their physician to hand them a magic pill to fix it all and when they don’t the pts get angry and find a new doc. It’s a “damned if you do, damned if you don’t” situation. Physicians need to step up their ability to help people prevent and reverse diseases with lifestyle choices but pts need to be accountable for their own health, you can lead a horse to water but you can’t make him drink. Also, have you noticed how many physicians are overweight? Don’t you think they must think “how can I possibly tell this pt to lose a few pounds and have them respect me when I could stand to lose a few myself.” ? it is not as simple as you make it sound. True change has got to come from the pts, the traditional medical training system and the government. We are all accountable in this battle and instead of pitting pts against physicians we need to find a common ground to work together. Just as a pt has the right to find a new doctor physicians are allowed to “fire” pts who will not take an active role in their own health. Clearly, if you are reading this you are not one of the people who needs to get the message but we all know people who do not take responsibility for their own health. Perhaps as good friends and good people we should hand them a copy of the Primal Blueprint and one to their doctor as well. What they do with the information is out of our control but we can, at least, try.

    Juli wrote on July 11th, 2013
  6. Five years ago at the age of 37 I was overweight and had a nice list of medical issues going. My doc gave me several prescriptions. I declared I wasn’t going to take them and asked if there was something else I could do. She simply said “diet and exercise” and for me to come back in 60 days. Thankfully I was also seeing an amazing chiropractor who told me to do away with wheat, corn, dairy, and sugar and begin walking as much as I could and eat as much meat and veggies as I wanted. I did exactly as the chiro said and when I returned for the doctor’s visit in 60 days I had lost 40 lbs and the health issues were gone. The doc was amazed and said that 90% of the people she has seen who vowed lifestyle changes never change. That is a sad statement. But I believe it’s because people do not know what to do. I keep pointing friends/family to this website and Primal Blueprint. These are great resources and differences are being made.

    Derek H. wrote on July 11th, 2013
  7. My understanding of the research on weight loss is that sustained weight loss (for at least five years) is generally successful for only a small percentage of people, and that weight loss in and of itself does not predict future health or longevity. Why then, would doctors make it a priority to discuss *weight* (as opposed to healthy eating or appropriate exercise) with patients? Perhaps they are paying attention to the research in this area? Seems to me like maybe doctors realize that “eat less, exercise more” doesn’t work, so they have stopped recommending it.

    I am hopeful, as are others, that primal/paleo holds the key to sustained weight loss… but it remains to be seen.

    And I sympathize with the writer’s friend, above, whose doctor is not helping with knee or back pain except to say he should lose weight. Too often, I think, doctors blame patients’ complaints on excess weight without looking for other answers. My partner (obese) suffered from foot pain for a decade and got only a referral to a podiatrist, until finally she experienced arm pain (hard to blame on weight) that got a diagnosis of rheumatoid arthritis. Subsequent x-rays showed that the RA had caused permanent damage to her feet. Would have been great to have been referred to a rheumatologist earlier… but it was obviously her weight that was the issue, right? This attitude is so pervasive–we have ourselves to blame as well as the doctor, because we did not pursue a second opinion about the foot pain. It was clearly related to her weight, in our minds as well.

    Susan wrote on July 11th, 2013
    • “I am hopeful, as are others, that primal/paleo holds the key to sustained weight loss… but it remains to be seen.”

      No, it doesn’t remain to be seen. Low carb and paleo work long term, as does calorie restriction if you’re talking strictly body fat. (Pure calorie restriction will bring on other health problems, however, if done in a mindless way.)

      The real reason why “diets” don’t work long term most often is that people won’t face the responsibility that their lifestyle has to change. They’ll do Paleo and eat potatoes and/or some Paleo friendly baked good at every meal and wonder why their not losing weight. Life has be okay when 80% of meals are meat (or animal based) and vegetables. Food can’t be the ultimate comfort or never ending party. If people don’t accept that, no “diet” will ever work.

      I’m sorry about your partner’s experience. However, what I don’t see is an explanation of how your partner was actively perusing other options rather than passively accepting the status quo. Truthfully, blaming the weight would be my first instinct, too. If your partner felt that it wasn’t too blame – that there was something else going on – then she needed to keep looking for the answers.

      Amy wrote on July 12th, 2013
  8. I have been mostly Primal for almost a year now. But despite initially losing some weight, I have gained more. According to the gov websites, I am now officially overweight. Diabetes runs in my family. So, I have been exercising until heal pain stopped that, and eating healthy and even watching my calories.

    I went for a check up with the nurse practitioner last December. Who is overweight by a 100 or more pounds. She did agree to check my thyroid levels because I am cold all the time, my hair is thinning and such. But her main thing was “My Fitness Pal.” Which yes, I am doing. She gave me some B12 supplements for depression. Thyroid levels came back “normal.”

    So I went in again this spring. Male, thin doctor this time. Who said my thyroid is fine. Hair thins every so often. You are just cold. I was actively asking for help losing the weight or finding out why I can’t loose it. And he just said that some people can’t loose it. Period. And that I am 5 pounds lighter than I was a year ago. Big whoop. I work my butt off, eat healthier, lose the grains and over a year I have all of 5 pounds to show for it. And my clothes still don’t fit and I would rather not have to worry about diabetes. Oh, and he was no use at all about my heal pain. Told me to do exercises that I am already doing and have been doing and nothing is getting better.

    So much for the help from doctors. I guess it is good they weren’t pushing pills, but I still think there is something going on with my body that it won’t take off any pounds. And my gut is thinking it is thyroid.

    CrazyCatLady wrote on July 11th, 2013
    • See if you can be checked for an autoimmune disorder; my mother-in-law has been diagnosed with Lupis (waiting to hear from the rheumatologist regarding my wife on the same note) and she struggles with constant pain (which she combats with ibuprofen on really bad days only, and no more frequently than 4 days off 4 days on to avoid allowing it to become inneffective) and with her weight as well.

      Isaac wrote on July 11th, 2013
    • Start looking for 2nd opinions. The only thing there is to be done is to keep bouncing from Doc to Doc until you can find someone who believes there’s something wrong and wants to fix it.

      Amy wrote on July 12th, 2013
    • CrazyCatLady (great name! got the cats? {wink})
      Please go educate yourself at the website Stop the Thyroid Madness — it saved my life! You cannot rely on docs to be able to learn everything known about every disease and syndrome and injury-repair and nutrition and prevention and and and and and…. No human COULD learn it all, even if it were made available, which in med school it isn’t!

      I actually feel sorry for docs — the good ones, the one who WANT to do things right — because even if they do try to help patients, they are under the watchful (evil!) eye of the local medical standards board. If they are wandering too far off the prescribed (<– ha.) path, they will have their livelihoods affected. No one is going to stick his or her neck out and damage their own family's survival on behalf of a patient whose insurance is paying them less than $25 per visit! (Medicare pays my mom's doc a whopping EIGHT DOLLARS! How can he possibly do all he can for her, AND protect his own family?!)

      The biggest systemic problem I see is that most people are too … well, shall I be kind and call them merely uneducated? Nah, let's speak the truth: they're flat-out too stupid to learn enough about medicine and illness to have a icecube's chance in a fire of knowing what is and isn't good treatment. The people on this forum (Happy Birthday Mark, and many thanks!!) are all *self-selected*: smart (and better educated), health conscious, willing and able to spend time and brain power learning what they need to know, and willing and able to speak up to docs, or find different docs, or figure out on their own what to do.

      The vast vast vast majority of folks cannot possibly do this! And as long as medicine is in the stranglehold of Big Pharma, and Big Insurance, and Big Ag — and Big Govt! — most folks will rely on the unthinking and tightly controlled 'treatments' of their local docs.

      Elenor wrote on July 12th, 2013
  9. I want to know more about this version of the Hippocratic Oath you can ‘jive’ with… :b (I guess you means jibe.)

    Nick Bowman wrote on July 11th, 2013
  10. Turned 60 a couple of months ago. This forum and Leangains have made a huge impact on my health, people cannot believe how fit and … well … lean I’ve become even though I’ve been pretty healthy and fit my whole life. As far as the medical profession goes, my wife has been in Medical Education for something like 30 years … the stories I could tell. What do you tell a physician or friend who steadfastly denies that your diet, lifestyle and discipline is why you are so fit, it’s because of good genes or luck? The best you can do is lead by example, I don’t try to evangelize at this point.

    George wrote on July 11th, 2013
  11. Mark,

    Just 3 Chapters left to go! Given the responses here, I think the book well be well-received and quite an eye-opener.

    People…your doctor does not work for you. Your doctor works for big government and all of the rent seeking NGO’s it has spawned. The tripod of big med, big agra and big pharma has produced so many seriously ill patients that even the best doctors are buried in symptom management. Patients with the mindset of MDA followers are less than a fraction of 1% of the average primary care doctor’s practice. Most will not even conceive of a lifestyle change.

    Practicing medicine is a lot more like the recent movie “World War Z” than you might believe.

    Watch the trailer from the documentary Code Black (codeblackmovie.com) to see what life is like…not just at LA County, but in ER’s all across the country.

    Doug McGuff, MD wrote on July 11th, 2013
    • Sounds like there’s no answer:

      People in general don’t want to change.
      Doctors ( people too) in general don’t want to change.

      Doctors won’t change because people won’t change.
      People won’t change because doctors won’t change.

      Next generation follows the last.

      The cycle continues….

      Mitch wrote on July 12th, 2013
    • BRAVO!!! Dr Doug!

      Just watched your YouTube speech on medicine and life at the 21 Conference — SUPERB! (Loved your list to these young men on how to stay out of the “belly of the beast”!) (I used to be medical affairs director for an ambulance corps — ER docs are my ALL-TIME fav docs!!)

      Elenor wrote on July 12th, 2013
  12. As long as enough Americans have the belief (and unfortunately there is more than enough who do) that everything I don’t like must be banned and everything I like is a human right that must be paid for by others, we’re going to have ever growing problems cascading from such a belief.

    Medicine is a product like a Mercedes or a beach ball or toothpaste. Products aren’t rights. No one is right to demand free-to-them medicine.

    Employers write off their expenses related to the perq of medical bills insurance (wrongly parroted as “health insurance” by the clueless) and thus taxpayers who can’t avoid taxes with write-offs always have paid for the insurance of the insured through employment. As long as adults involve politicians in their matters of exchanges of money and credit for products of any kind, adults are going to end up suffering the consequences.

    It’s wicked adults using politics to enrich themselves without competing and becoming efficient by corrupting enough with free-to-them stuff that screws up everything for everyone.

    Mark needs to talk more about the politics and less about the science of nutrition if he wants to get the heart of the matter of the practice of medicine.

    Jackie wrote on July 11th, 2013
    • Jackie,

      You have hit the root cause for all of the medical system’s woes. I think you will really appreciate the forthcoming Primal Rx.

      Doug McGuff, MD wrote on July 11th, 2013
  13. You are asking a lot of modern medicine, in my opinion. It’s not your doctor’s fault that the government and large agencies bought the “conventional wisdom” about losing weight, and there is a lot of money behind corn etc. The articles we all mention (and by the way I AM a doc) are swamped by the ones that parrot the CW. Diabetes and obesity are only two diseases among 2,500 that we need to keep up with.

    The vast majority of docs want to do the right thing and are in medicine primarily to be helpful. There are so many negatives to medicine (hours, demands, no family life, regulations, communicable diseases to catch) that if you don’t have the call to help people you tend to get out despite the (mostly imaginary) huge paychecks. Look up the average pay of an internist or pediatrician or family medicine doc.

    Whose responsibility is your health? I think it’s mostly yours and I am here to advise, help, prescribe, use my expertise to assist YOU. Do the primal thing or the low carb thing and come back 6 months later with results. Bring your doc a copy of The Art and Science of Low Carbohydrate Living (it’s written in doc language.)

    Yes there are some bad apples in the Doctor basket but not that many. We are human beings, struggling against mighty forces, doing our best in an overwhelming world.

    and on the alternative medicine front, there are two types of medicine: tested and untested. Many alternative approaches may work, but they are mostly untested for safety and efficacy. We have a lot of techniques to overcome the placebo effect and find out what really works; it’s a fumbling, trial and error process but if you have pneumonia, many kinds of cancer, celiac disease, or a whole slew of other problems you are a lot better off in the good old US healthcare system that you would be almost anywhere else in the world. Go ahead and use homeopathy or another alternative medical technique, just have your eyes open that there is probably no real science behind it. If there is real science, mainstream medicine will take it on sooner or later and it will no longer be “alternative.”

    Jim wrote on July 11th, 2013
  14. When my now 4 year old was an infant, he had eczema. I suspected it was a sensitivity to dairy in my diet (he was exclusively breastfeeding). I brought him to the ped to confirm it was eczema and told her of my plan to remove dairy from my diet to see if it would help. She insisted that it would be much too difficult to meet my nutritional needs without dairy and gave my a prescription for a steroid cream for my son. So, even though I was the one offering to make a change to treat the CAUSE of his symptoms, she tried to talk me out of it in favor of slathering my newborn in steroids everyday to mask his symptoms. She’s a nice lady and I’m sure her attitude is a result of dealing with other people who are not willing to make changes, but it’s hard to be met with so much resistance. I’ve learned to educate myself for most things and save the medical professionals for things like infections that don’t improve with our own treatment and sewing body parts back on. :)

    Claire wrote on July 11th, 2013
    • And I should add that my son’s skin cleared up with my dietary changes, which I stuck with for nearly a year. After that point we tried slowly introducing dairy back to my diet and he did well. We waited longer to give it directly to him, but now he eats it just fine. In my primal/paleo research I’ve come to think I likely had/have a leaky gut that was the underlying cause of his troubles.

      Claire wrote on July 11th, 2013
  15. I guess I’m lucky. When I told my doc I was switching to a paleo/primal diet and lifting more instead of doing cardio, she just said “I keep hearing about that. keep me posted on how that works”. She seems quite open to the whole thing and told me her approach to diet is to let patients experiment on themselves because she may have an MD, but different people do better on certain types of diets and that isn’t her area of expertise. All she could tell me is that she agreed that I needed to lose some excess weight.

    His Dudeness wrote on July 11th, 2013
  16. I am a primary care physician (GP) in the UK – things are a bit different here compared with the US healthcare system! Firstly, you register with your local practice and all your care is needs-based and free, you don’t ‘employ’ your doctor and you don’t pay for consultations, referrals, investigations, and in my area (Scotland) prescriptions are free too. The GP contract with the government is based on money received for each patient (a per capita allowance) and an allocation of money based on the Quality and Outcomes Framework (QOF) which is a series of ever-more-complicated clinical, social and administrative hoops through which each practice has to jump in order to achieve a high enough score to make enough money to exist and provide a service. There are bits and pieces of money to be gained from offering other services and meeting prescribing targets (i.e. using generic medications rather than branding etc) but the main stuff comes from QOF. Obviously a lot of the money comes from taxes but it’s not guaranteed, we have to work very hard to get maximal points so we can provide the best care for our patients.

    I work in a relatively deprived area where a very large proportion of my patients are on benefits, live in council houses and do not pay taxes. There is a pretty high level of obesity, morbidity, depression and drug and alcohol problems. I’m sure I’ll be unpopular for saying this, but I suspect the vast majority of MDA readers are fairly middle class, reasonably affluent and pretty well educated, and I do feel that a reasonable level of education is necessary to understand a lot of the science behind a primal diet – a lot of my patients left school at 15 or 16 and are not university educated. I’m not saying that not having a higher level of education precludes people from following a primal diet, but it definitely helps.

    When I am asked about dietary issues, which I sometimes am but I have to say not all that often, most of my obese patients don’t admit to eating more than lettuce and soup and are completely resistant to any suggestions about altering their diet. I feel a lot of pressure to advise a CW diet and medication because firstly my patients just don’t want to know about ways to change how they eat – they are generally very resistant to any suggestions I have to make (what with the I-only-eat-lettuce denial and all) so the only way to minimize the damage from their medical conditions is to prescribe, and secondly our whole healthcare system is funded based on meeting targets of CW prescribing. So we’re over a barrel a bit.

    I try to hit a middle ground of advising people eat a diet of minimally processed foods, based on fruit and vegetables and whatever they can eat that is as close to its natural state as possible, and hope for the best – as with any profession, I can offer advice but I can’t force people to take it.

    There seems to be a lot of anger and animosity directed at doctors throughout the comments – it’s a shame so many people seem to have had bad experiences, and I’m sorry that’s been the case, but I have to insist that the vast majority of us try to be as caring and empathetic as possible, keep up with the latest research and do the very best for our patients. There also seem to be a lot of ‘I know better than my doctor’ feelings – while I acknowledge that patients are experts in their symptoms and their experiences, they don’t always know or understand what’s best for them, they frequently over- or underestimate the severity of their conditions, and they do need advice, and I guess that’s the point of me and my 12 years of training – to identify worrying symptoms and investigate and treat them accordingly, to educate about the things to look out for, to reassure when the ailment is not serious and to empower the patient to live the best life they can.

    Sorry this was a long post…I’ll stop now!

    Jo wrote on July 11th, 2013
  17. The question that the government, media, corporations, professionals, academics, and the general public are afraid to ask:

    How healthy is the average health professional?

    whistler wrote on July 11th, 2013
    • Important question to a point I guess, but surely irrelevant in a lot of situations – would you refuse treatment from a doctor who you knew had a lifestyle-related medical condition if they were treating you for your MI/trauma/surgical problem? Would you refuse treatment from a dentist because they had a filling? Does that one thing negate all their knowledge and experience?

      Jo wrote on July 11th, 2013
      • I won’t choose an overweight family physician.

        whistler wrote on July 11th, 2013
  18. I don’t think that we should castigate the medical profession. A very close relative struggles with diabetes and obesity. She sees a doctor for her insulin and he spoke to her about the fact that in 90 percent of his patients, the root cause is emotional and psychological (in addition to diet and exercise). He also said that with high patient load he does not have time to spend unpacking all of that with them but offered it as a consideration.

    Like most people with obesity, she is aware of all of that and as Jo mentioned making lifestyle changes is very challenging.

    As a medical professional, they are obliged to reduce the harm and that means prescribing medications. Clearly, most, if not all doctors, know that is not the core but this is what they can provide.

    For our part, we need to support and care for people in positive health directions and MDA is a good place to start.

    George wrote on July 11th, 2013
  19. In order to thrive and survive in the latter years of our lives we must REFUSE to do what most doctors want us to do … doctors might actually be doing far more harm than good over the last few years. There is NO CHANCE of them listening to you/us rather than the drug-company reps. What we need are strategies allowing us to convince the doctors we’re doing what they suggest when we’re doing the opposite. Leave them to it. There is no MONEY in our way, for them.

    Ulfric douglas wrote on July 11th, 2013
  20. I think the reason so few doctors actually take the time to talk about weight management or losing weight is because they have the same problems as the rest of the general population. I know I wouldn’t take weight loss or exercise “tips” from most doctors I’ve been to. Many…not all, are the just as out of shape or worse than their patients.

    Paul-E-C wrote on July 11th, 2013
  21. Let me start by saying I am definitely on Mark’s side. However, as a soon-to-be college grad who is currently applying to medical school, I think there is another side to this. I can’t think of anyone who becomes a doctor for the money. The money for primary care, geriatrics, pediatrics, and all the others we need more of just isn’t that great. For example, I want to do primary care. In texas, the average PCP makes about $120,000 a year, but also acquires 170,000 in debt. How are we supposed to pay this off? Doctors take about a half a semester of nutrition in medical school. This should be expanded. Also, doctors should have more freedom and electives to be able to explore alternative and nutritive therapies. If no one is telling doctors this, how can they tell you? I shadow several doctors across many fields, and I am constantly disgusted by patients reactions when the GOOD and SMART doctors tell them…hey, you can’t eat bread and processed food at every meal and expect to feel good. So many patients say, isn’t there a pill I can take? Talking to people about nutrition is worse than talking to them about religion or politics. What we need is for government subsidies of the corn that makes high fructose corn syrup to end. If LOBBYISTS for big food companies weren’t allowed, maybe our representatives could make decisions based on FACT instead. There is a study for anything you want to prove, so maybe more long term studies are in order. I guess I’m just saying this is a much larger problem. Even if doctors are more educated, how do we make people LISTEN to them?? Drug non-compliance is already a huge issue. Lets work on changing the big picture, and the little stuff will work itself out :)

    Kelly MC wrote on July 11th, 2013
    • Then why are you going to become an MD if you want to do primary care? The economics are hitting you over the head: you’re going to under up over-trained. Med school only makes sense for specialists (and not even for some of them) and surgeons.

      Become either a nurse practitioner or PA if you’re serious about primary care. Less training (and more appropriate), better hours, cheaper, and less overall stress.

      The other thing to remember is that healthy people avoid medical care. How often do you suppose Mark ends up in an MD’s office? I go for my annual checkup every decade or so. There’s a selection bias in the people you’re seeing because they want “magical pills”. I wouldn’t even take the older kids except that outside orgs insist a Doc give them a clean bill of health.

      Amy wrote on July 12th, 2013
      • Great advice Mark. I have a daughter who is a PA specializing in oncology care and I would trust her advice over most ‘specialists’ in a lot of areas. I see a PA and my wife sees an APN. I have no ‘quality of care’ issues with either of them. Plus, the PA route can have someone on the job, helping people, in 4-6 years less time.

        Don in Arkansas wrote on July 17th, 2013
  22. Hi Mark! Just realized we are the same age this year.

    HAPPY BIRTHDAY!!

    Great letter! I always have to do (mental) battle with myself before seeing a new primary care doc. I have seen many in my life and never have any of them been (apparently) able or willing to work with me about thinking outside the conventional wisdom box. I’ve had much better luck with internists for some reason.
    Thanks for such a great letter, can’t wait to see what the response is.
    ShaSha

    ShaSha wrote on July 11th, 2013
  23. I’m an MD family doctor in Des Moines, IA and come from a family that farms using conventional methods. I recommend to my patients, multiple times every day, to get Primal. I’ve written http://www.marksdailyapple.com down nearly a thousand times. I’ve recommend books like The Primal Blueprint, The Truth Behind Statins almost every day. I took 2 people off statin medicines today, and have probably taken 6 people off statins already this week. It is my intention to always give people the tools they need to make lifestyle medications and to always inform them about the negative effects of the pills they are taking. I think 75% of my patients are overweight and I give my weight loss talk probably 10 times a day. Some people are willing to make changes, unfortunately way more people aren’t willing to and just want the pill. I can’t tell you how many times I’ve literally argued with patients about the fact they don’t need an antibiotic. I’m gearing up to open my own medical clinic in the future where I can attract the type of patient that is looking to do what it takes to get healthy and doesn’t just want to take pills. It is easy to rag on the doctors, but doctors in the clinical role rely heavily on the standard recommendations put forth by societies like the AHA or ADA. If the “experts” who supposedly have gone over all the research with a fine toothed comb say that diabetics should be on a statin to get their LDL below 100, it takes some cajones to advise patients otherwise. Luckily, some doctors like me do think for themselves and can see thru the BS.

    Tim wrote on July 11th, 2013
  24. Mark,

    Thanks for the letter. The problem is the system… not the doctors. I am fighting the battle though don’t worry!

    Spencer Nadolsky DO wrote on July 11th, 2013
    • Thank you. ;-)

      Leah wrote on July 11th, 2013
  25. Don’t blame it all on the doctors….

    To understand where they’re coming from you need to understand where/how they’re getting paid. They don’t get paid for the time, they get paid per the visit thanks in part to how insurance reimburses them. So yes, unfortunately, they don’t discuss weight. But that’s not the only issue. It’s multifactorial. What if a doctor is seeing a patient for diabetes and the patient is hispanic and the doctor tells him he can’t eat beans or enchiladas as much? Or the patient is Vietnamese and the patient needs to cut out rice big time. There are so many cultural barriers to this that makes getting weight/nutritional education at a doctors office a multi-hour task.

    There needs to be a shift in healthcare to preventative medicine to include others such as nurses to play a part in healthcare education. The sooner the insurance companies get on board, the sooner we’ll have better education.

    Matt wrote on July 11th, 2013
  26. To reiterate what Spencer said, the system does not encourage good lifestyle therapy. All doctors and our professional societies emphasize lifestyle changes as first line for all that is being discussed. For more focus, patients should see Obesity physicians, endocrinologists, cardiologists, etc who have more education in those matters. So help the movement to improve the system instead of trying to blame the physicians. We are all on the same team!

  27. Dear Mark,

    I love you! I’ve been fighting with doctors ever since I was pregnant and refused to drink a bottle of sugar water for a gestational diabetes test. (Yes, that would do my baby so much good right?). I took my son to the Dr. recently and was told that he was overweight (his BMI was 0.3 over the limit for normal weight, hes a healthy not-fat 10 year old) and the pediatrician told him he: did not eat enough grains (he is gluten free and doesn’t really like bread) and to drink low-fat milk!!I told her we do the “modified paleo thing” and she told me that “that’s why he’s overweight” and ….wait for it…..SHE’s fat! I’m a size 2 so I had to bit my lip to keep from being rude. I can’t tell you the amount of obese children who are being raised by poor people following bad advice from Drs. Its nuts. You’re awesome, happy birthday. I love my primal lifestyle!

    Mia

    Mia wrote on July 11th, 2013
  28. I LOVE my Naturopath. She gives out fabulous nutritional advise and lifestyle guidance first, spends time with you to listen and is personally available, She’ll recommend and run tests and prescribe herbs or pills when needed. I pay out of pocket because my emyployer-provided health insurance won’t cover it, which is a shame considering how much she has done for me and how much money it has saved them.

    AbiTOKO wrote on July 11th, 2013
  29. My doctor used to bring up my weight and cholesterol often, but he was confused by what I presented to him. I was slightly overweight with fairly high cholesterol but I was 10x more active than most people he had ever met and a vegetarian who hadn’t set foot in a fast-food restaurant in a decade. All he could say was maybe I just drank too many glasses of wine and had hereditary high cholesterol. He never prescribed anything, thankfully.

    I found primal and have lost a little weight but I am a muscular woman thanks to all the lifting I do and will never fit in the BMI charts. Even though I think I can wear a bikini without complete mortification nowadays, I probably weigh well over the limit for ideal weight. I can only imagine the ridiculous conversation if my weight “problem” was brought up. I’d have to pull down my pants to flex my squat-sculpted thigh muscles or deadlift the patient table or something.

    Diane wrote on July 11th, 2013
  30. Well, one thing that is very sure with this article is that you have raised is that a number of very controversial issues have been hinted at.

    One, you talked of the mismatch between standard medical advice and simple lifestyle practices.

    What I will say is that it gets to a point when the lines become really blurred, and making clear distinctions between the two is all but impossible.

    You also stated that a majority of doctors do not really advice their patients, especially the adults patients on issues relating to their weight.

    I would have countered that but I see that you backed up the assertion with the relevant statistics.

    Allan wrote on July 11th, 2013
  31. It doesn’t have to be like this. Primary care physcians should stop taking insurance. They need to quit working for hospital groups, and go back into business for themselves. Read up on Direct Primary Care. We need to kick the insurance company bureaucrats out of the exam room. It’s suppose to be the doctor-patient relationship, not the doctor-insurance company-patient relationship. Most people should have a catastrophic care plan and cover their primary care themselves.

    Matthew Hitchcock wrote on July 11th, 2013
  32. Happy 60th Mark! You’ve helped scores of people turn their life around (like me!) without ever meeting them. Your blog is worth its weight in gold. Still thinking about starting up a podcast? If so, I am there.

    Chris wrote on July 11th, 2013
  33. bravo…

    Ferdie wrote on July 11th, 2013
  34. Happy Birthday, Mark! It’s about time for you to adopt the “Primal Calendar” in order to calculate your metabolic age. Take your age and subtract it from 100. The result is your “Primal Age”. In my case the result is 37. Bonus….next year I will be another year younger!

    skeedaddy wrote on July 11th, 2013
  35. 3 years ago I started getting kidney stones.
    I asked my urologist how I could prevent them all he could tell me was drink lots of water.
    First year after my first stone I drank so much water I thought I would have to strap a bag to my leg if I wanted to go anywhere!
    I had two attacks that same year even with all the water drinking.
    At the same time I was getting bad leg cramps at night and found I was low in magnesium.As soon as I started taking the magnesium,the cramps went away.I started reading about magnesium more and found some studies where magnesium was the cure for kidney stones.
    2 years later I am still stone free.

    Peter C. wrote on July 11th, 2013
  36. After struggling with my weight for since 8th grade (I’d loose, be healthy, then bad times would come along with the weight…only with more). After 33 years of struggle with undiagnosed depression and anxiety, I met with a counselor, which led to prescriptions, which led to weight fluctuations (again) and horrible side effects. I now weigh over 200lbs and I am so ashamed of my weight. I’ve lost 20 lbs. just because I got off the last psych med and I’ll never touch the stuff again. But when I was injured at work I was prescribed different pain killers and muscle relaxers to deal with the sciatica flare-ups…which led to other digestion and emotional effects that have started to put the weight back on again! Not to mention loss of any motivation or energy. (Not taking them anymore after realizing that was happening)

    My point in sharing this is there is a lot more to being overweight than diet counseling from a doctor can fix. If modern medicine doesn’t start to consider the whole person and look closer at the side effects of their treatments on people, then a lot of doctors are going to get frustrated at their patients and patients are going to see themselves as failures.

    I realize you want to help overweight people realize a healthy lifestyle. I wouldn’t be here if I didn’t believe you have very valuable information and encouragement to get where I want to be someday. I just hope you realize that there’s often more to the story than a lifestyle choice.

    Thank you for your website!

    Candice wrote on July 11th, 2013
  37. Maybe you need to catch up on Mark’s view of homeopathy…

    http://www.marksdailyapple.com/homeopathy/#axzz2YnAue9q0

    Hale wrote on July 11th, 2013
  38. though I agree with most of the rhetoric here I can disagree with one thing. I have never seen a placebo cure cancer and I’m a fourth year med student. On the argument that weight is not addressed in a health maintenance check by your primary care is just ludicrous it’s often a topic told to many patients otherwise we would not track weights and bmi.

    Med student wrote on July 11th, 2013
  39. This is all very true unfortunately. As a medical student, it frustrates me when we are tested on the drug regimes for certain lifestyle illness’. Drilled and drilled and drilled we are, like good abiding little children. What a load of nonsense! The “nutrition” we do learn is taught by chubby dumb nutritionists who come in and preach the virtues of the processed food industries food pyramid. It’s all a load of crap, and just makes you sick when you think how simple it should be.

    I’ve forwarded this on to my mum who has been a GP for the last 30 odd years. She deserves a medal. She has seen the results of, and has been totally in line with the Paleo lifestyle for some years. Many of her patient’s have vouched that she has changed their lives for it. Like you Mark, she and I too are totally disillusioned by the ‘quick fix with a magic pill’ emphasis in medicine today.

    Alice wrote on July 11th, 2013
  40. Mark, could you write an article on how to find a doctor? I see the network websites, but none of the live nearby. What kind of questions should I be asking? How can I tell they are going to be easy to work with?

    Toaster for sale! wrote on July 11th, 2013

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