Here’s a really bad idea. Send a dozen nutritionists to work alongside regular doctors in a Medecins Sans Frontières team providing emergency treatment to the wounded in a war zone. It’s a bad idea because they would lack any relevant skills. They might help speed up recovery but in the operating theatre they’d be worse than useless as the wounded come in.
It’s obviously a ludicrous idea but how is it different to GPs trying to deal with a daily stream of people with chronic disease? With (usually) the most cursory knowledge of nutrition and ways to change lifestyle, aren’t they doing something very similar? Everyone agrees we have an increasingly unhealthy population with rates of obesity, diabetes, cancer and Alzheimer’s soaring. And many estimates put the proportion of cases that could be avoided by eating well and following a healthier lifestyle at around 50%. Yet 40,000 skilled and expensively trained GPs sit on the front line to deal with patients needing help with nutrition and lifestyle with no real knowledge of how best to do it. The only difference between them and the theoretical nutritionists in an operating theatre is that their patients die over years rather than hours. The GPs’ toolbox needs a major upgrade.
Why this mismatch between medical skills and what patients need has to change was the focus of the Food: The Forgotten Medicine conference, organised by the College of Medicine. The speakers were nearly all doctors or clinicians who had already incorporated nutrition into their practice.
They talked with passion and authority on how this approach can offer GPs a far more sophisticated set of options to deal with the myriad problems that come with chronic disease. By the end it was all too clear that the existing toolbox GPs and other medics rely on to deal with chronic metabolic diseases – eat a healthy balanced diet and try to get a bit of exercise – is desperately in need of a massive upgrade.
The grand old man of nutritional medicine, the American doctor Andrew Weil, took us on a whistlestop tour of some of the possibilities. ‘A patient is more than just a physical body’, he began, immediately introducing a much broader perspective than the one usually available in a time-poor GP’s surgery emphasising the importance of such lifestyle issues as sleep, ways of handling stress and social connections as factors that can help or hinder health.
All of which can directly impact on such an obviously physiological problem as raised inflammation, often found in people with chronic disease. The aim of the non-drug approach is to return the system to a healthy balance between enough inflammation for repair and protection but not enough to cause damage.
Sophisticated nutrition offers options
Nutrition and changes in lifestyle offer a number of ways to do this including fasting, taking an anti-inflammatory compound such as curcumin (from the spice turmeric) and Weil’s Anti-Inflammation Diet – which is a variation on the familiar Mediterranean one. ‘It’s very similar to the traditional Japanese or Asian diets,’ he says, ‘which are now tragically being displaced by SAD – Standard American Diet.
One of the attractions of sophisticated nutrition is the number of options – nearly all low risk when used carefully – that may work for different conditions. So another route to bringing down inflammation is to reduce intake of polyunsaturated vegetable oils, used for cooking and found in processed foods.
This is now controversial since vegetable oils have long been sold as the healthy option, in contrast to those dangerous saturated fats, but the evidence increasingly suggests that the two should swap approval ratings. Here again a good grip on nutrition is needed to help patients to understand the evidence and to make this switch not just with fats but also to make sense of the confusion currently swirling around the debate over the benefits of a low carbohydrate diet.
‘Instead of vegetable oils go for fats found in fruits such as olives and avocado which are generally beneficial,’ says Weil. ‘This is the kind of data that doctors need to advise patients about but they can’t do it at the moment as they don’t have the data.’
How lifestyle can turn on healthy genes
Not only are there more safe options with nutrition but when used together they tend to co-operate rather than compete. For instance, there is a third way to bring down inflammation, in addition to fasting and compounds such as curcumin, which is with exercise. But why those three? At first sight they seem rather arbitrary.
This is a good example of the way that the lifestyle approach can use multiple approaches that benefit the whole body. It’s been known for a long time that both fasting and exercise are, obviously, ways of losing weight but also for living longer and, more recently, that one of the ways they work is by cleaning up the garbage and waste products that can build up in the cells of older people.
One of the attractions of sophisticated nutrition is the number of options …that may work for different conditions
But how does curcumin fit in here? The reason that, along with exercise and fasting, it provides similar benefits is because they are all able to turn on a set of genes known as sirtuins which have been linked with increased lifespan, garbage clean-up and reducing inflammation. Curcumin is just one of a type of plant chemical known as a polyphenol, which can have very specific effects, often by altering gene activity.
There are thousands of polyphenols found in a wide variety of fruits and vegetables and researchers are teasing out the huge range of their effects such as encouraging weight loss, slowing tumour growth, lowering blood sugar and protecting the brain. Plants known to be rich in them include red grapes, green tea, dark chocolate (the expert on polyphenols at the conference was Simon Mills of the National Institute of Medical Herbalists).
How can you advise on fats if you don’t know nutrition?
Among the many natural substances that can also affect gene activity are the omega 3 fatty acids, commonly found in fish oils, nuts and seeds. ‘But even though the evidence for their benefit to the brain and cardiovascular system is very strong and has been growing for years, it continues to be largely ignored,’ says Dr Alex Richardson of Oxford University, one of the leading lipid researchers.
‘We know it is vital for mother and baby, yet despite widespread deficiencies in pregnant woman there is no programme for supplementing it. The benefit for children with behavioural difficulties is well established and yet it is not a regular part of any psychiatric programme.’
Being able to ignore omega 3 benefits is to be expected if you know very little about fats in general. However the recent increasingly heated debate over the high fat/low fat issue highlights the way doctors’ ignorance may have been tipping patients out of the frying pan and into the fire for years. And the issue is not just how much fat we should be getting but what sorts.
Polyunsaturated vegetable oils have long been recommended as the healthy alternative to saturated fats, but experts like Weil and Richardson claim they should be used sparingly, not least because of their effect on inflammation. Yet omega 3 is also polyunsaturated but it’s anti-inflammatory. It’s complicated. And that’s just the start, Richardson points out. If you want to properly advise patients over saturated fats you really need know there are at least 30 different types with quite different properties before you start.
Your poo: the new medical frontier
So nutrition and lifestyle is not a soft option and it is about to get a lot more complicated as Professor Tim Spector of King’s College London made clear when he took us on a witty and lightening tour of our microbiome – poo to you. It’s emerging as a leading player in our health, also regulating weight gain or loss, how well we handle fats, our levels of inflammation, and probably our moods and mental states also.
There is a big difference in the way different people respond to a food. That’s why setting guidelines is so fraught
The influence of this two-pound colony of bacteria living in our guts is one of the reasons why it is hard to get consistent and clear results from trials involving diet,’ says Spector. ‘We all share around 99% of our genes with other people but our microbiome is far more individual. Yours is only about 20% similar in its combination of bacterial species to anyone else’s. That means a big difference in the way different people respond to a food. That’s why setting guidelines is so fraught.’
But there are also certain common patterns. Having a large number of species down there is a sign of health. ‘People with chronic diseases, such as heart disease and diabetes, all have much less diversity. It seems possible that increasing diversity will become a treatment and diet and lifestyle will be key ways to do that.’
Knowing nutrition gives doctors more levers to pull
Spector reported on a trial of one – his own son – which showed why some people become ill after a relentless diet of meals from food outlets like McDonald’s. ‘After just 10 days of eating nothing else, the number of species recorded in his poo was down by 1,200.
Exactly what’s going on isn’t clear. It could be the lack of fruit and vegetables or it could be all the chemicals – the emulsifiers, the artificial sweeteners and maybe the number of antibiotic courses you had as a child affects how you handle it.’
After what was only a brief glimpse of the specific and varied ways you can directly affect the working of your whole system with nutrition and lifestyle you couldn’t help wondering – why on earth wouldn’t doctors want to know this stuff? Not only does it allow the patient to become more in control of their health but it provides the doctor with so many more levers to pull.
The medicinal power of kindly helpful listening
But an integrated approach combining drugs and nutrition is not all about the biochemistry of fats or turning genes on and off with food or fasting or teasing out the astronomical complexity of the interactions of the microbiome. Very simple things can also be very effective. Ruth, a one-time exercise instructor who now works in the surgery of the College of Medicine’s chairman Dr Michael Dixon, described what she does with patients in the practice. It’s called a ‘social prescription’.
The results for nothing but chat and kindness were remarkable
I talk to them and I listen. I get to understand what works for them and what they need,’ she told us. ‘Often it’s something very simple like how to read a food label. I’ll get to find out about their home life. Maybe I’ll introduce them to the staff at our café who run diabetic cooking lessons. We’ll talk about what they need to be healthy. It might involve tweeting their goals to friends to give a bigger incentive to stick to them or to join some local social groups.’
It all sounds like the best sort of neighbourliness but does it actually achieve anything? This is what Dr Marie Polley, lecturer in health sciences at the University of Westminster, wanted to know too. So she tracked 124 diabetic and pre-diabetic patients who had been given Ruth’s social prescription but no other sort of treatment.
The results for nothing but chat and kindness were remarkable. The key blood measurement for diabetics is the HbA1c which tells you how high your blood sugar has been on average over the past three months Over 48 and you are diabetic, 47 to 42 is pre-diabetic and below 42 is normal.
‘Only 4 increased their waist circumference, on average they lost an inch,’ says Polley. The change in the HbA1c was just as impressive. ‘At the start the pre-diabetic patients averaged 47 and after three months that had dropped to 45; at 9 months it was 44 and still dropping.’
Of course there are huge issues with the cost of running nutrition trials and the best ways of gathering evidence for multiple lifestyle interventions but pretending none of it is effective and can be ignored really isn’t an option.