Patient education page

[NaLi]

Hello,

new here. Not sure if this is the right forum, and it's a bit of a long read, but bear with me.

Background: I am an ER doc and changed to a paleo diet to cope with shift work. More often than not, I don't get a chance to eat during my 10 hour shift. I used to do the 2 am junk food run on the way home from work, eat in my car, and feel terrible. Now, my shifts at work are planned intermittent fasts and going paleo has helped the quality of my sleep and work a lot.

Since afew months I have started incorporating nutrition advice to my patients. Not surprisingly, the vast majority of my patients are not in optimal health: diabetes, overweight, hypertensive, smokers. Most are not particularly motivated to change their lifestyle, or are in denial ("I only ever eat fish and vegetables, doc" ... you'd be surprised how many - morbidly obese - people tell me this). Most patients will ask me what supplements I recommend for weight loss. The general philosophy on health in this Western society seems to be that the solution for all health problems comes in the shape of a pill, and this is what most patients request. My impression is that most people frequenting this forum are not representative of the general population that sees their doctor for health issues.

Occasionally, though, I do see a patient who is interested and motivated in nutrition and lifestyle changes. I spend some time talking about the basic principles of paleo. At the moment, I think I am the only doctor in the department who advocates paleo, or who gives nutrition advice at all (it's an emergency department - poor diet is not an emergency).

I'd like to make it a more formal Patient Education process, supplemented with written documentation and referrals to websites and other sources of information. However, I am a little concerned trying to roll it out on a larger scale, because of a lot of the rhetoric of the paleo diet. By rhetoric, I mean the argument that "our paleolithic ancestors didn't eat this, therefore we shouldn't either" or worse "Grok didn't eat this". It makes me cringe. My feeling is that this has done the dietary recommendations more harm than good. The evidence of what life and health were like ten thousand years ago, is highly debatable and not that relevant to the world we live in today. It simply is not an solid argument and too easy to refute and ridicule (our ancestors also did not have clothes, cars, computers etc and what was the under five mortality rate at that time?). I sometimes recommend this website, but add a qualifier that the name paleo/primal makes no sense and people should just ignore this, try out the dietary recommendations instead and see how they feel. I am also hesitant to convince my colleagues of the benefits of a lifestyle, when the scientific evidence is peppered with such debatable historical and irrelevant arguments.

So, for now, I'll stay semi-closeted. I am interested in hearing your thoughts on this. Also, if there are any paleo friendly doctors out there with experience on formalizing patient education, that would be great.

[Neckhammer]

I can say that as an ER doc you probably are going to face more challenges rolling this out that many others. Heck, I'm a chiropractor and the people who come to my office are suppose to be the demographics more interested in holistic treatment or nutrition, but I haven't really found that to be true either. Everyone is basing their decisions on putting out fires rather than preventing them....Anyway you may consider reaching out to Doug McGuff. He is an ER doctor also and the author of Body by Science. He is also a big proponent of the paleo approach and has several on youtube Paleo Diet | Doug McGuff MD | Biochemistry of the Paleo Diet and Strength Training - YouTube. Personally, I have Mark's book, Robb Wolf's, and a few others in the office that I loan out regularly to those who seem genuinely interested in making significant lifestyle changes. I also printed out and made copies of the old Kurt Harris ten steps type program Archevore - Archevore Diet. I just feel that if someone is really going to make a change then they have to go "all in" and really own the information for themselves. The ICA council on wellness (chiropractic) has a great program, but it really is a full years worth of follow ups and questionnaires for the patients to determine significant changes and adherence (most studies indicate new habits need to be maintained for a year to be conducive to real change). I don't actually do this program...I stick with lending out books and provide the one sheet explanation, but this is the best I've seen from my profession. Again, not something your likely to be looking for in an ER department. Either way great to hear that your looking into it! I wish you the best!

[sarasue624]

Hey doc,

you have a split audience - your patients, for many of whom the "Grok didn't eat this" logic makes perfect sense - and yourself and other medical professionals for whom such non-scientific perspectives cause cringing.

The truth is that people remember sound bites. "Grok didn't eat this" is a much easier shorthand way of framing the lifestyle than understanding the chemical and physical interactions of particular nutrients. Grok is in the literature because he works for the lay audience. If you're going to remove him from your recommendations you'll need to come up with another, all-encompassing, shorthand soundbite to replace him with.

If I were you, I'd start with the idea of "non-processed food eating" or "food with only 1-3 ingredients." I expect just that would help most of your patients. Then you're also not taking sides in the low fat/low carb debate.

Of course, you'll also have to deal with patients like me who know how to eat primal/paleo, have done it enough to know we feel better when eating this way, and still persist in eating poorly most of the time. Don't make the mistake of assuming a lack of knowledge is the problem! Adherence is a problem.

[EyeOfRound]

I'm impressed the ER contingent is willing to listen to this, considering just last week I saw someone who had advanced COPD, lost 1 leg and was about to lose another one to peripheral artery disease, and was STILL SMOKING. Reasoning was "it's too stressful not to smoke." Evidently, NOT HAVING LEGS is somehow less stressful.

[PrimalJayne]

Hi NaLi

Good on you!! I say keep on trying with the patients. I'm a Nurse on a busy surgical ward and I honestly cringe when I look at some of the meals that are served up to patients. The one that sticks out was a Diabetic Diet offering of Macaroni Cheese served with a large portion of mashed potatoes. No. I am not joking. There was not a vegie in sight and could someone please explain how that is carbohydrate controlled?? Beats me - it looked sad.

As I'm so new to this new lifestyle I don't feel that I know enough about the science behind it and need to do way more reading before I would recommend this to others.

But please don't give up - read more, explore the web, gather some evidence for yourself and go for it!! I plan to do the same.

[RitaRose]

How much of an issue is this going to be for your hospital? I know last time I was in, the ER doc said I needed more fiber, like whole grains, but he also wasn't surprised when I said I didn't eat grains. I'm not sure if he was just teling me what he was supposed to or really thought fiber was going to help me out (I'm much better off without it).

I really think it's going to be tough. Unless people can see that it's something directly related to food, I don't see them getting much out of the visit other than "I'm still alive" and maybe "I need to be healthier", then turning around and doing it the old CW way. It might be too much to mentally digest at the time.

It's going to be a lot easier if it's obviously something intestinal/obesity related. I really like the Gutsense.org website. Very helpful in my case. I hope you have some success!

[Damiana]

I also have a problem with the rhetoric of going paleo/primal. If asked to explain my diet, I'm sure as heck going to feel silly trying to explain who Grok is and what he ate, much less trying to fight off the critics of the lifestyle beyond those that argue that one cannot live a true Paleolithic lifestyle these days. It's true, if we were striving to live as our ancestors do, we'd all be foraging for wild game and eating insects and whatever we could get our (literally) grubby paws on. Therefore I just tell people that I eat little to no processed foods, a lot of vegetables, meats, and natural fats because dietary fats are not the sole cause of atherosclerosis. It's a hard sell, and I'm not even a doctor trying to convince people. You have my respect for having an open mind and I wish you luck with convincing your patients and fellow doctors.

[Pamsc]

When I first went low carb I so wanted to get diabetes educators to understand that there was an alternative approach. But then I learned that they are required to teach the American Diabetes Association approach in order to get insurance reimbursement. Since it isn't your job to teach nutrition you can probably get away with saying whatever you want, but the hospital in general is stuck with best practices. My experience is to take the approach: "This has worked really well for me--you might want to explore it." Yes, you would like your authority to come from science rather than personal experience, but you aren't going to be able to convince outsiders that the weight of scientific evidence is in your favor. And I think recognition that different things work for different people will both improve medicine and is an effective argument to get people away from conventional wisdom.

[Knifegill]

I'm a lab assistant and I meet people all the time who are clearly reaching out for help. And the best I can do is tell them what I did personally, and to talk to their doctor (SNAP) about any changes they plan on making. I just hate knowing that the conversation they'll have with their doctor will probably end with "eat more wheat" and I'll be nowhere around to slap a physician.

[EyeOfRound]

When I first went low carb I so wanted to get diabetes educators to understand that there was an alternative approach. But then I learned that they are required to teach the American Diabetes Association approach in order to get insurance reimbursement. Since it isn't your job to teach nutrition you can probably get away with saying whatever you want, but the hospital in general is stuck with best practices.

Yup! I guess a compromise would be saying "This is what I'm required to teach you according to such-and-such guidelines (insert spiel about whole grains and low-fat), but my personal opinion based on such-and-such research is that a high-fat, high-protein diet free of processed foods may be a better choice. However, guidelines can take decades to change, so in the meantime, you can read these-and-these resources and decide for yourself."