keto

As a former clinical physician I’ve always been fascinated by the promulgation of clinical guidelines, ostensibly crafted by leading minds in a given field convening to articulate treatment and diagnostic pathways to follow based on, what we’d all presume to be at least, the latest and greatest empirical evidence.

The overwhelming challenge is of course that human pathophysiology varies widely from person to person, given their unique genetics, history, constellation of conditions, nutrition, and even behavior. One-size-fits-all guidelines are often somewhat muddled in real-world application, and can lead to inappropriate, sub-optimal, or even harmful treatments being offered.

I personally know physicians who would be offended at the paragraph above, yet examples are stunningly commonplace of clinical guidelines run amuck today. For example, I have an 86-year old family member who’s currently being pressed to take statins for an incorrectly interpreted lipid panel, with her internist refusing to pursue the most specific testing, reporting it’s not allowed in his employer’s guideline directives.

For further example, here are two clinical guidelines released in the past few weeks that miss the mark impressively.

From Canada, T2 Diabetes Clinical Practice Guidelines for Physicians

From the Canadian Family Physician, Diabetes Canada 2018 Clinical Practice Guidelines, was published in January, detailing an intensive and comprehensive, pharmacologically-focused treatment pathway with stunningly little discussion of dietary guidelines focused on rational management of carbohydrate intake.

The article was presented on MedScape here (free account required); as always the comments were illustrative (and saddening), with one RN insisting that T2DM is best managed by increasing complex carbohydrates and limiting protein, a stunningly incorrect approach. Critically these articles referenced failed to address diet/nutrition in any detail, which has been increasingly shown to be impressively effective in management of T2DM.

Obesity Management in Primary Care

The second example is this: European Practical and Patient-Centred Guidelines for Adult Obesity in Primary Care.

The recommendations are multi-faceted and listed in some detail; they to their credit suggest pursuit of a “typical balanced Mediterranean style diet”, though suggest that at least of quarter of caloric intake come from starchy foods including cereals, legumes, and grains, with robust consumption of fruits as well, despite ample evidence suggesting these very foods can be obesogenic for many.

Of particular interest are the recommendations regarding targeted weight loss objectives (5-10% weight reduction), which while helpful would be woefully inadequate for many, and the responses on the Medscape summary of the guidelines, including one physician claiming the obesity epidemic to be unstoppable/untreatable.

The Take Home: Don’t Be Distracted By One Size Fits All Guidelines

Two Points of Interest. First, one-size-fits-all clinical guidelines, whether written by the AMA (or some other bastion of traditional medicine) or your favorite alternative health guru, need to be interpreted for you personally with great care.

Some recommendations you’ll come across, like the two examples above, have such glaring foundational flaws (missing fundamental nutrition and diet principles), one doesn’t have to venture too far out on the proverbial limb to suggest genuine harm is being done to many as they’re overmedicated, passing time waiting for complications of their lifestyle ‘diseases’ and treatments to manifest.

Some recommendations you’ll come across, and I’m thinking social media driven “advice” here, touting magical ingredients, supplements, workouts, etc, are not only anecdotal, but occasionally frankly duplicitous, evening bordering on the absurd. The keto world on social media is a hotbed of “experts” right now, prompting Mark Sisson to even refer to folks doing “caricature keto” in this post covering The Curious Phenomenon of Keto Crotch.

You physiology is unique to you; pay attention to what your body is telling you, and find supporting team members, including a good physician(s) when needed, who are willing to do the same.

And secondly, when anyone offers you recommendations based upon their guidelines, it’s absolutely fair game to apply several common sense tests: Do the recommendations make sense? Do the recommendations start with the least risky intervention or activity? What potential risks (or comorbidities) are involved?

An easy example – it’s my opinion that treating T2DM with pharmacological agents without a well-thought out, well-designed interval in a low carb (or VLC) diet trial is, given the information available today, clearly inappropriate. Another easy example is the liberal use of statins in clinical practice today, without adequate trials of dietary modification, particularly given statins’ long list of problems/side effects and questioned efficacy in reducing all-cause mortality in populations without proven heart disease, the risks very well may outweigh the benefits (more on statins to come another day).