The Mediterranean Diet: Where 'True' Reform Misses the Boat

Melissa Walton-Shirley

Disclosures

November 07, 2013

My patient is "pleasantly plump," a description being pushed to the cliff's edge as our nation begins to traverse that great public-health divide between knowledge and action. In the information age, the understanding of what it takes to stay alive and to practice an economically favorable lifestyle is attainable for some. But middle- and advanced-age patients, like the one who is the focus of this story, still face a life with no navigation system, and worse, they are now herded into healthcare arenas with time constraints and quotas. In many instances, they see physicians and healthcare providers who've had a collective five hours of nutrition training in their armamentarium. Those physicians are now servants to their new lord and master, the relative-value-unit (RVU) tally, which doesn't reward a 45-minute sit-down talk about such menial issues. These patients are lost in a sea of disease- producing adipose tissue. They see the shore, peopled by Victoria's Secret ads and the Chris Hemsworths of the world, but there is no buoy, no map, and no firm plan to teach them how to practically and comfortably get to safety. So how will they achieve the newly important goal of costing our healthcare system less?

With yet another affirmation of the virtues of the Mediterranean diet recently published, I briefly got my second wind. Already, my vocal chords are strained at the end of every office day from preaching lifestyle change. My audience is a willing group of patients who've never had training in how to shop at the grocery, prepare food, or when to eat it. They can't afford the resources to access it and as far as I can tell, the Affordable Care Act doesn't address providing access to this information for this large sector of the American public. So, I try. Until yesterday, I thought I was making great headway.

In the past six months, a patient walked in 90 pounds lighter after a year of better food choices. I bragged about my greatest success, a nursing home patient who lost 130 pounds over two years. Another patient weighed in at 40 pounds lighter this week, but the majority are firmly clinging to their BMIs of 33 and waist circumferences of 42 inches. Yesterday, it hit me. I'm really losing the battle.

"How are you doing with that diet?" I asked my patient.

"It's not working," she said. "I've tried everything."

I glanced at her height (5"5') and her weight (173 lbs) at this, her third visit over the past two months, a visit prompted by shortness of air on exertion and dizziness.

"Well, let's look at what you've eaten for the last few meals. If you've adhered well to the diet, and nothing is working, perhaps you need more exercise or maybe we should do a metabolic workup to see if there is something wrong," I conceded.

She nodded her head with enthusiasm, truly game for this exercise in self-examination.

"Tell me what you ate for breakfast this morning," I directed.

"Hmm . . . well, I ate two eggs, one patty of sausage, a biscuit, and gravy," she replied. "Guess I didn't do so well this morning did I?" she lamented.

"Well, let's keep going," I said. "And what did you drink this morning for breakfast?" I asked.

"An RC cola," she replied. "What size?" I inquired.

"16 ounces," she said.

"What about supper last night?" I asked.

"Let's see. . . . I ate fried chicken, an order of French fries, some green beans . . . and that's it," she said.

"And what did you drink?" I asked.

"I always drink a 16-ounce RC Cola nearly every time I eat. That's probably bad isn't it?" she acknowledged, while I nodded in absolute disbelief.

"What about lunch yesterday?" I asked.

"I had fish," she exclaimed, rather proud of her accomplishment.

"And how was that fish prepared?" I asked.

Crest-fallen she realized it was also fried, plus she had two slices of bread, a boiled egg, and another RC cola.

In the back of my mind, the 45 minutes I spent with her last time evaporated into dust.

"Okay, just to round out yesterday's menu, what did you have for breakfast?" I asked.

"Well, I had two eggs, bacon, a biscuit, and an RC cola."

I took a deep breath, checked my mental clock, and knew I'd spent already 20 minutes in the room just examining her and speaking with her, but what it would require to save her life was going to take another 30 minutes. Patients were being brought back, treadmills were running, phones were ringing, but the choice was clear: it didn't matter, unless someone needed CPR in my lobby, the right thing to do was just shut down the office and try this again. Though this was not the first time I'd explained the Mediterranean diet, I reasoned that if she were drowning, I'd not just throw out the life preserver to her once. I'd do it every time she started to go under, so I rolled up my sleeves.

This time, something clicked.

"You had 175 carbs yesterday in RC Colas alone," I pointed out. "You are only allowed 100 to 150 carbs for the entire day. That doesn't even include all the bread you ate or your other 'good carbs' that you need. You only had one real vegetable. French fries don't count."

The patient brightened. "I really didn't know what you meant by carbs that first time you talked to me. I left here and I just didn't know what to do," she confessed, despite the fact that I gave her information on the diet.

I explained that the Mediterranean diet was more about what you need to fight disease than what you should avoid and that living within a range of around 100 to 150 carbs per day along with around 35 to 40 g of good fat per day would help her get down to a healthier weight. I explained the concept of good carbs and bad carbs. I told her to "avoid eating what a caveman couldn't get." I explained that I modify the Mediterranean diet for my patients in the office by directing them to simply cut in half what they currently eat in bread, sweets, potatoes, pasta, and rice. I explained that patients who are 30 pounds overweight are 300 times more likely to die an early cardiovascular death. I gave her an order for a two-hour glucose tolerance test. I then dangled the carrot that is valued more than longevity by many patients, "You can actually get off many of your medications for BP, GERD, etc, if you get your weight down."

She left my office truly grateful with what seemed to be a new understanding of what it takes to live as a human organism. Here's the rub. I can't do it for her by myself. Doctors can't do it. We don't have the time to do it. We are too busy fighting the glut of established disease that comes our way every day all day long. We are failing because we have not demanded that nutrition be a required class at every level of education, every year of every American student's life. We can't be dieticians or life coaches: as much as I try and as hoarse as I may be, at the end of the day, my time constraints have failed my patients.

So, America! Government officials! Elected politicians! Dieticians! Educators! I need help. We've done a great job with "sex education," but we need to busy ourselves with a rewrite of required curriculum of elementary and secondary education. We need to teach and test on what fuels and protects our bodies. We need to throw in important stuff like "which side of your body your gall bladder lives" and "how you feel when it gets sick." We need to demand an hour of physical activity every day. We need to teach that lifesaving and life-preserving information with even more zeal than we teach a high-schooler how to put on a condom. We need a complete overhaul and rewrite of something more than lunchroom menus. God help (and I don't ask that in vain) all of those folks who are caught in middle age or older with no tools to navigate what goes into their mouths. They are writhing with disease-producing fat lining their middles. They are breaking our budget. They are dying a slow, fairly miserable death. They are lost.

The solution for those who are beyond elementary and high school education?

Put into motion a true healthcare reform, a true reformation of access to information by funding nutrition counseling and access to exercise facilities. Reward large-scale employers even more by providing tax breaks for getting their subjects to a healthy body weight, normal blood pressure, and glucose metabolism. I refuse to accept that these people who are failing are just stubborn ne'er-do-wells who don't care. My "pleasingly plump" patient cared, but she didn't understand. She wants to do better, but my measly 45 minutes in two office session, though attention-getting and encouraging, are not nearly enough. We need to make access to this information the norm, not an exception.

President Obama, pick up the phone and call your education chief. Have a round table discussion. Rep Pelosi, I saw you on a recent talk show, and you demurely soaked up a bit of praise for our current plan for healthcare reform. Call your friend President Obama for an urgent discussion on something besides our defunct website failures. Dr Sebelius, give your team this article as "required reading," and go to work. You guys still have a couple of years to really and truly make a difference. Nutrition and lifestyle education must be a required, concerted, concentrated effort, or all the "healthcare reform" in the universe will never work for the very nice, well-meaning, pleasingly plump patients of our nation.

See also:
Healthy Diet, Healthy Aging

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