We have been Kaiser patients for decades. For the most part I appreciate the health care provided and the care of the physicians and other providers. But nutrition education for patients with high cholesterol is so dated it borders on being more harmful than helpful.
Both Frank and I are tested regularly and show elevated total and LDL cholesterol. Because our HDL-C levels are high and triglyceride levels are low, my guess is that the LDL-C is a harmless light and fluffy type. Not the small dense LDL-Cholesterol associated with increased risk of cardiovascular disease (CVD). On Kaiser’s own risk calculator, I have less than a 1% chance of CVD in the next 10 years.
My doctor knows better than suggesting that I attend a cholesterol education class, but Frank was given an appointment and he attended the class today. Mostly he wants to avoid taking a statin, and attending the class was a way out. He came home grateful that he has access to personalized information from his at home dietitian, me.
Frank’s recollection of the class was disturbing. The authoritarian tone of the class, led by a nurse with little sophisticated understanding of the issues, underscores why so few patients are “compliant” with nutrition advice. Kaiser’s approach to delivering nutrition information minimizes the likelihood that people will actually succeed in changing behavior. What are the chances that this education will actually reduce their risk of disease?
THE SAME RECOMMENDATIONS GIVEN TO EVERYONE
All eight participants were told the same thing–as if each of them would respond exactly the same way to the same information. There were two elderly black women in the class, despite the fact that an elevated cholesterol level is not a valid indicator of cardiovascular risk in patients over 70 years of age. Maybe they were there because they had a stroke, or kidney disease.
There were several middle aged Latino laborers who probably lived a different lifestyle with different activity levels than the elderly women. There was a young Latino couple and one other Caucasian. I have a hard time believing that the same message is appropriate for each of the participants.
IS THE ISSUE WEIGHT OR BODY COMPOSITION
My husband was the only participant who exercises regularly, yet he was told he should weigh about 165 pounds, maybe up to 180 if he considers himself “large boned.” Preoccupation with weight is the Achilles heel of health care. It would be convenient if weight and health were tightly aligned. But they aren’t.
It is disingenuous at best to continue reinforcing this myth. Weight is a very crude measurement, it can’t differentiate between lean body mass and fat mass. The height weight charts used at Kaiser were developed by life insurance companies. The are derived from data on death certificates. Mostly the numbers associate weight at death with longevity. The numbers don’t have much to do with health, fitness, or quality of life.
No one bothered to talk about body composition. My husband is an avid cyclist and basketball player, a classic mesomorph with significant muscle mass. Could he lose a few pounds of fat? Of course. But recommending that someone lose 50 plus pounds without measuring body composition is negligent. His lean body mass accounts for about 175 pounds of his total weight. Is Kaiser really recommending him to lose every ounce of fat and some lean body mass as well?
DIETARY ADVICE RIGHT OUT OF THE ’70’s
It was the dietary advice that made my hair stand on end. While the essence of the Mediterranean diet was encouraged, there was too much dated and inaccurate information. It is easy to encourage more fruits and vegetables, plenty of nuts, seeds and legumes. I have little argument there.
But there is plenty of controversy and more progressive thinking regarding the rest of our food supply. You just wouldn’t know it from the very conservative and dated dietary recommendations provided by Kaiser. I’ve listed a few of my primary concerns below:
1. Recommending a low saturated fat diet– NOT NECESSARILY THE ONLY WAY Researchers and clinicians alike are moving away from the fat hypothesis and cardiovascular disease. Excessive refined sugars and starches seem to be more of the problem. At least the nurse wasn’t recommending a high carbohydrate, low fat diet.
A high carbohydrate diet can actually makes the insulin resistance worse, increasing risk of cardiovascular disease. Without adequate fat, people can get hungry sooner after meals and end up over eating calories.
Yet there still is a great deal of angst about saturated fat, even though not all sources of saturated fat are created equal. The typical culprits, red meat and full fat dairy products, are problematic because the animals eat excessive amount of grain and starch themselves, increasing the ratio of omega 6 to omega 3 fatty acids in the fat. This fatty acid imbalance is a recipe for inflammation–the core factor associated with increased incidence of disease.
Food sources were beyond the scope of the nurse educator. My husband didn’t want to be confrontational, but I wonder what she would have said if he asked about eating grass fed meat, pastured chickens and eggs, milk and dairy from grass fed cows. These animal fats are rich sources of omega 3, conjugated linoleic acid (CLA), alpha lipoic acids and other heart healthy factors. Most of the research associating animal fat and cardiovascular disease has been done since the 1950’s when we started preferentially feeding cows grain. Nutrition science hasn’t adequately addressed these issues.
2. Eat no more than 2 eggs a week– UNNECESSARY Even the American Heart Association (AHA) allows almost one egg a day. In addition the cholesterol in egg is not the same as the cholesterol measured in the blood. There is little association between serum cholesterol and eggs. Eggs have been vindicated for years.
3. Avoid all fried foods to cut out trans fat –OUTDATED Cooking oil with trans fat has been banned in California since Jan 1, 2010. In addition, the greatest source of trans fat is found in baked goods. Even products that register “0” trans fat on a food label may still have up to 0.5 grams of trans fat per serving. AHA recommends no more than 2.5 grams trans fat per day.
4. A portion of protein is 3 ounces– ABSURD How can 3 ounces of protein be the right amount for those 70 year old sedentary women as well as my younger, active husband? Very active individuals may need up to 2x the amount of protein as a sedentary individual. In addition, protein is the key nutrient that helps us feel satisfied. When people don’t eat enough protein, they often crave and overeat carbohydrates.
There is no data showing larger amounts of protein are harmful, unless excess Calories are consumed overall. Higher protein intake doesn’t cause osteoporosis or kidney disease.
5. Eat a Mediterranean diet and use whole wheat pasta–UNBELIEVABLE My family is Italian and I consider myself somewhat of a pasta snob. The issue isn’t the pasta, it is the quantity eaten. If we ate pasta like Italians it would be about a 1/2 cup serving. It is a small side dish, not a mountainous entree with meatballs on top.
Another problem is that pasta is too often overcooked, increasing the glycemic index. That means it increases blood sugar, insulin and fat synthesis faster. A modest portion of pasta cooked al dente is the answer.
If we are going to recommend a Mediterranean diet, then it is imperative to stick with the research. People living near the Mediterranean don’t eat whole wheat pasta. The USDA love affair with whole grains is over rated. You can eat too many whole grains, too.
A SET UP FOR “WHAT THE HELL EFFECT”
The most glaring omission of the class was the lack of personalization, underscored by the pre-printed handout outlining a neat checklist of exactly what to do to prevent heart attack, stroke, or kidney disease.
Frank said that if he didn’t know better he would have left the meeting feeling depressed. He could eat fruits, vegetables, whole grains, fish, chicken without the skin, 2 eggs a week, and red meat once or twice a month. He knows that eating such a restrained diet would leave him feeling hungry, unsatisfied, and struggling with the deprivation I see in too many of my clients.
No wonder most people are disillusioned with mindless dietary advice. Universal, restricted diets are bound to lead to “what the hell effect.” That’s when people try to follow an overly restricted food plan, get frustrated and finally give up, often overeating everything that is considered taboo. It is a set up for failure.
Nutritional support is ideally delivered to an individual in light of their personal medical history and lifestyle. I can hardly imagine doctors handing out diagnoses and pharmaceutical prescriptions to groups of people at one sitting based on a couple of lab measurements without consideration of the whole person. Why do we think dietary recommendations can be delivered that way?
It is one thing to educate, allowing people insight into the risk factors that contribute to cardiovascular disease. But that is not what happened. This class wasn’t about education, it was delivering a nutrition prescription. A arbitrary prescription delivered in an authoritarian and absolute fashion, directed equally to every person present despite their unique personal experiences and circumstances.
Kaiser should do better.