Asking a Lot, Trusting a Little: The Nutrition Doc and the Informed Patient
Context: Multiple Sclerosis
Episode 79 of the Ernährungsdocs podcast is about nutrition alongside treatment for multiple sclerosis. The first part of this article was about the burden of proof: which studies are enough for Dr Riedl to make a recommendation - and which are not. This one is about the second yardstick he applies in the same episode, the one that has nothing to do with studies: what you put a patient through, and what you trust her with.
Part 1: Two Kinds of Burden of Proof
Eating with Two Yardsticks: The Nutrition Doc's Burden of Proof
Dr Riedl earns both praise and criticism for a single podcast episode: giving up wheat even without coeliac disease👍, double standards on nutrition studies👎.
Read more →For context: I follow a ketogenic diet myself, with exclusively positive effects on my health, and I pay close attention to how it is talked about. There is more on that in the first part.
Extreme Difficulty
After about 20 minutes the ketogenic diet comes up - and with it a core part of his statement:
A ketogenic diet is a severe restriction of quality of life, and it is extremely difficult to carry out, and in the long run it also leads to deficiency symptoms. That is why you also have to have damned good evidence in the studies in order to recommend it. Because a reduction in quality of life and perhaps even deficiency symptoms(1) in MS, that is something I would not saddle myself with there.
First of all: if I compare two restrictions of quality of life with each other, I consider a life with MS the elephant in the room, next to which - in terms of difficulty - everything else takes second place. But then, what do I know… I will come back to this.
Dr Riedl finds the ketogenic diet difficult - as we have seen in the quote above. And so he withholds the choice from the patient. She might possibly not manage to keep it up. There are many possible answers to that:
Perhaps she does not have to keep it up - perhaps half the way is enough, and there is no need for values as extreme and as permanent as in the treatment of epilepsy. A low-carb diet with considerably fewer carbohydrates could be another option - but we will never find that out this way, that would be too easy.
Astonishingly: things cannot carry on quite as before where carbohydrates are concerned. Earlier on, at about 7:30, the subject was “simple” carbohydrates, which the patient was to avoid. I will leave the fitting words to the people involved:
[Presenter:] But when she got the tip from you to do without simple carbohydrates, she said she would gladly give it a try, though at the beginning it really was not easy for her. … The changeover was really hard.
[Patient:] I was completely wrecked and had a massive craving for carbohydrates… Now it is behind me. It is really odd, but the craving is gone. I would rather have a salad now, or maybe an apple or something. But a baguette or a pizza is something I do not need any more.
[Presenter:] To this day, it has to be said, she eats hardly any sugar, and above all no white flour products. And the latter in particular is something that pleases you especially.
[Dr Riedl:] Yes, that pleases me especially, because it was also particularly hard for her. Anyone burdened by an illness also has little strength to change anything, one has to say that clearly.
You don’t say - it was hard? And she managed it anyway? Might she have been motivated enough, what with the illness and the results?
Hard to believe that it apparently seems advisable to propose a fairly difficult dietary restriction - even at the risk that the patient might not keep it up.
One wonders what else she might have kept up with - with the motivation of an MS diagnosis breathing down her neck.
Self-Efficacy
I have highlighted self-efficacy and the informed patient in earlier articles: people affected by an illness often want to contribute something to their treatment - in this podcast the patient says so herself, and Dr Riedl sums up that he is fully aware of this wish (at about 31:30):
[Patient:] And at last I could contribute something myself
[Dr Riedl:] And I see this with all chronically affected people, that they say, “what can I do myself?” And this self-efficacy that we can activate there, that, I believe, is also really wonderful for the psyche
I applaud this attitude towards self-efficacy without reservation - but I would wish that he acted accordingly:
It is astonishing that he knows about the need of not just this one patient, that he is well disposed towards it, and yet apparently proposes to her only what he himself considers sustainable - even though her illness gives her a completely different motivation from his.
To sum up: she took a hard deprivation upon herself (“I was completely wrecked and had a massive craving for carbohydrates”) and, once the adjustment period was over, is very happy with the result of that short-term deprivation.
So the line is not drawn where it gets difficult for the patient, but where the doctor considers it too difficult - and that outranks even his explicit knowledge of her wish for self-efficacy.
Closing Remarks
I promised to come back to the matter of diminished quality of life:
To have the nerve to talk about quality of life on the grounds of one’s choice of foods, when what stands on the other side of the fence is an MS diagnosis, strikes me as remarkable.
I have said it above already: what I wish for is that somebody would demonstrate an optimum for nutrition, from which informed patients can then decide for themselves how far - and whether - they want to move towards that optimum.
The example of Dr Terry Wahls alone gives some indication of the criteria for quality of life that hardly any doctor applies: after her illness had confined her to a wheelchair, and after she then made an “extremely difficult” change of diet, these days she rides a bicycle again.
I will spare you my answer to the question of whether “wheelchair vs bicycle” or “pasta vs steak” has the greater influence on quality of life.
At the same time, that leaves open the question of whether this single example is enough, or whether I have to produce another 15 of them before Dr Riedl says, in this case too,
Then for me as a nutritional physician the point has come where I have to recommend it, because it does not harm the patient.
Because we did learn in Part 1 that a study of that order of magnitude is enough for him to recommend something.
🫳 🎤More comments on the same podcast episode
Eating with Two Yardsticks: The Nutrition Doc's Burden of Proof
Dr Riedl earns both praise and criticism for a single podcast episode: giving up wheat even without coeliac disease👍, double standards on nutrition studies👎.
Read more →