"I loved [Keto] because I lost the weight" - Nutrition Medicine (Part II)

In this episode, Nate, Justin, and Tina sit around the proverbial dinner table to discuss different types of eating patterns or "diets" and why a whole food plant-based diet might deserve a spot at the top of the food chain.

Share your reactions and questions with us at  Speak Pipe . We might feature you on a future episode!

=== Outline ===
1. Introduction
2. Chapter 1: Types of Eating Patterns
3. Chapter 2: Whole Food Plant-Based Diet
4. Chapter 3: Emotional and Psychological Nature of Eating
5. Conclusion

=== Learning Points ===

1. Patients have different motivations for changing their eating habits: they may wish to lose weight as measured on the scale, change their appearance, or prevent or treat chronic disease. 
2. The keto diet, a popular eating diet, can appear to be healthful in the short term: patients are able to lose weight, decrease their blood pressure, and decrease their blood sugar. However, it is not sustainable in the long term and may lead to increased risk of adverse health outcomes. 
3. Many scientifically vetted eating patterns, including the DASH diet and Mediterranean diet, share one thing in common: eating a whole food, plant-based diet. Eating a whole food, plant-based diet does not mean the same thing as “vegan;” rather, it emphasizes eating foods in their minimally processed form and minimizing consumption of animal-based foods. 

=== Our Expert(s) ===

Dr. Justin Charles is a graduate of the Yale Primary Care Internal Medicine Residency Program.

His clinical interests are in Lifestyle Medicine, the use of evidence-based lifestyle interventions to not only prevent, but treat and reverse chronic disease from a root cause perspective. He has received training in Plant-Based Nutrition through the T. Colin Campbell Center for Nutrition Studies and eCornell, as well as Dr. John McDougall's Starch Solution Certification Course. 

=== Recommended Reading ===

1. Comparison of sociodemographic and nutritional characteristics between self-reported vegetarians, vegans, and meat-eaters from the NurtiNet-Santé Study.
2. Rosenfeld DL. The psychology of vegetarianism: Recent advances and future directions. Appetite 2018; 131:125-38;and Ruby MB. Vegetarianism. A blossoming field of study. Appetite 2012; 58:141-150.
3. Plante CN, Rosenfeld DL, Plante M, Reysen S. The role of social identity motivation in dietary attitudes and behaviors among vegetarians. Appetite 2019; 141 https://doi.org/10.1016/j.appet.2019.05.038
4. Dehghan M, Mente A, Zhang X, et al. Associations of fats and carbohydrate intake with cardiovascular disease and mortality in 18 countries from five contents (PURE): a prospective study.

=== About Us ===

The Primary Care Pearls (PCP) Podcast is created in collaboration with faculty, residents, and students from the Department of Internal Medicine at the Yale School of Medicine. The project aims to create accessible and informative podcasts about core primary care topics centered around real patient stories.

Hosts: Nate Wood
Producers: Nate Wood, Helen Cai, August Allocco
Logo and name: Eva Zimmerman
Theme music and Editing: Josh Onyango
Other background music: pATCHES, Unicorn Heads, Asher Fulero

Instagram: @pcpearls
Twitter: @PCarePearls
Listen on most podcast platforms: linktr.ee/pcpearls

Transcript

Intro

[00:00:00] Nate: Hi everyone. And welcome to primary care. Pearl's a podcast made by learners for learners, and most importantly led by our patients' stories today. We're excited to talk even more about food

[00:00:15] Tina: Well, I watched the movie. Forks over knives to me, I was talking about chickens and then I saw the other guy saying that milk had pus in it and you know, just nasty stuff. And it just like, it makes you think like, Ugh, I don't wanna eat that. Like, you're gross, like nasty for eating it.  

[00:00:31] Nate: during our discussion today, we'll be joined by Tina Weston, a patient struggling with her nutrition.

[00:00:37] Tina: this is Tina Western. I do what I want. I eat what I want. I say what I want. I do what I want and it all comes back to, I eat what I want. 

[00:00:44] Nate: We'll learn more about her experience with different eating patterns, including Keto and the whole food plant-based diet.

We'll also be joined by a resident expert from the Yale school of medicine.

[00:00:55] Justin: I'm Justin Charles. I'm one of the residents in the Yale primary care program, really passionate, interested about nutrition and lifestyle medicine, and excited to talk to Tina today about nutrition and her journey.

[00:01:09] Nate: This discussion will be part two of a four-part series that will explore eating habits, the psychological underpinnings of eating behavior and strategies for the primary care provider to address. My name's Nate wood. I'm an internist, a chef, and a culinary medicine researcher.

And it's truly my pleasure to be your host for this episode. Before we get started, please know that this content is meant to be for learning and entertainment purposes only, and should not be used to serve as medical advice. If you or a loved one is suffering from anything discussed in today's episode, please be sure to discuss it with a medical expert.

Let's get started.

Chapter 1: Types of Eating Patterns

[00:01:50] Justin: what kind of diets, quote unquote, have you tried before and what's been your experience with them

[00:01:57] Tina: Um, I think the best thing, but I think you told me is it is a healthy is Keto. I lost like 30 pounds in a month. I swear to God the other day I saw a doctor in that hospital and she told me that her boyfriend was 80 pounds in the last couple of months when keto.

And she only does keto and I should do keto. And it's funny that you said it because I was like, oh wow. Then I was thinking about what. The fact, she said, people tell you fat is bad for you. Fat is the best thing for you. And this is a doctor telling me this. So you think it's not good? 

[00:02:28] Justin: Yeah. Well, I want to hear before I tell you my thing, what was your experience like with keto 

[00:02:32] Tina: I love it because I lost the weight, but like I said, I had the headaches. It was this nasty, sweet taste I had constantly in my mouth. I couldn't get rid of it. No matter how many times I brushed my teeth, um, it was like, Sweet sickening taste. And then it was, um, like the headaches, the irritability, the just, it just wasn't good

You don't feel good with it. I know that for a fact, like it's not a good feeling. but I did look good.

[00:02:59] Justin: Let's say that you had all of the self control. what kind of eating pattern would would you do? 

[00:03:07] Tina: I would eat once a day, one big meal, a day, a healthy meal, and then just drink water all day long. Like I wouldn't get. Like the fool will be in there and I would just keep drinking the water.

 the other thing you told me about, um, the plant-based diet that was good. Yeah, because I started and there's a lot of stuff that you could buy that's plant-based yeah. Like those burgers and things like that.

[00:03:29] Justin: with keto it's, it's good. In the short term, in the very short term, your blood sugar goes down, your weight goes down, your blood pressure goes down. Right. But eating all of that. Animal fats and animal proteins worsens your heart disease, worsens or insulin resistance.

the reason I like talking about. Plant-based diets and whole food plant-based diet specifically without all the processed junk is it helps with weight loss and it helps with diabetes and it helps with heart disease and it helps with high blood pressure and it helps with mood and energy.

And there's not this trade off between I'm going to lose weight. But I'm going to feel terrible. My cholesterol is going to go up and I'm going to end up having a heart attack. 

[00:04:13] Nate: I just love being a fly on the wall for conversations like these as part of the podcast, because it gives us an opportunity to learn so much, not only from the expert, but also from the patient. And I think that's really, really evident here from Tina's words. The first thing that we're honing in on is that a diet really can have a bunch of different purposes for some patients.

They're just hoping to lose weight for some patients, they're hoping to increase their longevity. Or prevent or treat their chronic disease for others. They're just trying to look good or feel good. So when we, as providers get caught up in this discussion of what is the best diet, we have to stop and ask ourselves the best diet for.

So for Tina, it seems like her primary goals were losing weight, looking good and feeling good. So after incorporating some anecdotal evidence from someone she met in the hospital, she decided to give the keto diet a try. And as we heard, she just didn't feel good on the keto diet, despite achieving a couple of her other goals, like losing weight and liking how she looks.

Justin does a nice job of jumping in to kind of clarify that some diets have some good evidence for some outcomes in the short term, while other diets have much more impressive data regarding long-term outcomes. Besides the whole food plant-based diet, which we're focusing on here with our resident expert, Dr. Justin Charles, some other evidence-based diets for positive long-term health outcomes include the dash diet and the Mediterranean diet. All of which focus on consuming primarily minimally processed plant. So as you can see, we as providers have a lot of information to collect and then juggle as we counsel patients on diet and nutrition, we need to take into account the patient's reasons for wanting to try a particular dietary pattern.

What specific goals the patient hopes to achieve with their diet and our health goals for the patient as their provider, all in the context of the current state of the literature, as we try our best to practice in an evidence-based manner. And the clinic Justin and Tina have previously discussed a whole food plant-based way of eating.

Let's listen in, as they reflect back on this. 

Chapter 2: Whole-Food Plant-Based Diet

[00:06:26] Justin: So when we talked about the plant-based stuff, did that sound weird to you?

Did it sound like something you could do? 

[00:06:33] Tina: Well, I watched the movie. Forks over knives to me, I was talking about chickens and then I saw the other guy saying that milk had plus in it and you know, just nasty stuff. And it just like, it makes you think like, Ugh, I don't wanna eat that. Like, you're gross, like nasty for eating it.

[00:06:49] Justin: Who did they talk about? The different health benefits or health harms different stuff. What did they talk about?

[00:06:55] Tina: Lowering your cholesterol low end. Like insulin, um, you know, resistance and things like that. So everything that they said would happen happened, it's just that I messed up and I never went back.

[00:07:08] Nate: you've mentioned this now and I heard tina mentioned it and this is forks over knives documentary, which brings up and really popularized. I think for a lot of Americans, what a whole food plant-based diet is. And you, I know you touched on this briefly, but just thinking about why everyone should care about nutrition now that you've already convinced fellow primary care physicians, why should our patients care about nutrition?

Um, and I think to get to the core of that, we really have to discuss in a little more detail, um, something that happens to be of extreme interest to you, which is the whole food plant based diet. So if you would mind, uh, if you wouldn't mind, please educate us on, you know, what is, um, the most convincing argument would you say for a whole food plant based diet? 

[00:07:52] Justin: I would not mind at all a whole food plant-based diet. And for those of you who don't know what that is, I will break it down quickly for you and then go into all the benefits So two components, one is whole food, and one is plant-based. The plant-based part means getting most of, if not all of your calories from plant-based sources, vegetables, fruits, whole grains, legumes, nuts, seeds, avocados, some minimally processed soy like tofu and not getting your food from animal-based sources, meat, chicken, or other poultry, lamb, pork, eggs, dairy fish, shellfish, et cetera.

Not saying all of those are equal, but generally speaking, when we look at the evidence plant-based foods tend to be health promoting animal-based foods tend to be health, harming, leaving all ethics and environmental impact aside. So that's the plant-based part. The whole food part, as I like to joke does not mean you have to do your grocery shopping at whole foods. It means you're eating foods in their whole form, minimally processed. What does that mean? We are not breaking down the food too much and not adding things to the food that make it. unhealthy, take an apple, for instance, with skin on it. It has a ton of fiber, a ton of nutrients in it, a ton of water, which does tend to not only hydrate us, but keep us full.

And that fiber is really such an important part. The nutrients follow the fiber. We break that down into applesauce, especially flavored applesauce with added sugar. Now we've removed the fight. We've removed a lot of the nutrients. We've removed a lot of the water, the bulk that keeps us full and we've added preservatives.

We've added sugar. Sometimes they sneak some oil and whatnot in there. And now we break that down further into apple pie. And now, you know, the apple is a supporting cast member in the butter, sugar, all of these other very unhealthy things, high in preservatives, high in calories, very 

little fiber. So we've taken that, that gorgeous apple and completely just ruined it from a nutritional standpoint by putting it into an apple pie.

So what does that mean, It means The white rice, the white flour products, where they've been stripped of so many nutrients from their whole grain counterpart, the junk food, the fast food, the things with the added salt oil, sugar preservatives really don't belong in the diet. And that's what distinguishes this from vegan, which I don't like using that word in a nutrition standpoint.

[00:10:28] Nate: Now, a lot of you may be wondering what the difference between a whole food plant-based diet and a vegan diet is. Justin's about to break that down very nicely, but first let's hear why he doesn't like using the word vegan in the first. 

[00:10:43] Justin: One, because it brings up a lot of ethical things that may or may not be relevant to someone and two for a vegan diet. You can have an impossible burger with vegan cheese, with a side of vegan, Mac and cheese, with a whole sleeve of Oreos and a liter of Pepsi. And 

that's a totally vegan meal. And I would never ever tell anyone that that is a healthy thing that they should eat. Whereas the whole food, part of the plant-based would eliminate all of those foods and make sure you're really getting your food sources that are full of fiber full of nutrients have minimal additives and other unhealthy things. So that's from a definitional standpoint. So what, who cares? What does it do? Prevents treats and can even most of the chronic medical conditions 

that kill most people reverse reverse. So when we're talking about diseases, most of the time in primary care, we're talking about managing them. When you have diabetes, it's a chronic progressive condition that you, we can only hope to slow the progression. As much as we can to minimize downstream complications disease. Reversal is saying, we can look at the root cause of this disease in the case of diabetes, insulin resistance. And we can fix that with nutrition and other lifestyle changes. So you can start to come off of your medications and have normal or near normal blood work and maintain that where you're in remission from your diabetes or your hypertension or your obesity or your coronary artery disease. And there's really good evidence that 

we can reverse, or at least partially reverse. So many of these chronic conditions that we deal with day in and day out in the primary care setting. And I never learned that I never learned in medical school that coronary artery disease, you can actually improve the diameter stenosis of coronary arteries without stenting, that you can reverse insulin resistance and get someone off of their insulin and off of their Metformin that you can reverse someone's obesity and get them to a level where they're at a more normal BMI and have more normal physiology. 

It's really incredible. And you're making people better. They're not just having better numbers and feeling terrible. They're feeling better. Their lab work is better. They're able to go and do all of the things that they like doing and all of the side effects, are good ones. 

They're not dealing with the, well, you might have dry mouth. It's like, well, side effects might include weight loss, improved strength of erections, ability to run around and play with your kids and fix your depression. 

[00:13:26] Nate: we have such powerful and effective tools like you've said before, right? In our own pantry, that can be, and our first-line for these diseases, but we're just not telling patients about them. Why is that?

[00:13:38] Justin: Well, I definitely don't think that we are knowingly withholding that information. I have a lot more faith in our profession than that I think a lot of us don't know that, or don't believe it is first. nutrition education in medical school

and residency is abysmal. We probably can all remember that one nutrition lecture we had with the modules from the 1980s that we don't remember, we just clicked through to get credit. And then we learned about the Krebs cycle, and we learned about niacin deficiency and Kwashiorkor and morass MIS and all of these things for board questions.

And we never learned, should I eat carbohydrates? You keep telling me that nutrition and diet is the first-line therapy for diabetes. What kind of diet, what should we be telling our patients to eat, to lose weight? 

We can answer the board question that someone comes in with an A1C of 6.0, what's the first line therapy, lifestyle modifications. But what are those. Is there actually evidenced behind. And a lot of times we tell patients what we think is right from what we read on the internet. And if we were going to manage AFib that way we'd lose our license, but we do it with nutrition and exercise and stress management all the time.

So being educated on what is optimal and the evidence behind it enough where we can explain it in a very simple way, understanding how to assess someone's motivations and how to get them to that point. And then combining our knowledge with motivational interviewing to actually help the person in front of us make a change that's realistic that will help them on their way to their goals. 

Chapter 3: Emotional and Psychological Nature of Eating

[00:15:21] Nate: so this is going to seem like a bit of a departure, but stay with me. So I'm not a professional op ed writer, but I've heard some folks who are really good at writing op-eds and in the op-ed, there's this very standard structure wherein you lay out your argument, you provide all this backup, um, data and, and, uh, Evidence to support your claims.

And then there's this paragraph towards the end called the, to be sure, which is where basically you try to envision what your critics are going to say, and you address those criticisms. That is something that I think comes to bear so strongly here with this discussion, because a lot of primary care physicians out there are going to say, well, that's all fine and dandy.

And we can all learn about how we should eat best, but this diet and getting to the point where we're eating good nutrition, that's nourishing and not harming our bodies is not feasible. And I think there's a lot to be said about that. And I know you have a lot to say about that. So I have a few to be sures if you'll indulge me. 

So one is. This sense of food being more than just food. So Tina talked a lot about this. She had, um, a childhood that extended into adulthood wherein she had this really complex relationship with food, including these battles with self-control and childhood experiences related to the role of food as a source of power and control.

[00:16:49] Tina: I'm so sick of myself. I can't lose any weight. I can't do anything. So what I did was I cut off all my hair cause I can control. I can't control what I eat. So it was just like, I'm going to cut all my hero home and start exercising.

I'm gonna start diet. And so now I have no excuse because I did this to myself. 

[00:17:05] Justin: Got it. So, oh, that's, that's why you have that mindset. I had, I 

[00:17:09] Tina: didn't have, yeah, it was like, I was cutting the fat out, but it was my here. So visually it was my here, but it, it it's like I'm going to get in shape. I have no excuses now.

I can't cut the fat. I could cut my. And that's going beat me when I exercise.

[00:17:25] Justin: So what is that like your relationship with control? I know we talked about that a little before of not feeling like growing up. You had a lot of control. How does that play into your life now? 

[00:17:37] Tina: Um, I do what I want. I eat what I want. I say what I want. I do what I want and it all comes back to, I eat what I want.

[00:17:42] Justin: It's kinda like a statement. Like I can do whatever I want. No one can tell me what to do. I'm in charge. And then at the same time, not feeling as in control and feeling like you can't help it anymore.

[00:17:56] Tina: growing up, we had my stepfather and house. My mother would make his food, which was, you know, a better choices of food, I guess.

And we couldn't ask her his food and we would have to eat the less good food. So now that I'm older, I could eat what I want to eat. I don't have anybody telling me you can't have this. You can't have that because that's for him now was for me. 

[00:18:15] Nate: This is something that is not unique to Tina. This is something that's a common issue for a lot of folks. So thinking about this to be sure, is it really possible to get patients to meaningfully change their eating habits when these are the kinds of things that you're up against? 

[00:18:29] Justin: Excellent question. And I've said this many times before, when we get to the core of it, any discussion about nutrition has to have a discussion about your motivations for eating and the psychological underpinnings that inform those motivations for eating. Now that doesn't mean that we have to necessarily be the people to get that knowledge and to fix it. But we have to be aware of it because most people eat for reasons other than hunger they eat, because they're sad They eat because they're stressed that you'd because they're happy they eat because they had fractured relationships with their family.

A lot of psychodynamic things go into our eating decisions and we eat to feel whole in some kind of way. And it's really important to keep those in mind and use our other health professional colleagues to help people unpack those reasons and to get at the core of why they're doing those things and develop insight into them. So they don't fall into the same traps. So I think it's a really important barrier that we need to focus on, but not an insurmountable one. 

And one that we need to help build up the discrepancy to help patients realize that there is an emotional relationship with the way they're eating. So we can then help them solve that and resolve that to whatever degree we can.

What is your thoughts on the role of judgment versus self-compassion in terms of, um, eating 

[00:20:04] Tina: healthy? The self-compassion at this point, it's just like, I'm just out of control. It's is like. It's just, the only word I could come up with is nasty. Like the food did it to me.

I did it to myself, but eating the food, did it to me. And it's just like, um, I need not, it's not even so much about food. I need to start working out. And then I eat something that makes me feel sluggish and tired. So I don't have the energy. Then it's just a circle, a cycle.

I went to the dentist the other day and I asked her, I said it seriously, this is what I asked her about getting my teeth.

Um, my jaw wired shut, and she said that they wouldn't do it here, but she's heard of people going over to different countries to get it done. So that's something I was looking into. And then I would just eat like purify foods, like a like baby food or something like that to lose the weight. Trying to lose weight. You're so depressed. And you think of, if you're really honest, I've thought about going out and buying street drugs, I've thought about, um, just all kinds of stuff.

Like you see these girls they're on drugs. They no matter what they're doing to get it, they always look good. They never had fat on them. You know, and could you buy street drugs and just lose the weight and stop? No, but a little part of you wants to believe that you can, because these are my honest feelings. Like I'm like the almond girls out there and they look good.

They really do until they get to a certain point and then they don't look good. Right.

You never see a fat one out there. Yeah. So it's just like you choose what this addiction has got me looking crazy and their addiction has them looking good.

[00:21:38] Justin: I hear you. And I think this is really important to share for both other people out there who also feel a lot of desperation and that they would do absolutely anything. And a lot of doctors to realize just what people are willing to go through to do that, and that we really need to understand nutrition and how to talk to people and how to motivate people because yeah. People could end up in some pretty serious situations trying to do this on their own.

Outro

[00:22:07] Nate: I think maybe the best reaction I have to all of that is just one word. And that is wow. To hear Tina talk about her journey with food and trying to lose weight and explaining how she's felt. Quote, out of control. Nasty and depressed how she's contemplated buying street drugs to look thin and how she even asked her dentist about getting her mouth wired shut in order to control her eating so that she can lose weight. And Justin did a really good job of naming the emotion. All of this just screams desperation.

But as you can probably tell, and this is perhaps most important of all, Tina still hasn't lost. Her resilience reminds us all just how important it is for us to engage with our patients about nutrition, which is why I'm so excited for our next episode, where we'll be exploring some evidence-based ways of doing this, including of course, one of our favorite techniques in the clinic, motivational interviewing.

Here are some key takeaways that I took from today's episode and hope you will. Number one, there are various diets that our patients often try for various reasons and they each of course have their own pros and cons.

The most important thing about diet selection is not thinking about it as a diet, but rather selecting a sustainable way of eating long-term that will promote health and wellness. Number two, the whole food plant-based diet and other evidence-based diets recommend that we quote, eat food, not too much, mostly plants as so well summarized by one of my favorite food journalists, Michael Pollan.

Remember this is different than some vegan diets, which can still include a lot of those processed foods that are so detrimental to our. And number three, eating carries a lot of emotional weight. I know it does for me. And it does for so many of our patients as well. So it's really important for us to be cognizant of this as we're working with them, as they try to adopt healthier eating.

Be sure to tune in next time, wherever you listen to your podcasts to catch part three in our four part nutrition series, where we'll introduce some of the general principles of motivational interviewing and get equipped to engage our patients on nutrition and provide them the support they need. Well, everyone, it's that time again, that concludes our episode for today.

We hope you enjoyed this episode, which was made possible by contributions from our patient, Tina and Dr. Justin Charles, who served as our patient interviewer as our experts and who also provided peer review for this. Special. Thanks as always to our producers, Madison Swallow, August Allocco, Helen Cai and Dr. Joshua Onyango as well as our faculty advisor, Dr. Katie Gielissen be sure to follow us at PC pearls on Instagram, where you can expect to get sneak, peeks, additional learning content and the most up-to-date details on show release times. Thanks again for joining us today. Farewell from all of us at the primary care pearls podcast. We'll catch you in the next one.