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Friday 29 April 2016

Confessions of a renegade doctor

By Joanne McCormack

Until fairly recently I was a pretty conventional medic. I graduated from Manchester University as a doctor in 1986 and became a GP in 1990. Back then nutrition was very much a minority topic and certainly eccentric interest, while drugs and the pharmaceutical industry occupied the high ground of medicine. Now as far as I’m concerned when it comes to chronic disease, which is what I spend most of my times dealing with, the positions are pretty much reversed.

Inevitably I learnt very little about nutrition in medical school and didn’t come across the Eat Well Plate until I was already in practice. Back then I just accepted it, but now I can see that much of it doesn’t make sense.

For instance, even in my limited nutrition classes I learnt that there were essential fatty acids and essential amino acids but no essential carbohydrates (that is starches and sugars). And yet the Eat Well Plate advises us to fill up with carbs. It is what shapes menus in our schools and hospitals, precisely where you need protein and fats to build new bodies and repair older ones. Watching Public Health England execs still trying to justify the EWP would be funny if it wasn’t so tragic and harmful. Shockingly I’ve even been told that they are aware that they’ve got it wrong but claim they can’t do anything about it.

My conversion to a more nutritionally orientated approach to treating patients was triggered a couple of years ago when I was talking with a group of doctors about what they ate. I’d never believed calorie controlled diets worked well – they certainly didn’t for me – and while I parroted the mantra about “eat less, move more” I’d already found that it didn’t begin to tackle the problem for seriously overweight patients unless they also greatly altered their diet.

Avoiding sugar is a great way to start

So what should we be eating? A couple of the doctors said their health had improved a lot when they went on dairy and wheat free diets. The reason they helped, suggested one, was that they inevitably meant you ate a lot less sugar.

That made sense to me. If you avoided those foods and didn’t go for the processed substitutes, such as non-dairy yoghurt, gluten free bread and cake, which were usually packed with sugar, you had to eat real food, which had to be better for you.

This set me off on a trail of reading widely about diets and real food for a couple of years. The only healthy diet I’d been told about was the standard low fat one but I soon found plausible alternatives that stood this advice on its head such as the low carb high fat diet and the London AS diet (low starch which can help with a rheumatic disorder called ankylosing spondylitis).

My experience exploring diets then lead me to question the benefit of automatically treating every disorder with drugs. When two of my patients cured their arthritis with the London AS diet, this approach seemed a valuable alternative to the monitoring, frequent specialist appointments and unpleasant side effects that are all part of the multiple drug regime that is needed to achieve the same effect.

Patients who are heavily drugged with little benefit

Then I began to notice that our reliance on drugs didn’t always seem in the patient’s interests. I watched elderly, frail bed-bound Alzheimer’s patients in nursing homes being kept on an increasing number of drugs that did little to benefit them on a day-to-day basis. It seemed a total waste of time when they had such a poor quality of life. The only ones who improved were those who were cantankerous enough to refuse them.

It was only a decade or so ago that doctors were warning about the perils of getting medical advice from Internet sites, but now it is where you should turn if you have a questioning mind. It is a place where the international, free speaking, medical and scientific world cam freely debate scientific papers, guidelines and dogma. A place where we can swap notes on the Key Opinion Leaders, (paid for by drug companies) who run our conferences or the (sometimes) dubious Department of Health target.

Most GPs would acknowledge that their patients are prescribed too much medication, and that it may often cause more harm than good. I’ve only recently realized that there are no trials and so no scientific evidence base for the multiple drugs schedules followed by large numbers of those over sixty.

Unfortunately as GPs our freedom of action is partially limited by the guidelines and incentives we work under. Most important are the QOF (Quality and Outcome Framework) points that GP practices get for hitting various targets every year (not all GPs get the payments though).

The invisible third party in the consulting room

So when you have a consultation, especially towards the end of the financial year, the QOF points system is likely to be a silent third party in the room – encouraging the GP to test and prescribe in order to hit targets which may not be aligned with your goals or needs. These include taking your blood pressure and running various blood tests. Failing to do them make doctors feel they are failing as well reducing their pay.

And the results of these tests are far more likely to lead to drug prescriptions than to dietary or other holistic advice. If you want to know what your doctor’s normally hidden agenda is, you can ask him or her to show you what is “missing” on your QOF file.

Luckily, there are many fewer targets than there used to be. Interestingly many of those that have been dropped involve cholesterol – silently removed without explanation. The official line is still that raised cholesterol is an important marker for a raised risk of heart disease and there is even a new and very expensive drug called Rapatha on the way which can drop cholesterol levels even more effectively than statins, but does not reduce deaths.

So I’m concerned about the advice patients are getting and I’ve spoken about it to public health directors and consultants about it. While some of them are open-minded enough to admit the government have got it wrong, they seem unable to translate that into practice. The times are changing however and doctors and industry can and will adapt. I’ve had more mental flexibility from key workers on the ground – nurses, doctors and school meals managers – than from the higher echelons of health service management.

Public health managers need to change

Listen up Public Health management – your hands are not as tied as you think! Individualized care and low GI diets are now options, while QOF cholesterol targets are vanishing. These changes allow you to be much more flexible. Train yourselves in nutrition too. The last Public Health Doctor I met told me and a group of diabetes docs and nurses that low fat didn’t work and that healthy fat was fine. So she is certainly more up to date than the EWP.

So when I find the official recommendations for my patients haven’t worked, such as a low fat diet for diabetes, I’m happy to suggest a range of other options and that is fine because government guidelines all say we must take individualised approach and I agree with that. We are each unique after all.

It is not so much unconventional as the beginning of a global movement of doctors and scientists who treat chronic diseases in a non-interventionist way based ultimately on the very simple idea that if a food has been eaten for millions of years, it must be safe, and that non drug methods may have less side effects and be more effective.

I’m also is my own small way trying to encourage a more informed approach to nutrition in schools and by official bodies. Last week I saw an 11 year old child with non-alcoholic fatty liver disease. It had nothing to do with fat intake or alcohol; It was entirely due to carbohydrate in the diet. So I’m working with the local school meals service in the hope I can persuade them to provide more nutrient dense food and avoid junk carbohydrate foods like chips, pasta, pies and cakes, which can cause weight gain, fatty liver, and diabetes.

I’ve been taught to follow evidence based medicine but the clinical trials, the supposed “gold standard” of the system, clearly has a massive problem with unfavourable results going unpublished. Let’s face it: a lot of our medical evidence base has been distorted or hidden, which can make informed decisions impossible. So what do I do?

I aim to give people unbiased information where possible and to encourage them to make active choices of drug and non-drug treatments. To help them I trawl the Internet and highlight the most useful sites and books, and link to them on my websites.

Often an individual and I decide together what the best course of action is, looking at the evidence of what works for him or her, and what does not, rather than blindly following guidelines that may be inappropriate. Beyond the consultation I direct my patients to my websites and So have a look and tell me what you think.



DeniseinVA said...

Great article, thank you for sharing this. I can see I will be coming back to read it again.

Margaret D said...

Interesting long read.

Anonymous said...

Great article and refreshing to read that the aim is to give people unbiased information where possible and to encourage them to make active choices of drug and non-drug treatments. To help them I trawl the Internet and highlight the most useful sites and books, and link to them on my websites.


Anonymous said...

Good to see another GP prepared to challenge the status quo lots of useful info on her website


system trader77 said...

Excellent. Well said. For more about why docs end up prescribing meds that may not be so good please take a look at When Good Doctors Prescribe Bad Medicine at: