Talking diet with your doctor
I’m always amazed at the number of comments this blog gets from readers who are worried about discussing health issues with their doctors. Most are a variant of this composite of many comments I’ve read:
I’ve been on a low-carb diet, and I’m afraid my cholesterol is going to be up a little and my doctor will want to put me on a statin. How can I show him/her that I’m really on the right track?
Another common variant:
I want to go on a low-carb diet, but I’m sure my doctor will be against it. What should I tell him/her?
I’m always puzzled by these comments. I’ve been on the other side of countless doctor-patient conversations, so I know how doctors (at least this one) think. And I’ve been in countless doctor-doctor conversations, so I know how doctors think about their patients. While there are a few old, crusty it’s-my-way-or-the-highway types still out there, it’s been my experience that most doctors are willing to work with their patients.
The important thing to remember is that you – not your doctor – are the one ultimately in control of your health. I can guarantee you that if you have been reading this blog for any length of time or have roamed through and read in the archives, you are much more nutritionally savvy than the vast majority of doctors out there. The old saw is absolutely true: doctors get very, very little nutritional training in medical school and even less in their post-graduate training. In my own case, I got exactly one lecture on nutrition in medical school, and that was from a registered dietitian, which should tell you all you need to know. And it wasn’t even a lecture on nutrition; it was a lecture on how to write orders for various diets for hospitalized patients.
Virtually all of my nutritional knowledge was self taught. And most doctors don’t bother – I didn’t bother for the first five years of my practice. I said all the same ignorant things and gave the same terrible advice that most doctors still give today. Had statins been available then, I would have been giving them to everyone who walked through the door with elevated cholesterol levels. I would have been telling patients that these drugs were a gift from the gods and that the evidence was conclusive that they worked. And I would have been dead wrong.
Which brings me back to my first point. You are in control of your own health. And you likely know at least as much about nutrition as your doctor does. So, why worry about what he/she thinks or says about nutritional issues? Besides, he/she is working for you, not the other way around.
But, it’s pretty apparent that many people are concerned about this issue, so let me tell you how to go about discussing diet with your doctor.
First, don’t bring a copy of Protein Power or some other diet book in and tell your doc to read it. Just seeing a diet book makes the ‘fad diet’ warnings go off in a doctor’s head. Plus, your doctor will never read it, so you’ll be wasting a perfectly good book. And don’t bring in magazine articles or copies of posts from this blog because they will scream the same ‘fad diet’ message.
Instead, bring in a short medical article. I’m going to give you one you can print and use. I’ll describe it a little later. I’m going to provide you with a published case report, which is about all most physicians can read. It will probably surprise you to learn that most practicing physicians don’t know how to and virtually never do search the medical literature. (Academic physicians do know how to use the medical literature, but for the most part, don’t know how to take care of patients.) So, if you bring in a long New England Journal of Medicine article, it will never get read. A case report is what you want.
Then tell your physician that you’ve had friends or family that have been successful on this diet and that you are planning on giving it a short-term try. And that you want your physician to monitor you.
If it’s a statin issue, you can do the Nancy Reagan and just say no. Or you can say that you’ve done so well on your diet in other respects that you want to give it a little more time. Or you can leave with the prescription and simply not get it filled if you don’t want to take the drug. If you continue on the diet, your cholesterol will probably fall before your next visit anyway, and you can say that you decided to give your diet a little more time to work. (If you want a lot of information to really discuss statins with your doctor, simply enter ‘statin’ or ‘statins’ in the search function of this blog and you’ll find plenty.)
I’ve got an interesting (and short) case report in my files that was published in the journal Aviation, Space, and Environmental Medicine, the official journal of the Aerospace Medical Society and sort of the unofficial NASA journal. Here is a downloadable pdf file of this paper suitable for presentation to your physician.pp-diet-in-an-aviator-av-spc-envir-med-2001
The paper presents the case of a 54-year-old army helicopter pilot with high-blood pressure (controlled with medications), obesity, diabetes, and elevated cholesterol. When he presented for his annual flight physical, his blood sugar problems had worsened from glucose intolerance to diabetic proportions, and he was removed from flying status. This pilot decided to go on Protein Power, and his flight physicians monitored him. Here is the brief history of his dietary journey:
After documenting normal renal function, that patient adopted a recovery plan of exercise and a high-protein diet. His exercise consisted of walking 2 mi 3-4 times per week. He kept his daily carbohydrate intake below 30 gms, but otherwise did not count calories. In a 3-mo period of time, he lost 35 lbs. His cholesterol was lowered to 204, his triglycerides [which had been greater than 500] lowered to 238, his fasting blood sugar lowered to 100, a 2-h post glucose load lowered to 122, and he discontinued his hypertension medication and remained normotensive. The patient has continued the high-protein, low-carbohydrate diet with a gradual increase in the amount of calories from carbohydrates and for 1 yr has maintained quarterly hemoglobin A1C in the low 5 range. He reports feeling better than he has in many years and has successfully returned to flying.
The article goes on to describe specifically the Protein Power diet in a comprehensive way. It’s a much better short description of our own diet than one I could have probably written. The paper then confirms the data we presented on the superiority of the low-carb approach with one other paper (there were more out there at the time, so I don’t know why they quit with just this one) that you can read in full text or download in pdf here.
This is the kind of case report you can simply give your physician and tell him/her that you are going to try this diet. Your doc probably will read this one since it’s only two pages and reads like one doc writing to another, which is what a case report really is.
When you do go on the diet, your results should speak for themselves. Your physician will then be as surprised as the docs were who wrote this case report. Why do I know they were surprised? Because you only write case reports on unusual or surprising findings. You’ll never see a case report that says the patient came in with strep throat, we treated him with antibiotics, and he got well. That’s an everyday occurrence. It’s only the stuff that makes you sit up and take notice that inspires a written case report. Your doc will be pleasantly surprised at your outcome just as these doctors were surprised at this aviator’s outcome.
Then maybe, just maybe, your doctor will want to know more. And then you can give him or her the book.
I just wanted to post some info regarding Brian’s post about high cholesterol and getting private health insurance. I went through this exact issue last year, and posted it on this blog.
I had been on low carb for well over a year at the time. The insurance company took a blood sample and found total cholesterol of 221, HDL of 112, and LDL of 98.
They rejected me for “high” cholesterol of 221, regardless of such optimal HDL and LDL numbers. I thought it was a futile effort, but I wrote them a letter explaining that high HDL is good and low LDL is good, and total cholesterol doesn’t matter. I sent them a link to the AHA’s website showing these were both optimal numbers.
Lo and behold they wrote back and said I was right! I got the policy at a low rate. Maybe they’re finally learning what the numbers mean.
Congratulations! I guess there are still a few people out there who aren’t brain dead on this issue.
LDL = low density lipoprotien (LDL is NOT cholesterol. LDL is a lipoprotein PARTICLE)
LDL-C = the amount of cholesterol inside LDL particles (usually calculated, can be direct)
LDL-P = the number (or concentration) of LDL particles
Cholesterol is an oil and blood is water-based. Oil and water do not mix, so for cholesterol to be transported in the blood stream it must be carried inside lipoprotein particles. It is useful to think of the cholesterol as “passengers” and the lipoprotein particles as “vehicles.”
If I have an LDL-C of 100 mg/dL (100 passengers), how many vehicles (LDL particles) do I have? I could have 10 vehicles with 10 people each, 20 vehicles with 5 people each, 50 vehicles with 2 people each, 100 vehicles with 1 person each, etc. I have NO IDEA what my LDL-P is just because I know my LDL-C.
This simple analogy is biologically accurate because atherosclerosis works just like a traffic jam — it is a gradient driven process. Just as it is the number of cars on the road that causes a traffic jam, it is the number of LDL particles in circulation that drives the disease process — NOT the amount of cholesterol the particles contain inside them.
Dr. Eades says he is using a “direct LDL test” rather than a calculation, but all this test does is directly measure cholesterol “passengers.” If you want to predict the risk of a traffic jam, wouldn’t you rather know the number of VEHICLES instead of just a more accurate measurement of the number of passengers?
Furthermore, LDL particle size is greatly misunderstood by many people. Lots of folks think that small LDL particles are terribly bad, and that large “fluffy” particles are much safer. As a group, patients with diabetes tend to have a HIGH NUMBER of SMALL particles, and they have a lot of risk, but guess what? As a group, people with Familial Hypercholesterolemia tend to have a HIGH NUMBER of LARGE particles, and they, too, have a lot of risk. I don’t care if your cholesterol is being transported in Mazda Miatas or Chevy Suburbans — if you have too many vehicles on the road you’re at risk of a traffic jam (cardiovascular disease). It’s particle NUMBER that is driving this process — particle size just helps influence therapeutic decision-making.
The American Diabetes Association and the American College of Cardiology issued new Lipoprotein Management recommendations in April (see Diabetes Care and the Journal of the American College of Cardiology April editions). In a nutshell, the ADA & ACC are now recommending that high risk patients be treated to both cholesterol AND particle number goals of therapy, and the two means of measuring particle number that the ADA/ACC recognize are a test called apoB and LDL-P by NMR (the NMR LipoProfile test).
Note: Atherotech (VAP) is now reported a calculated apoB. The ADA/ACC recommendation is for a MEASURED apoB utlizing standardized assays. VAP’s apoB calculation has NOT been recognized and some laboratories will not even report this value because it has not been scientifically vetted. In other words, the two choices are a standardized, MEASURED apoB, or the NMR LipoProfile test.
Best Regards,
Marc
marcwgarber@comcast.net
Thanks for the didactic. These issues have all been covered in various posts throughout this blog. And they matter, I suppose, to people who have bought into the lipid hypothesis of heart disease. Those who are convinced that cholesterol in whatever form is the driving force behind the development of cardiovascular disease will continue to develop ad hoc hypotheses to confirm their beliefs. I happen to fall into a group who believe that cholesterol has very little, if anything, to do with cardiovascular disease, so I tend to not follow all the latest developments in new lab tests that continue to slice cholesterol more and more thinly in an effort to give some credence to the lipid hypothesis.
Dr. Mike,
Seems people are just giving up….
http://www.boston.com/news/nation/articles/2008/09/21/interest_in_dieting_slims_down/
At least according to this article. But who knows if it’s really a trend or not. I doubt it.
Dr. Mike:
I agree with you that cholesterol is not “the” answer it has been presented to be, and I am not advancing the “cholesterol hypothesis.” As a point of clarification, tests such as apoB and the NMR LipoProfile test are NOT cholesterol tests, and therefore they do not “slice cholesterol more and more thinly.” Rather, these tests are direct lipoprotein assays (not direct measurements of the cholesterol inside the lipoproteins, but a direct measurement of the lipoprotein particle numbers themselves).
I agree with you that cholesterol is not a causal agent in atherosclerosis. There are correlations between cholesterol levels and atherosclerosis, but correlation does not equal causation, and two people with identical cholesterol levels can have VERY different numbers of lipoprotein particles transporting that cholesterol, and VERY different levels of cardiovascular risk.
Furthermore, the correlations between lipids and cardiovascular disease become progressively weaker as lipid levels drop, so using lipid measurements in an attempt to predict and manage cardiovascular risk is especially dicey for people with low levels of LDL-C and non-HDL-C (the two guideline goals of therapy). The inverse is generally true for HDL-C (although HDL is an extremely complex topic).
The fact remains, however, that when we dissect an atherosclerotic plaque, it’s full of cholesterol. The ONLY way for cholesterol to penetrate the endothelial lining of the arterial wall is for a lipoprotein particle to carry it inside, and when the number of lipoproteins (especially LDL particles) is high, the risk of this penetration occuring is higher. A growing number of studies around the world (including some truly enormous ones -i.e. AMORIS followed 175,000 patients for 5 years) have shown that the number of lipoprotein particles is a stronger predictor of cardiovascular endpoints than cholesterol.
So has cholesterol been “the” answer? No. Can we do better with lipoproteins? Yes (which is why guidelines are starting to slowly move towards lipoprotein particle numbers).
Will lipoprotein particle numbers be “the” answer. No. Atherosclerosis is a multi-factorial disease, with a host of contributory factors. But lipoprotein particle numbers DO work better than cholesterol, and I hope we can agree that having tests which allow us to assess and manage cardiovascular risk better than we can with cholesterol tests is a good thing.
Best Regards,
Marc
I didn’t mean to literally slice cholesterol thinner and thinner. I was using ‘cholesterol’ as a metaphor for the lipid hypothesis. As far as I’m concerned, lipoproteins are a component of the overall category of lipids. I know they are proteins, but their job is to transport lipids. Some factor being a putative risk factor because it correlates with disease is not proof of cause. Many people with low levels of LDL and low particle numbers develop coronary artery disease. You tell me how the cholesterol gets there in their lesions.
All I’m saying is that the idea that lipids and their carriers are the causitive factors for heart disease is simply an hypothesis at this point. When one part of the hypothesis fails – as has the total cholesterol as risk factor part has – then people begin to develop ad hoc hypotheses to try to explain the situation and have it still involve lipids in some way. I’m not a believer in the lipid hypothesis, so it can be twisted and diced and sliced all you want, and I still won’t believe it. Not until I see strong evidence that I’m wrong. And I don’t consider observational studies as strong evidence.
Cheers–
MRE
Noah – that’s exactly what I have to contend with in regards to my fellow student naturopaths:
“whole grain, veggie heavy, lots of chicken and fish, little red meat eating philosophy” and don’t forget the fruit and juice detox. The one I hate the most is everything in moderation! The cholesterol one is also annoying – none of them have ever read anything disputing the lipid hypothesis.
I have finally decided to lose my current cardiologist and find another one with whom I can talk and advocate for my health. My current cardiologist has told me, “You’re going to fail”, when I told him I wanted to try losing weight and exercise to lower my blood pressure(which I have done, I might add). He recently prescribed Vytorin for my high cholesterol and when I asked him about the recent research regarding the drug(in the New England Journal of Medicine), regarding its efficacy and correlations with an increase in cancer, he told me that that was all coming from the New York Times and it had all been de-bunked. He even put down another cardiologist who was supporting further research of this medicine. The final stake in his heart was his departing comment for me to stop reading.
He is probably in his early 30′s. The medical schools are still turning them out…
I would appreciate any comments.
What can I say? Your doc sounds all too typical. It’s a real shame.
Funny how if I describe my diet as avoiding sugar and eating high quality protein and vegetables no one bats an eye, but the second I call it “low-carb” people start whipping out all of the vampire myths and LF propaganda statements (like how healthy the Chinese are) to try to argue with my choice of eating or stump me! This goes for medical as well as social situations. “Low-carb” simply conjures up the fad diet response in people, but “cutting sugar” seems to sound reasonable. I also don’t consider it a diet (like a previous poster mentioned), and if questioned I simply say I have to eat this way because of migraines. Invariably, I get an immediate slew of questions about how I eat because the questioner knows someone with migraines that they’d like to tell. Strange how we humans react to simple changes in presentation.
Dr Mike – you say that Mg Citrate is a salt; does it absorb better than Mg Oxide? I’ve had good luck with it not causing stomach upset, but may switch if the chelates are substantially better.
Mg Citrate definitely absorbs better than Mg Oxide. The chelates don’t necessarily absorb better than Mg Citrate, they just don’t compete with other elements for absorption.
As an expert in cardiovascular risk assessment, prevention and the management of lipids, i agree only partially with Dr Garber’s metaphor about the # of vehicles rather than the passenger count as being important. We wish cardiovascular disease and the development of plaque was that simple. Dr. Garber is entirely correct that the particle # or Apo B reflect risk in a patient more than cholesterol content. However, it is a simplistic notion to believe that it is only particle number or Apo B that determines the damage to the artery wall. If one had 10 bombers filled with mega-ton weapons, it would do more damage than 20 light planes with unarmed commercial passengers. The point is this—it is the combination of # of lipid particles (NMR LDL-P) or Apo B (VAP) and the actual content of the particles. As an admittedly biased advocate of Atherotech, maker of the VAP test, we tell you the # of particles (Apo B–an international gold standard) and the composition of the particles. So, if one had a low # of particles by NMR but didn’t know that many of those particles are highly atherogenic particles like Lp(a), one would tell a patient their risk is low. The VAP test tells me everything i need to know…whereas with other tests, one would have to order other tests to get what one needs to know.
So, it is the number of vehicles, the type of vehicle and the type of passenger that is critical. Particles don’t just take up room as in a traffic jam–they get into the arterial wall and based upon their characteristics, do damage.
And as far as accuracy of a VAP-derived Apo B, it has been validated as accurate and may even be more accurate than immunoturbidometry for technical reasons. The NMR LDL-P is also a calculation (uses a formula). Finally, both LabCorp and Quest and all other labs report Apo B
The number of vehicles, the type of vehicles and the type of passengers are simply putative risk factors – no one that I know of has shown that any of these are real (as opposed to putative) risk factors, so why spend a lot of time and money making the tests ever more accurate. Why not simply get a calcium score, which is a much more direct measure of plaque and quit fooling with putative risk factors? The literature is full of case reports of people who have low lipid levels and a lot of plaque and people with scary lipid levels with no plaque. So why not just measure the plaque and be done with it. An EBT scan for a calcium score can be had for about $400, which is about the same or even less than all the fancy lipid tests.
I am a type 1 diabetic. I went low carb in March after having an A1C of 8.9, numerous episodes of crashing and rebounding with the blood sugar, weight gain, and generally feeling lousey. Before I was diagnoised diabetic, I did low carb for many years. Once diagnoised, the diabetic educator nearly had a heart attack when I ventured that low carb might be a good way of eating for this disease. I could swear I saw her cross herself..ha, ha. Anyway, luckily my local doctor is pro low carb and has supported my new regime which has lowered my weight by 22 lbs and my A1c to 6.0. Unfortunately, my latest cholestrol break down shows my total up from 200 to 249, HDL seady at 87, and LDL from 90 to 151. She wants to start me on a statin. I don’t want to go on one. The pressure is on since not only do I have diabetes, but my father died at 59 from a massive heart attack and all three of my brothers have had by-passes. My question is, what other tactics might I try to lower the LDL before considering a statin. Oh, I neglected to say I have been on a statin before and experienced the muscle aches…which have vanished since stopping the drug. I enjoy your blog.
Why do you have to resort to other tactics to avoid the statin? The studies show that women of any age irrespective of their heart disease status gain no decrease in all-cause mortality by going on statins. So why go on them at all. Especially since you experience negative side effects. Ask your doctor to show you a study that is a double-blind, placebo-controlled study showing you will benefit from statin therapy in terms of a decrease in all-cause mortality. There is no such study.
Hi Dr. Eades
My mom needs to lose weight and get healthy and I recommend a low carb diet for her all the time. She now found out she has Diverticulosis. What would you say are the optimal foods she should eat with this condition? She’s just not sure what to eat in her condition.
Most docs would recommend a high-fiber diet, but all my patients with diverticulosis have done fine on low-carb diets. Increasing the fat intake usually makes the colon work better anyway.
I’m trying to learn about optimal nutrition for strength training and I keep coming across things like the text below that suggest low carb diets inhibit testosterone levels. Is this nonsense? I’ve been following a low carb diet and have gotten a little weaker, but I think that is mainly due to lowered overall calories while trying to get down to 4% BF, which I am now at.
“Research suggests that eating a high-protein, low-carbohydrate diet can cramp your testosterone levels. High amounts of dietary protein in your blood can eventually lower the amount of testosterone produced in your testes, says Incledon, who observed this relationship in a Penn State study of 12 healthy, athletic men.”
Whenever you see the words “research suggests” you’d better run. No, low-carb diets don’t “cramp” testosterone levels. In fact, it is just the opposite. The people who wrote this are probably the same kind of people who would finger low-carb diets as being too high in cholesterol. Well, cholesterol is the molecule from which testosterone is made. Cut cholesterol (think very low-fat, vegan diets) and you reduce testosterone. Also, it’s not just the overall amount of testosterone that’s important, it is the amount of free testosterone (that which isn’t bound to a binding protein making it unavailable for use), and it is well established that insulin resistance decreases free testosterone. How. Elevated levels of insulin drive the liver to make more SHBG (sex hormone-binding globulin), which binds more testosterone. More bound means less free. So a diet that reduces insulin levels (the low-carb diet is best at that) also reduces SHBG, which results in more free testosterone.
Dr. Mike
Another great post! I can’t thank you enough for all that you do, really! this blog is such a a God send. I read PP 10 years ago. Then PPLP, but it wasn’t until a year and half ago when my fasting blood glucose levels came at 125 that I took action. You see, I aways been a husky kind of guy, lift weights, jog a little, not your typical couch potato. I was really shocked when that FBG test stared at me, I decided to take action. Following the PPLP now my FBG is 102!
I just got my blood test results and they are as follows:
Fasting glucose——103, last time was 110
HbA1c——————Not measured, last time was 5.6
Total Chol————-303, up fom 260
Direct LDL————-209
Calculated LDL ——233
HDL———————-56, up from 47
Triglycerides———70, down from 88
I am not concerned about the Chol. levels, but I am curious as to why my tot. Chol has increased.
Maybe I am one of those individuals with less LDL-C receptors and thus have a higher LDL-C.
It’s difficult to say why you total cholesterol increased. It could even be a lab error. My bet, based on observing the cholesterol levels of thousands of patients on low-carb diets, is that it will drop with time. It’ll probably be back to normal by your next lab test.
Hello,
I love your site and have made a few comments here and there. I read it a lot because I am trying to educate a lot of my friends and family about the dangers of too many carbs, and I need a lot of “ammunition” to be able to support my arguments. So far, it’s an uphill battle.
Nonetheless, I need to tell you and all of your readers how much better I feel after reducing carbohydrate intake and eating lots meat and that oh-so-controversial nutrient, FAT! I am not overweight, not have I ever been (47 years old, 123 pounds, a lot of muscle). But I have blood sugar “issues”. In between meals (particularly high carb ones) and at the end of the day (pre-dinner), I have blood sugar “crashes” that make me irritable, anxious, etc…and can even result in binge-eating. I doubt seriously that I would qualify as hypoglycemic medically speaking, but I am sensitive to changes in blood sugar. The absolutely worst is eating cereal for breakfast…I have the shakes within a few hours and am ravenous. But NO MORE! I feel absolutely great–all day long.
I am lucky enough to live in France–the French, with their low incidence of CVD eat a lot of charcuterie (sausages, meats, foie gras, etc…)…Their only sin is eating a lot of baguettes, which as Mary Enig suggests, contributes to a high rate of degenerative diseases. The sad part is that the French have bought into the low-fat mantra generated by the US medical establishment and are now abandoning their healthy ways. Hope that changes soon.
Keep up the good work!
And, sadly but predictably, since the French have abandoned their ways in favor of the US low-fat approach, obesity has been on the rise in France.