“How much teaching about diet did you get at medical school?” asked Professor dietitian her indoors…she’s not actually a Professor! “Not much that I can remember, but you are pushing my memory a bit, why?” “Well this blog in the BMJ from a couple of medical students suggests you doctors need to have a lot more.
Maybe they don’t appreciate there is a whole profession specially trained to do this, I thought it was a team approach nowadays?! Are they saying that patients are going to listen more to doctors than dietitians?” I detected more than a bit of annoyance and some professional abrasion; there was a fine line to tread! I agreed, and not just for a peaceful dinner time. I don’t see my expertise reflected in giving dietary advice and it isn’t a major role for me as a cardiologist. Am I wrong?
I’m sure it’s the same for you; diet is quite a common question in clinic, especially from return ASCVD patients. I keep my lifestyle advice simple. I suggest a Mediterranean diet and “calories in should equal calories out”; you need to move around on your feet and get a sweat up for at least 30 minutes 5 times a week; and, being a little hungry is normal, it doesn’t need to be relieved right away and it’s best done with the non-refined sugar in an apple.
But it’s clear, the UK population are increasingly overweight, caused certainly from diminishing amounts of exercise and from an excess amount of calories.
Would a cardiologist knowing more about nutrition and giving more detailed dietary advice change the established behaviour of many or any of the patients they see? I’m not sure. It would be ideal if we were able to refer patients to dietitians who could then offer them continuing at least medium-term support to change their lifestyles. But I know that their service is overwhelmed by many demands and they find it very difficult to keep timely and maintained support to specialities such as diabetes, renal and GI, where their role has traditionally been stronger. More dietitians?
Self-help for all conditions is unquestionably important for patients, including those with many types of heart disease. But what is most influential in ASCVD happens a long time before most people see me. A now retired colleague of mine used to say that many ASCVD patients come to us after years of self-abuse and then expect us to turn them back into their unadulterated selves, a little harsh maybe. Atherosclerotic disease is a body-wide progressive process, temporisation is our main activity, and that can have a big and life-changing impact, but even with contemporary treatment, once it’s established it effectively doesn’t go backwards.
New information changes views
If I had received dedicated training in diet for my speciality what might I have learnt? Naturally knowledge changes and as in everything, there’s much to debate. The PURE (Prospective Urban Rural Epidemiology) study was visible in both medical and non-medical press from the ESC this year. The headlines were “high carbohydrate intake was associated with higher risk of total mortality, whereas total fat and individual types of fat were related to lower total mortality.” Dietitian her indoors and I debated this over more than one meal, it is challenged more articulately than we did here.
As well as the diet and lifestyle advice my patients do need to take home at least two other threads about their cardiology, some of which will have a complexity: their diagnostic options; the benefits and risks of prescribed medication, and often the importance of their compliance; the potential treatment paths; their follow-up plan, etc, etc. It is often a lot to take in, which news is retained and what gets forgotten is not sometimes clear.
Probably, I wouldn’t have benefited much by being taught more about nutrition and lifestyle as a medical student and I don’t think today’s students should get more, especially if it takes them away from teaching in key medical areas such as pharmacology.
I agree doctors can be pivotal in societal changes which are at the root of the developed world’s obesity epidemic, but in co-operation with many other professionals in the public health arena. Yes, there is no doubt that opportunistic advice on diet and lifestyle is important to give, but only sustained pressure and support leads to changes in established behaviours.
Specialists should know the most relevant studies and guidance relevant to their field. For cardiologists, ASCVD will be influenced more by society’s insulin resistant and fattening trajectory caused by too many calories with too little exercise, than the knowledge of the best split of fats and carbohydrate in its diet.
Look after yourself over the festive period, I’m certain you deserve a little excess of some things, keep moderation in all others! Enjoy the love of your families and pass on your good will to as many as you can. I look forward to sharing some more heart murmurs with you in 2018!